High Risk Newborn Infections Practice Question (Test #4, Fall 2020)

A nurse is performing a postpartum assessment on a client on postpartum day one. The nurse notes the following four signs/symptoms. The nurse should report which of the signs/symptoms to the client's healthcare practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids.

1 1. Foul-smelling lochia is a sign of endometritis. 2. The nurse can assist the client with actions to relieve breast engorgement. 3. The nurse can assist the client with actions to relieve cracked nipples. 4. The nurse can assist the client with actions to relieve hemorrhoid pain. TEST-TAKING TIP: Some nursing actions are dependent functions. For example, nurses are able to administer antibiotics only after receiving a physician's order. Other actions, however, are independent actions. For example, assisting a client with engorged breasts and cracked nipples to breastfeed effectively and providing a sitz bath for a client with hemorrhoids are independent actions. The nurse must report foul-smelling lochia to the physician so that the doctor can decide whether to order antibiotics for the client.

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

1 1. If the woman has manually removed milk from her breasts, her nipples will soften to the touch. 2. If the baby is latched well, he should swallow after every suck. 3. The nurse would expect the baby to transfer 60 mL or more at the feeding. 4. The mother should not squeeze her nipple. The area behind the areola should be gently compressed. TEST-TAKING TIP: This client is complaining of engorgement. The baby is having difficulty latching because the breast is inflamed, making the nipple tense and short. When the woman manually removes a small amount of the foremilk, the nipple becomes easier for the baby to grasp.

A 54-year-old client calls her healthcare practitioner complaining of frequency and burning when she urinates. Which of the following factors that occurred within the preceding 3 days likely contributed to this client's problem? 1. She had intercourse with her partner. 2. She returned from a trip abroad. 3. She stopped taking hormone replacement therapy. 4. She started a weight-lifting exercise program.

1 1. The fact that the client had intercourse in the last 3 days likely led to the symptoms she is reporting, which are symptoms of a urinary tract infection (UTI). 2. Returning from a recent trip abroad is not likely related to the symptoms the client is reporting, which are symptoms of a UTI. 3. Stopping hormone replacement therapy is unlikely related to the symptoms reported by the client. 4. It is unlikely that starting a weight-lifting program is related to the symptoms of a UTI that the client is reporting. TEST-TAKING TIP: The urinary meatus is often manipulated during foreplay and rubbed against during intercourse. To prevent a UTI, women are encouraged to urinate immediately after having intercourse to flush any bacteria from the urethral opening.

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

1 1. The perineum of female babies should always be cleansed from front to back to prevent bacteria from the rectum from causing infection. 2. Vernix may be in the labial folds at delivery. It is a natural lanolin that will be absorbed over time. Actively removing the vernix can actually irritate the baby's tissues. 3. Powder is not recommended for use on babies, especially in the diaper area. When mixed with urine, powders can produce an irritating paste. 4. The number of a baby's diapers used in each 24-hour period should be counted to assess for hydration, but weighing the diapers of full-term babies is rarely needed. TEST-TAKING TIP: It is important for nurses to provide needed education to parents for the care of their new baby. Diapering, although often seen as a skill that everyone should know, must be taught. And it is especially important to advise parents that introducing bacteria from the rectum can cause urinary tract infections in their babies, especially female babies

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

1 1. This client is at high risk for uterine atony. 2. The client is not at high risk for hypoprolactinemia. 3. The client is not at high risk for infection. 4. The client is not at high risk for mastitis. TEST-TAKING TIP: The uterus of a woman who delivers a macrosomic baby has been stretched beyond the usual pregnancy size. The muscle fi bers of the myometrium, therefore, are stretched. After delivery the muscles are often unable to contract effectively to stop the bleeding at the placental separation site.

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

1 1. This response is correct. Reassuring the client is appropriate. 2. It is unlikely that the client has a urinary tract infection. 3. The urine will be blood tinged from the lochia. 4. This question is unnecessary. It is unlikely that the client has a urinary tract infection. TEST-TAKING TIP: Frequent urination is normal after a delivery. The urine of a postpartum client will be blood tinged. This does not mean that the client has red blood cells in her urine, but rather that the lochia from the vagina has contaminated the sample. Unless a catheterized sample is obtained, it is virtually impossible to obtain an uncontaminated urine sample in the postpartum period.

Four women with significant health histories wish to use the diaphragm as a contraceptive method. The nurse should counsel the woman with which of the following histories that the diaphragm may lead to a recurrence of her problem? 1. Urinary tract infections. 2. Herpes simplex infections. 3. Deep vein thromboses. 4. Human papilloma warts

1 1. Women who use the diaphragm have increased incidence of urinary tract infections. 2. Diaphragm may be used with a history of herpes simplex infections, but the device will not protect the woman's partner from contracting the virus. 3. A woman with a history of DVT can safely use the diaphragm. 4. Diaphragm may be used with a history of HPV, but the device will not protect the woman's partner from contracting the virus. TEST-TAKING TIP: Because the lip of the diaphragm must be inserted under the symphysis, the woman's urethra is sometimes pinched. This makes it diffi cult to completely empty the bladder when urinating. As a result, the woman is at high risk for developing urinary tract infections.

A postpartum multiparous client diagnosed with endometritis is to receive intravenous antibiotic therapy with ampicillin. Before administering this drug, the nurse must do which of the following? 1.Ask the client if she has any drug allergies. 2.Assess the client's pulse rate. 3.Place the client in a side-lying position. 4.Check the client's perineal pad.

1 Before administering ampicillin intravenously, the nurse must ask the client if she has any drug allergies, especially to penicillin. Antibiotic therapy can cause adverse effects, such as rash or even anaphylaxis. If the client is allergic to penicillin, the physician should be notified and ampicillin should not be given. Checking the client's pulse rate or placing her in a side-lying position are not necessary. Assessing the amount of lochia by checking the perineal pad is important for all postpartum clients but is not necessary before antibiotic therapy.

A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results (see chart). The nurse should: pH: 6.8 RBC: 3 per high power field Color: Yellow Specific Gravity: 1.030 1.Encourage the client to increase fluid intake. 2.Withhold the next dose of antihypertensive medication. 3.Restrict the client's sodium intake. 4.Encourage the client to eat at least half of a banana per day

1. The client's urine specific gravity is elevated. Specific gravity is a reflection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.

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

2 1. Clients are not recommended to pump their breasts after feedings unless there is a specific reason to do so. 2. This statement is true. The best way to prevent engorgement is to feed the baby every 2 to 3 hours. 3. Clients should not restrict babies' feeding times. Babies feed at different rates. Babies themselves, therefore, should regulate the amount of time they need to complete their feeds. 4. Clients are not recommended to supplement with formula unless there is a specific reason to do so. TEST-TAKING TIP: This question is similar to the preceding question except that this question tests the nurse's ability to evaluate a client's response rather than to perform a nursing action.

A woman states that she feels "dirty" during her menses so she often douches to "clean myself." The nurse advises the woman that it is especially important to refrain from douching while menstruating because douching will increase the likelihood of her developing which of the following gynecological complications? 1. Fibroids. 2. Endometritis. 3. Cervical cancer. 4. Polyps.

2 1. Fibroids are benign tumors of the myometrium. Douching does not increase the incidence of fi broids. 2. Douching can increase a client's potential for endometritis. 3. Cervical cancer is almost exclusively caused by the human papillomavirus that is contracted through sexual contact. 4. Polyps are abnormal tissue growths. They do not develop as a result of douching. TEST-TAKING TIP: The act of douching can cause serious gynecological infections up to and including PID. When a woman douches, she disrupts the normal fl ora in her vagina. Pathogens can then invade the area and be pushed upward into the upper gynecological system. Douching should never be performed unless ordered by a healthcare practitioner.

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

2 1. Infection, not ineffective breastfeeding, is the priority nursing diagnosis. 2. Infection is the priority nursing diagnosis. A temperature of 104.6°F as well as the client's other signs/symptoms should immediately suggest the presence of infection. 3. Infection, not ineffective individual coping, is the priority nursing diagnosis. 4. Infection, not pain, is the priority nursing diagnosis. TEST-TAKING TIP: This client has a breast abscess. Although all of the nursing diagnoses are important, the most important diagnosis is infection. It is the only one of the four diagnoses that is related to the acute problem. Ineffective breastfeeding contributed to the development of the infection. Because of the infection, the client is in pain and is coping poorly. Once the abscess is drained and the antibiotics have been administered, the other three diagnoses will be on the road to being resolved.

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

2, 3, and 4 are correct. 1. Although clients should drink fluids, this is not a goal related to the identified nursing diagnosis. 2. An important goal is that the woman's WBC will remain stable. 3. An important goal is that the woman's temperature will remain normal. 4. An important goal is that the woman's lochia will smell normal. 5. Sitz baths are not given to prevent infections. They do help to soothe the pain and/or the inflammation associated with episiotomies and hemorrhoids. TEST-TAKING TIP: The WBC is elevated during late pregnancy, delivery, and early postpartum, but if it rises very rapidly, the rise is often associated with a bacterial infection. The lochia usually smells "musty." When a client has endometritis, however, the lochia smells "foul." A temperature above 100.4°F/38°C after the first 24 hours postpartum is indicative of a puerperal infection

A client has been prescribed nitrofurantoin for treatment of a lower urinary tract infection. Which of the following instructions should the nurse include when teaching the client about this medication? Select all that apply. 1."Take the medication on an empty stomach." 2."Your urine may become brown in color." 3."Increase your fluid intake." 4."Take the medication until your symptoms subside." 5."Take the medication with an antacid to decrease gastrointestinal distress.

2, 3. Clients who are taking nitrofurantoin should be instructed to take the medication with meals and to increase their fluid intake to minimize gastrointestinal distress. The urine may become brown in color. Although this change is harmless, clients need to be prepared for this color change. The client should be instructed to take the full prescription and not to stop taking the drug because symptoms have subsided. The medication should not be taken with antacids as this may interfere with the drug's absorption.

A 24-hour-old, full-term neonate is showing signs of possible sepsis. The nurse is assisting the primary health care provider with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure? Select all that apply. 1.Administer the IV antibiotic. 2.Hold the neonate steady in the correct position. 3.Ensure a patent airway. 4.Maintain a sterile field. 5.Obtain a serum glucose level.

2,3,4. Holding the neonate steady and in the proper position will help ensure a safe and accurate lumbar puncture. The neonate is usually held in a "C" position to open the spaces between the vertebral column. This position puts the neonate at risk for airway obstruction. Thus, ensuring the patency of the airway is the first priority, and the nurse should observe the neonate for adequate ventilation. Maintaining a sterile field is important to avoid infection in the neonate. It is not necessary to administer antibiotics or obtain a serum glucose level during the procedure.

The nurse teaches a female client who has cystitis methods to relieve her discomfort until the antibiotic takes effect. Which of the following responses by the client would indicate that she understands the nurse's instructions? 1."I will place ice packs on my perineum." 2."I will take hot tub baths." 3."I will drink a cup of warm tea every hour. 4."I will void every 5 to 6 hours."

2. Hot tub baths promote relaxation and help relieve urgency, discomfort, and spasm. Applying heat to the perineum is more helpful than cold because heat reduces inflammation. Although liberal fluid intake should be encouraged, caffeinated beverages, such as tea, coffee, and cola, can be irritating to the bladder and should be avoided. Voiding at least every 2 to 3 hours should be encouraged because it reduces urinary stasis.

A 24-year-old female client comes to an ambulatory care clinic in moderate distress with a probable diagnosis of acute cystitis. When obtaining the client's history, the nurse should ask the client if she has had: 1.Fever and chills. 2.Frequency and burning on urination. 3.Flank pain and nausea. 4.Hematuria

2. The classic symptoms of cystitis are severe burning on urination, urgency, and frequent urination. Systemic symptoms, such as fever and nausea and vomiting, are more likely to accompany pyelonephritis than cystitis. Hematuria may occur, but it is not as common as frequency and burning.

The nurse managing the admission nursery is beginning the shift. There are 2 infants under the care of a primary staff nurse and are remaining in the nursery while their mothers sleep. One newborn is waiting to be transferred to the special care nursery (SCN) with a diagnosis of possible sepsis. The SCN cannot accept a transfer for 30 minutes. The nurse has been notified that another infant has been born and is breathing at a rate of 80 bpm and needs to be admitted to the nursery. There are also two infants who are waiting for social services to determine follow-up. There can be no other additions to the nursery until at least one newborn leaves the area. How should the nurse manage this situation? 1.Ask the nurses in SCN if they can take the newborn with possible sepsis now. 2.Ask the primary staff nurses to take their babies back to the sleeping mothers' rooms. 3.Call social services to determine if either of the babies who are waiting to be discharged is ready to leave. 4.Ask the nurse with the infant who is breathing at 80 bpm to wait ½ hour.

2. The nurse should manage this situation by asking the staff nurses to take at least one baby back to a room with a sleeping mother. This would allow the babies who are in need of care in the nursery to remain there. To maintain safety, the SCN cannot admit a client until they are prepared and have the staffing for this infant to be transferred. Social services can be called to determine if either of the newborns who have been referred to them can be discharged, but releasing these infants from the nursery will take several hours. It is unsafe to keep the infant with a respiratory rate of 80s waiting for a bed.

A 30-week-gestation multigravida, G3 P1011, is admitted to the labor suite. She is contracting every 5 minutes × 40 seconds. Which of the comments by the client would be most informative regarding the etiology of the client's present condition? 1. "For the past day I have felt burning when I urinate." 2. "I have a daughter who is 2 years old." 3. "I jogged 1½ miles this morning." 4. "My miscarriage happened a year ago today."

1 1. This is the most important statement made by the client. 2. The age of her first child is not relevant. 3. Her exercise regimen is not relevant. 4. The date of her miscarriage is not relevant. TEST-TAKING TIP: Preterm labor is strongly associated with the presence of a urinary tract infection. Whenever an infection is present in the body, the body produces prostaglandins. Prostaglandins ripen the cervix and the number of oxytocin receptor sites on the uterine body increase. Preterm labor can then develop.

A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breast-feed my baby?" The nurse should tell the client: 1."You can continue to breast-feed as long as you want to do so." 2."Alternate your breast-feeding with formula feeding to help you rest. 3."You'll need to discontinue breast-feeding until the antibiotic therapy is stopped." 4."You'll need to modify your technique by manually pumping your breasts.

1 The client can continue to breast-feed as often as she desires. Continuation of breast-feeding is limited only by the client's discomfort or malaise. Antibiotics for treatment are chosen carefully so that they avoid affecting the neonate through breast milk. Drugs such as sulfonamides, nitrofurantoin, and cephalosporins usually are not prescribed for breast-feeding mothers. Manual pumping of the breasts is not necessary.

A nurse who is caring for a pregnant type I diabetic should carefully monitor the client for which of the following? Select all that apply. 1. Urinary tract infection. 2. Multiple gestation. 3. Metabolic acidosis. 4. Pathological hypotension. 5. Hypolipidemia.

1 and 3 are correct. 1. Pregnant diabetic clients are particularly at high risk for urinary tract infections. 2. Pregnant diabetic clients are not at high risk for twinning. 3. Pregnant type I diabetic clients are at high risk for acidosis. 4. Pregnant diabetic clients are at high risk for hypertension, not hypotension. 5. Pregnant diabetic clients are at high risk for hyperlipidemia, not hypolipidemia. TEST-TAKING TIP: It is very important for the test taker to read each response carefully. If the test taker were to read the responses to the preceding question very quickly, he or she might choose incorrect answers. For example, the test taker might pick pathological hypotension, assuming that it says "hypertension." Pregnant type I diabetics are at high risk for UTIs because they often excrete glucose in their urine. The glucose is an excellent medium for bacterial growth. They also should be assessed carefully for acidosis because an acidotic environment can be life threatening to a fetus.

The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? Select all that apply. 1. Gently massage the areas toward the nipple, especially during feedings. 2. Apply warmth to the areas during feedings. 3. Alternate bottle feedings with breast feedings. 4. Apply lanolin ointment to the areas after each and every breastfeeding. 5. Feed from the affected breast first

1, 2, and 5 are correct. 1. This answer is correct. She should gently massage the area toward the nipple. 2. The woman should apply warm soaks to the breast during feedings. 3. The woman should be advised to feed her baby frequently at the breast. She should not be advised to bottle feed. 4. The woman should apply lanolin (Lansinoh) to sore or cracked nipples, not for a problem of tender hard nodules. 5. To promote emptying of the nodules, she should be advised to feed from the affected side first. TEST-TAKING TIP: A client who palpates a tender, hard nodule in her lactating breast is experiencing milk stasis. The stasis may be related to a blocked milk duct. It is very important that the woman gently massage the nodule while applying warm soaks and feeding her baby to prevent mastitis from developing. She should not skip breastfeedings but rather should breastfeed frequently.

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

1, 3, 4, and 5 are correct. 1. The nurse should palpate the breasts to assess for fullness and/or engorgement. 2. The postpartum assessment does not include carotid auscultation. 3. The nurse should check the client's vaginal discharge. 4. The nurse should assess the client's extremities. 5. The nurse should inspect the client's perineum. TEST-TAKING TIP: The best way to remember the items in the postpartum assessment is to remember the acronym BUBBLEHE. The letters stand for: B—breasts; U—uterus; B—bladder; B—bowels and rectum (for hemorrhoids and too inquire about most recent bowel movement); L—lochia; E—episiotomy (and perineum); H—Hormones (for emotions); and E—extremities. It is important to note that Homans sign is no longer recommended. Rather, careful inspection of the calves without dorsifl exing the foot for signs of DVT should be performed.

To prevent recurrence of cystitis, the nurse should plan to encourage the female client to include which of the following measures in her daily routine? 1.Wearing cotton underpants. 2.Increasing citrus juice intake. 3.Douching regularly with 0.25% acetic acid. 4.Using vaginal sprays.

1. A woman can adopt several health-promotion measures to prevent the recurrence of cystitis, including avoiding too-tight pants, noncotton underpants, and irritating substances, such as bubble baths and vaginal soaps and sprays. Increasing citrus juice intake can be a bladder irritant. Regular douching is not recommended; it can alter the pH of the vagina, increasing the risk of infection

Which of the following statements by a female client would indicate that she is at high risk for a recurrence of cystitis? 1."I can usually go 8 to 10 hours without needing to empty my bladder." 2."I take a tub bath every evening." 3."I wipe from front to back after voiding." 4."I drink a lot of water during the day.

1. Stasis of urine in the bladder is one of the chief causes of bladder infection, and a client who voids infrequently is at greater risk for reinfection. A tub bath does not promote urinary tract infections as long as the client avoids harsh soaps and bubble baths. Scrupulous hygiene and liberal fluid intake (unless contraindicated) are excellent preventive measures, but the client also should be taught to void every 2 to 3 hours during the day.

A physician writes the following order—Administer ampicillin 1 g IV q 4 h until delivery—for a newly admitted laboring client with ruptured membranes. The client had positive vaginal and rectal cultures for group B streptococcal bacteria at 36 weeks' gestation. Which of the following is a rationale for this order? 1. The client is at high risk for chorioamnionitis. 2. The baby is at high risk for neonatal sepsis. 3. The bacteria are sexually transmitted. 4. The bacteria cause puerperal sepsis.

2 1. Although the bacteria can cause chorioamnionitis, this is not the rationale for administering the antibiotic during labor. 2. Babies are susceptible to neonatal sepsis from vertical transmission of the bacteria. 3. The bacteria are not sexually transmitted. Approximately one-third of all women carry group B strep as normal vaginal and/or rectal flora. 4. Puerperal sepsis is usually caused by Staphylococcus aureus or group A streptococci. TEST-TAKING TIP: At approximately 36 weeks' gestation, pregnant women are cultured for group B strep. If they culture positive, standard protocol is to administer a broad-spectrum antibiotic IV q 4 hours from the time their membranes rupture until delivery. That action markedly decreases the vertical transmission of the bacteria to neonates.

A client complaining of frequency, urgency, and burning on urination is seen by her healthcare practitioner. Which of the following factors in the client's history places her at risk for these complaints? 1. The client urinates immediately after every sexual encounter. 2. The client uses the diaphragm as a family planning method. 3. The client wipes from front to back after every toileting. 4. The client changes her peripads every two hours during her menses.

2 1. Voiding after each sexual encounter decreases women's chances of developing a urinary tract infection. 2. Clients who use the diaphragm as a family planning device are at high risk for urinary tract infections. 3. To prevent the introduction of rectal flora into the urinary tract, it is important for women to wipe from front to back after toileting. 4. Because blood is an ideal medium for bacterial growth, it is recommended that women change their peripads frequently. TEST-TAKING TIP: Women are much more at high risk for UTI than men because of the close proximity of the urethra to the vagina and rectum. Women should be counseled on ways to prevent UTI, and women who are prone to UTI should consider changing their family planning method from the diaphragm to another method.

A newborn who is 20 hours old has a respiratory rate of 66, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98°F (36.6°C); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. Based on these data, the nurse should include which of the following in the management of the infant's care? 1.Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours. 2.Place a pulse oximeter and contact the primary health care provider for a prescription to draw blood cultures. 3.Arrange a transfer to the neonatal intensive care unit with diagnosis of possible sepsis. 4.Draw a complete blood count (CBC) with differential and feed the infant.

2 The concern with this infant is sepsis based on prolonged rupture of membranes before birth. Blood cultures would provide an accurate diagnosis of sepsis, but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results. Continuing with vital signs, voiding, stooling, and eating every 4 hours is the standard of care for a normal newborn, but a respiratory rate greater than 60, grunting, and occasional flaring are not normal. Although not normal, the need for the intensive care unit is not warranted as newborns with sepsis can be treated with antibiotics at the maternal bedside. The CBC does not establish the diagnosis of sepsis but the changes in the WBC levels can identify an infant at risk. Many experts suggest that waiting until an infant is 6 to 12 hours old to draw a CBC will give the most accurate results.

Which of the following pregnant clients is most high risk for preterm premature rupture of the membranes (PPROM)? Select all that apply. 1. 31 weeks' gestation with prolapsed mitral valve (PMV). 2. 32 weeks' gestation with urinary tract infection (UTI). 3. 33 weeks' gestation with twins post-in vitro fertilization (IVF). 4. 34 weeks' gestation with gestational diabetes (GDM). 5. 35 weeks' gestation with deep vein thrombosis (DVT).

2 and 3 are correct 1. Clients who have a history of prolapsed mitral valve are not at high risk for PPROM. 2. Clients with UTIs are at high risk for PPROM. 3. Clients carrying twins, whether spontaneous or post-IVF, are at high risk for PPROM. 4. Clients with gestational diabetes are not at high risk for PPROM. 5. Clients with deep vein thrombosis are not at high risk for PPROM. TEST-TAKING TIP: Although the exact mechanism is not well understood, clients who have urinary tract infections are at high risk for PPROM. This is particularly important because pregnant clients often have urinary tract infections that present either with no symptoms at all or only with urinary frequency, a complaint of many pregnant clients. Also, clients carrying twins are at high risk for PPROM.

To prevent catheter associated urinary tract infection the nurse should do which of the following? Select all that apply. 1.Change the catheter daily. 2.Provide perineal care several times a day. 3.Assess the client for signs of infection. 4.Encourage the client to drink 3,000 mL fluids daily. 5.Recommend the health care provider prescribe antibiotics.

2, 3, 4. Catheter-acquired urinary tract infection is the most frequent type of health care-acquired infection (HAI), and represents as much as 80% of HAIs in hospitals. The nurse should provide meticulous perineal care, encourage the client to obtain an adequate fluid intake, and assess the client for signs of infection such as an elevated temperature. It is not necessary to change the catheter daily. It is recommended that long term use of an indwelling urinary catheter be evaluated carefully and other methods considered, if the catheter will be in place longer than 2 weeks. It is not necessary to request a prescription for antibiotics as the client does not currently have an infection.

When teaching the client with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the client to report which of the following to the health care provider? Select all that apply. 1.Cloudy urine for the first few days. 2.Blood in the urine. 3.Rash. 4.Mild nausea. 5.Fever above 100°F (37.8°C) 6.Urinating every 3 to 4 hour

2, 3, 5 The nurse should instruct the client to report signs of adverse reaction to the antibiotic or indications that the urinary tract infection is not clearing. Blood in the urine is not an expected outcome, rash is an adverse response to the antibiotic, and an elevated temperature indicates a persistent infection. These signs should be reported to the health care provider. Cloudy urine can be expected during the first few days of antibiotic treatment. Mild nausea is a side effect of antibiotic therapy, but can be managed with eating small, frequent meals. Urinating every 3 to 4 hours or more is expected, particularly if the client is increasing the fluid intake as directed.

Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who gave birth 24 hours ago and is receiving intravenous antibiotic therapy for cystitis? 1.Limiting fluid intake to 1 L daily to prevent overload. 2.Emptying the bladder every 2 to 4 hours while awake. 3.Washing the perineum with povidone iodine after voiding. 4.Avoiding the intake of acidic fruit juices until the treatment is discontinued.

2. The client diagnosed with cystitis needs to void every 2 to 4 hours while awake to keep her bladder empty. In addition, she should maintain adequate fluid intake; 3,000 mL/day is recommended. Intake of acidic fruit juices (eg, cranberry, apricot) is recommended because of their association with reducing the risk for infection. The client should wear cotton underwear and avoid tight-fitting slacks. She does not need to wash with povidone iodine after voiding. Plain warm water is sufficient to keep the perineal area clean.

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client that before nursing her baby, the client should do which of the following? 1.Apply an ice cube to the nipples. 2.Rub her nipples gently with lanolin cream. 3.Express a small amount of breast milk. 4.Offer the neonate a small amount of formula

3 Expressing a little milk before nursing, massaging the breasts gently, or taking a warm shower before feeding also may help to improve milk flow. Although various measures such as ice, heat, and massage may be tried to relieve breast engorgement, prevention of breast engorgement by frequent feedings is the method of choice. Applying ice to the nipples does not relieve breast engorgement. However, it may temporarily relieve the discomfort associated with breast engorgement. Using lanolin on the nipples does not relieve breast engorgement and is unnecessary. Use of lanolin may cause sensitivity and irritation. Having frequent breast-feeding sessions, rather than offering the neonate a small amount of formula, is the method of choice for preventing and relieving breast engorgement. In addition, offering the neonate small amounts of formula may result in nipple confusion.

A client with a urinary tract infection is to take nitrofurantoin four times each day. The client asks the nurse, "What should I do if I forget a dose?" What should the nurse tell the client? 1."You can wait and take the next dose when it is due." 2."Double the amount prescribed with your next dose." 3."Take the prescribed dose as soon as you remember it, and if it is very close to the time for the next dose, delay that next dose." 4."Take a lot of water with a double amount of your prescribed dose.

3. Antibiotics have the maximum effect when the level of the medication in the blood is maintained. However, because nitrofurantoin is readily absorbed from the gastrointestinal tract and is primarily excreted in urine, toxicity may develop by doubling the dose. The client should not skip a dose, if one dose is missed. Additional fluids, especially water, should be encouraged, but not forced to promote elimination of the antibiotic from the body. Adequate fluid intake aids in the prevention of urinary tract infections, in addition to an acidic urine.

The client with first-time bacterial cystitis is being treated with an antibiotic to be taken for 7 days. The nurse should instruct the client to: 1.Limit fluids to 1,000 mL/day. 2.Notify the health care provider when the urine is clear. 3.Take the entire prescription as ordered. 4.Use condoms if having sex.

3. The client should take the prescription as ordered. The client should increase fluid intake to 3,000 mL/day to increase urination. Even though the urine may become clear in a short period, it is not necessary to notify the health care provider. The client should continue to take the entire prescription of antibiotics. Cystitis is not sexually transmitted, so protection by using a condom is not necessary.

A breastfeeding client, 6 days postdelivery, calls the postpartum unit stating, "I think I am engorged. My breasts are very hard and hot and they really hurt." Which of the following questions should the nurse ask at this time? 1. "Have you taken a warm shower this morning?" 2. "Do you have an electric breast pump?" 3. "How much did you have to drink yesterday?" 4. "When was the last time you fed the baby?

4 1. A warm shower may help to promote the milk ejection reflex, but this is not the question the nurse should ask at this time. 2. The client may need to pump her breasts to soften them enough for the baby to latch well, but this is not the question the nurse should ask at this time. 3. Unless a client has a very low intake, the quantity of fluids that the client consumes is not related to the quantity of milk she will produce. 4. The nurse should ask the client when she fed the baby last. TEST-TAKING TIP: Engorgement rarely develops if a mother breastfeeds frequently. Breastfeeding mothers should be encouraged to feed every 2 to 3 hours. Plus, it is especially important to encourage them never to skip a feeding. If they must give the baby a bottle in place of a breastfeeding, they should pump their breasts at the same time as the missed feeding.

A client informs the nurse that she intends to bottle feed her baby. Which of the following actions should the nurse encourage the client to perform? Select all that apply. 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day. 5. Stand with her back toward the shower water.

4 and 5 are correct. 1. It is unnecessary for a bottle-feeding mother to increase her fluid intake. 2. It is inadvisable for a bottle-feeding mother to massage her breasts. 3. It is inadvisable for a bottle-feeding mother to apply heat to her breasts. 4. The mother should be advised to wear a supportive bra 24 hours a day for a week or so. 5. The mother should be advised to stand with her back toward the warm shower water. TEST-TAKING TIP: The postpartum body naturally prepares to breastfeed a baby. To suppress the milk production, the mother should refrain from stimulating her breasts. Both massage and heat stimulate the breasts to produce milk. Mothers, therefore, should be encouraged to refrain from touching their breasts and when showering to direct the warm water toward their backs rather than toward their breasts. A supportive bra will help to minimize any engorgement that the client may experience.

The client asks the nurse, "How did I get this urinary tract infection?" The nurse should explain that in most instances, cystitis is caused by: 1.Congenital strictures in the urethra. 2.An infection elsewhere in the body. 3.Urinary stasis in the urinary bladder. 4.An ascending infection from the urethra

4. Although various conditions may result in cystitis, the most common cause is an ascending infection from the urethra. Strictures and urine retention can lead to infections, but these are not the most common cause. Systemic infections are rarely causes of cystitis

The client, who is a newlywed, is afraid to discuss her diagnosis of cystitis with her husband. Which would be the nurse's best approach? 1.Arrange a meeting with the client, her husband, the physician, and the nurse. 2.Insist that the client talk with her husband because good communication is necessary for a successful marriage. 3.Talk first with the husband alone and then with both of them together to share the husband's reactions. 4.Spend time with the client addressing her concerns and then stay with her while she talks with her husband.

4. As newlyweds, the client and her husband need to develop a strong communication base. The nurse can facilitate communication by preparing and supporting the client. Given the situation, an interdisciplinary conference is inappropriate and would not promote intimacy for the client and her husband. Insisting that the client talk with her husband is not addressing her fears. Being present allows the nurse to facilitate the discussion of a difficult topic. Having the nurse speak first with the husband alone shifts responsibility away from the couple

The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. The nurse should tell the client to drink: 1.Twice as much fluid as usual. 2.At least 1 quart (950 mL) more than usual. 3.A lot of water, juice, and other fluids throughout the day. 4.At least 3,000 mL of fluids daily.

4. Instructions should be as specific as possible, and the nurse should avoid general statements such as "a lot." A specific goal is most useful. A mix of fluids will increase the likelihood of client compliance. It may not be sufficient to tell the client to drink twice as much as or 1 quart (950 mL) more than she usually drinks if her intake was inadequate to begin with

The nurse is teaching an older adult with a urinary tract infection about the importance of increasing fluids in the diet. Which of the following puts this client at a risk for not obtaining sufficient fluids? 1.Diminished liver function. 2.Increased production of antidiuretic hormone. 3.Decreased production of aldosterone. 4.Decreased ability to detect thirst

4. The sensation of thirst diminishes in those greater than 60 years of age; hence, fluid intake is decreased and dissolved particles in the extracellular fluid compartment become more concentrated. There is no change in liver function in older adults, nor is there a reduction of ADH and aldosterone as a normal part of aging.

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

1 1. Clients should be strongly encouraged exclusively to breastfeed their babies to prevent engorgement. 2. Massaging of the breast will stimulate more milk production. That is not the best action to take. 3. It is unnecessary to culture the breast. This client is engorged; she does not have an infection. 4. It is unnecessary to assess this client's temperature and pulse rate. This client is engorged; she is not infected. TEST-TAKING TIP: The lactating breast produces milk in response to being stimulated. When a feeding is skipped, milk is still produced for the baby. When the baby is not fed, breast congestion or engorgement results. Not only is engorgement uncomfortable, it also gives the body the message to stop producing milk, resulting in an insufficient milk supply.

A client has nephropathy. The physician prescribes a 24-hour urine collection for creatinine clearance. Which of the following actions is necessary to ensure proper collection of the specimen? 1.Collect the urine in a preservative-free container and keep it on ice. 2.Inform the client to discard the last voided specimen at the conclusion of urine collection. 3.Obtain a self-report of the client's weight before beginning the collection of urine. 4.Request a prescription for insertion of an indwelling urinary catheter.

1. All urine for creatinine clearance determination must be saved in a container with no preservatives and refrigerated or kept on ice. The first urine voided at the beginning of the collection is discarded, not the last. A self-report of weight may not be accurate. It is not necessary to have an indwelling urinary catheter inserted for urine collection.

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

2 1. It is unnecessary to apply antibiotic ointment to the perineum after delivery. 2. Clients should be advised to change their pads at each voiding. 3. The clients should void about every 2 hours, but this action is not an infection control measure. 4. It is unnecessary to spray the perineum with a povidone-iodine solution. Plain water, however, should be sprayed on the perineum. TEST-TAKING TIP: Postpartum women should be advised to perform three actions to prevent infections: (1) change their peripads at each toileting because blood is an excellent medium for bacterial growth; (2) spray the perineum from front to back with clear water to cleanse the area; and (3) wipe the perineum after toileting from front to back to prevent the rectal flora from contaminating sterile sites

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

2 1. The woman should not wash with soap. Soaps destroy the natural lanolins produced by the body. 2. A small amount of lanolin should be applied to the nipple after each feeding. 3. The baby will not become sick from the blood. The woman should be warned that he may spit up digested and/or undigested blood after the feeding, however. 4. Topical anesthetics are not used on the breasts. The woman could receive an oral analgesic, however. TEST-TAKING TIP: Using lanolin on the breasts is a type of moist wound healing. The lanolin is soothing and allows the nipple to heal without a scab developing on the surface of the nipple. Mothers are often very concerned about their babies swallowing the blood. Ingesting the blood does not adversely affect the babies unless, of course, the mother is HIV positive or carries another bloodborne virus.

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

2 1. This action is inappropriate. The woman should apply warm soaks to the breast. 2. The action is appropriate. The woman should breastfeed frequently. 3. The woman should be discouraged from weaning. 4. It is unnecessary for the client to notify the pediatrician. The baby's health is not in jeopardy. TEST-TAKING TIP: Mastitis is a breast infection that usually affects only one duct system. If the mother were to wean abruptly, milk stasis would occur, the bacteria would proliferate, and a breast abscess is likely to develop. The mother should feed her baby frequently, use warm soaks to promote milk fl ow, and notify her obstetrician. Antibiotics are usually prescribed to eradicate the bacteria.

Which of the following would be most important for the nurse to encourage in a primiparous client diagnosed with endometritis who is receiving intravenous antibiotic therapy? 1.Ambulate to the bathroom frequently. 2.Discontinue breast-feeding temporarily. 3.Maintain bed rest in Fowler's position. 4.Restrict visitors to prevent contamination.

3. The nurse should encourage the client to maintain Fowler's position, which promotes comfort and facilitates drainage. Endometritis can make the client feel extremely uncomfortable and fatigued, so ambulation during intravenous therapy is not as important at this time. The client does not need to discontinue breast-feeding, although she may become quite fatigued and need assistance in caring for the neonate. Typically, breast-feeding would be discontinued only if the mother lacks the necessary energy. The institution's policy regarding visitors is to be followed. However, visitors do not need to be restricted to prevent contamination because the client is not considered to be contagious. The nurse should maintain the client's need for privacy and rest and should respect the client's wishes related to visitors.

The nurse is caring for a neonate shortly after birth when the neonate is diagnosed with sepsis and is to be treated with intravenous antibiotics. Which of the following will the nurse need to instruct the parents to do because of the neonate's infection? 1.Use caution near the isolation incubator and equipment. 2.Visit but do not touch the neonate. 3.Wash their hands thoroughly before touching the neonate. 4.Wear a mask when holding the neonate.

3. The parents of a neonate with an infection should be allowed to participate in daily care as long as they use good handwashing technique. This includes touching and holding the neonate. The parents must be careful around medical equipment to ensure proper function and around the intravenous site so that it is not dislodged, but being careful with the equipment is not sufficient to prevent transmission of microbes to the neonate. Restricting parental visits has not been shown to have any effect on the infection rate and may have detrimental effects on the neonate's psychological development. Normally, the neonate does not need to be isolated. It is not necessary for the parents to wear a mask while holding the neonate. The neonate is not contagious and is receiving treatment for the infection.

A woman who is in pain from a diagnosis of mastitis has abruptly weaned her baby to a bottle. Her actions place the woman at high risk for which of the following? 1. Mammary rupture. 2. Postpartum psychosis. 3. Supernumerary nipples. 4. Breast abscess.

4 1. She is not at high risk for mammary rupture. 2. She is not at high risk for postpartum psychosis. 3. She is not at high risk for supernumerary nipples. 4. The client is at high risk for the development of a breast abscess. TEST-TAKING TIP: When clients wean abruptly, the breasts become engorged with milk. Mastitis is a breast infection usually caused by Staphylococcus aureus . When the milk is not removed from the breast, an abscess, or collection of pus, can develop in the breast.

A couple has decided not to circumcise their son. Based on this decision, which of the following instructions should the nurse include in the parent teaching? 1. The couple should check their son's temperature every evening because he will be at high risk for urinary tract infections. 2. The couple should fully retract the foreskin to assess for the presence of exudate every morning. 3. The pediatrician will observe the baby void during each well-baby examination to assess for a phimosis. 4. The prepuce should be cleansed with soap and water every day during the baby's sponge bath.

4 1. The incidence of UTIs is slightly higher in boys who have not been circumcised, but there is no need to check the baby's daily temperature. 2. The prepuce should not be fully drawn back during the newborn period because of the potential for inducing pain and scarring. 3. The pediatrician will not have to evaluate the baby. Phimosis, or a tightened prepuce, may be present at birth or may develop subsequent to an infection. The mother, therefore, should be advised to watch that the baby's urine flows freely when he voids. 4. This response is correct. The baby's prepuce should be cleansed with soap and water during the daily bath. The mother should not force the foreskin to retract, but if it does naturally loosen from the glans, she and, in later years, the boy should gently clean underneath. TEST-TAKING TIP: Whether or not to circumcise a male child is a decision for the parents to make. There is some evidence that males are less at risk of developing sexually transmitted infections if they are circumcised, and the incidence of UTI is slightly higher in boys who have not been circumcised. The American Academy of Pediatrics, however, does not recommend that all males be circumcised

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

4 1. The nurse would not expect to see engorgement. 2. The nurse would not expect to see mastitis. 3. The nurse would not expect to see a blocked milk duct. 4. The nurse would expect that the woman would have a low milk supply. TEST-TAKING TIP: The placenta produces the hormones of pregnancy, including estrogen and progesterone. When placental fragments are retained, those hormones are still being produced. Estrogen inhibits prolactin, which is the hormone of lactogenesis, or milk production. Women who have retained placental fragments, therefore, often complain of an insufficient milk supply for their babies. Women with retained placental fragments are also at high risk for postpartum hemorrhage and intrauterine infection

Thirty-six hours after a vaginal birth, a multiparous client is diagnosed with endometritis due to β-hemolytic streptococcus. When assessing the client, which of the following would the nurse expect to find? 1.Profuse amounts of lochia. 2.Abdominal distention. 3.Nausea and vomiting. 4.Odorless vaginal discharge.

4 Scant and odorless vaginal discharge is associated with endometritis due to b-hemolytic streptococcus. The client also will exhibit "sawtooth" temperature spikes between 101°F and 104°F (38.3°C to 40°C), tachycardia, and chills. The classic symptom of foul-smelling lochia is not associated with this type of endometritis. Profuse and foul-smelling lochia is associated with classic endometritis from pathogens such as chlamydia or staphylococcus, not group B hemolytic streptococcus. Abdominal distention is associated with parametritis as the pelvic cellulitis advances and spreads, causing severe pain and distention. Nausea and vomiting are associated with parametritis resulting from an abscess and advancing pelvic cellulitis.