Maternity

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? A. I am so excited to be in labor B. I can't stand this pain any longer C. I need ice chips because I'm so hot D. I have to push the baby out right now!

B "I can't stand this pain any longer" is consistent with a woman in the transition phase of stage 1. Excitement about labor would be consistent with the latent phase of labor. Desire for ice chips can occur at a variety of times in labor. The urge to push is consistent with a woman in stage 2 of labor.

A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following needles could the nurse safely choose for the injection? A. 5/8", 18 gauge B. 5/8", 25 gauge C. 1 inch 18 gauge D. 1 inch, 25 gauge

B An 18-gauge needle is too thick to be used. A 1-inch needle is too long and the gauge is too thick. A 5/8", 25-gauge needles is an appropriate needle for a neonatal IM injection.

A woman, G9 P8 delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? A. Pulse B. Fundus C. Bladder D. Breast

B An assessment of the woman's fundus is the most important assessment to perform on this patient. This patient's gravidity and parity indicate that she is a grand multipara. She has been pregnant 9 times and has had 8 deliveries. Because her uterus has been stretched so many times, she is at high risk for uterine atony during the postpartum period.

What does a nurse explain to a pregnant woman about the cause of her physiologic anemia? A. Erythropoiesis decreases B. Plasma volume increases C. Utilization of iron decreases D. Detoxification of the liver increases

B There is a 30-50% increase in maternal plasma volume at the end of the first trimester, leading to a decrease in the concentrations of hemoglobin and erythrocytes (dilution). Erythropoiesis increases after the first trimester. Iron utilizations unrelated to the development of physiologic anemia of pregnancy. Detoxification demands are unchanged during pregnancy.

A full-term baby's bilirubin level is 12 mg/dL on day 3. Which of thefollowing neonatal behaviors would the nurse expect to see? A. Excessive crying B. Increased appetite C. Lethargy D. Hyperreflexia

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

To initiate the milk ejection reflex, the mother should: A. Wear a firm-fitting bra B. Drink plenty of fluids C. Place the infant to the breast D. Apply cool packs to her breasts

C Oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. A firm bra is important to support the breast but will not initiate the let-down reflex. Cool packs for the breast will decrease the let-down reflex.

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

D

Rho immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh+, baby Rh- b. Mother Rh+, baby Rh+ c. Mother Rh-, baby Rh- d. Mother Rh-, baby Rh+

D

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is a. vaginal hematoma. b. uterine inversion. c. vaginal laceration. d. uterine atony.

D

What is a result of hypothermia in the newborn? a. Decreased oxygen demands b. Shivering to generate heat c. Decreased metabolic rate d. Increased glucose demands

D

Which woman is most likely to have severe afterbirth pains and request a narcotic analgesic? a. Primipara who delivered a 7-lb boy b. Woman who has started to breastfeed c. Woman who is bottle-feeding her first child d. Gravida 5, para 5

D

The pediatrician has ordered vitamin K 0.5 mg IM for a newborn. The medication is available as 2mg/mL. How many milliliters(mL) should the nurse administer to the baby? Calculate to the nearest hundredth. _____ mL

0.25 A simple ratio and proportion equation is needed to calculate the volume of vitamin K that should be given to the baby. Known volume: Known dosage = Desired volume: desired dosage; 2: 1 mL =0.5 x. The means are multiplied together and extremes are multiplied together. 2x = 0.5; x = 0.25 mL

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is ________ beats/min. a. 120 to 160 b. 150 to 180 c. 100 to 120 d. 80 to 100

A

The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called a. vernix caseosa b. acrocyanosis c. surfactant d. caput succedaneum

A

The nurse should alert the provider when a. the infant is dusky and turns cyanotic when crying. b. acrocyanosis is present at age 1 hour. c. the infant's blood glucose is 45 mg/dL. d. the infant goes into a deep sleep at age 1 hour.

A

The nurse should explain to new parents that the most serious consequence of propping an infant's bottle is a. aspiration. b. colic. c. ear infections. d. dental caries.

A

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by a. subinvolution of the uterus. b. cervical lacerations. c. defective vascularity of the decidua. d. coagulation disorders.

A

A baby's blood type is B negative. The baby is at risk for pathological (non-physiological) jaundice if the mother has which of the following blood types? A. Type O negative B. Type A negative C. Type B positive D. Types AB positive

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

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? A. Letting go B. Taking hold C. Taking in D. Taking on

A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. During the taking-hold phase the mother assumes responsibility for her own care and shifts her attention to the infant. In the taking-in phase the mother is primarily focused on her own needs. There is no taking-on phase of maternal adjustment.

Nurses can prevent evaporative heat loss in the newborn by: A. Drying the baby after birth and wrapping the baby in a dry blanket B. Keeping the baby out of drafts and away from air conditioners C. Placing the baby away from the outside wall and the windows D. Warming the stethoscope and nurse's hands before touching the baby

A Because the infant is wet with amniotic fluid andblood, heat loss by evaporation occurs quickly. Heat loss by convection occurs when drafts come from open door and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is termedradiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces.

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

A Both the upper and lower lips should be flanged. Breastfed babies usually feed every 2 to 3 hours. A 12% weight loss is significant in any neonate whether breastfeeding or bottle feeding.

A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. Which statement by the nurse is true? Bottle-feeding using commercially prepared infant formulas: A. Increases the risk that the infant will develop allergies B. Helps the infant sleep through the night C. Ensures that the infant is getting iron in a form that is easily absorbed D. Requires that a multivitamin supplement be given to the infant

A Breastfeeding is less likely to cause allergies. Newborns should be fed through the night regardless of feeding method. Iron is better absorbed from breast milk than from formula. Commercial formulas are designed to meet the nutritional needs of the infant and to resemble breast milk. No supplements are necessary.

A woman's prenatal education includes danger signs to report. Which of the following, if repeated, would indicate that the woman understood the teaching? A. Dizziness and blurred vision B. Occasional nausea and vomiting C. No bowel movement for 3 days D. Ankle edema

A Dizziness and blurred vision can be symptoms of preeclampsia, a complication that requires further assessment and medical management. Occasional nausea and vomiting, no bowel movement for 3 days and ankle edema are not danger signs of pregnancy.

What should a nurse include in the discharge teaching of a postpartum client? A The Kegelexercises should be continued B The episiotomy sutures will be removed at the first postpartum visit C She may not have a bowel movement for up to a week after the birth D She should schedule a postpartum checkup as soon as her menses return.

A Kegel exercises can be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after giving birth; a delay of bowel movements promotes constipation, perineal discomfort and trauma. The usual postpartum examination is 6 weeks after birth; menses can return earlier or later than this and should not be a factor when schedulinga postpartum examination.

A nurse is teaching participants in a prenatal class about breastfeeding versus formula feeding. A client asks, "What is the primary advantage of breastfeeding?" What is the nurse's best reply? A. Breastfed infants have fewer infections B. Breastfeeding inhibits ovulation in the mother C. Breastfed infants adhere more easily to a feeding schedule D. Breastfeeding provides more proteinthan does cow's milk formula

A Maternal antibodies are transferred from the mother in breast milk, which provides protection for a longer timethan those transferred to the fetus via the placenta. The neonate is protected by these antibodies; the fetuses own antibody system is immature at birth. Lactating mothers rarely ovulate for the first 9 postpartum weeks; however, they may ovulate and any time after that period; although this may be considered an advantage, it is not a primary advantage. Because of the higher carbohydrate content of breast milk, which is digested rapidly, breastfed babies wake more frequently than formula -fed babies. Their feeding demands take more time to regulate than the formula-fed infant's. Breast milk has 1.1 g protein/100 mL; cow's milk has 3.5 g/100 mL; whole cow's milk is unsuitable for infants.

How does the nurse identify true labor as opposed to false labor? A. Cervical dilation is progressive B. Contractions stop when the client walks around C. Contractions progress only in a side-lying position D. Contractions occur immediately after the membranes rupture

A Progressive cervical dilation is the most accurate indication of true labor. With true labor, contractions generally increase with activity. Contractions in true labor persist in any position. Contractions may not begin immediately after the membranes rupture.

The initial laboratory results for a primigravida indicate a hemoglobin of 12 grams/dL, hematocrit of 36%, and a blood group and type of A negative. What would be the priority nursing action to promote a healthy pregnancy for this woman and her fetus? A. Plan to administer RhoGam at 28 weeks gestation B. Encourage the client to eat more dark-green leafy vegetables C. Provide information on weight gain during pregnancy D. Suggest an iron supplement in addition to the prenatal vitamins

A The Rh-negative woman whose infant is Rh-positive would be at risk for Rh-sensitization, which could create risks for future pregnancies. The infant's blood type cannot be obtained until after birth, so RhoGam is administered at 28 weeks for all Rh-negative women during pregnancy. The woman is not anemic based on the hemoglobin and hematocrit values, so encouraging the client to eat more dark-green leafy vegetables and suggesting an iron supplement are incorrect. There is no relationship between the lab values and the woman's weight in this scenario.

The woman's vaginal examination reveals: 3 cm dilated, 80% effaced, vertex at zero station. The woman is talkative and appears excited. The nurse determines the woman to be in which phase and stage of labor? A. First stage, latent phase B. First stage, active phase C. Second stage, latent phase D. Third stage, transition phase

A The first stage of labor is from the onset of labor to complete dilation, and is divided into latent (0-3 cm), active (4-7 cm) and transition (8-10 cm) phases. The second stage of labor has no phases and extends from complete dilation until the delivery of the newborn to delivery of the newborn. The third stage has no phases and extends from deliver of the newborn to the delivery of the placenta.

Which behavior indicates to a nurse that anew mother is in the taking-hold phase? A. Calling the baby by name B. Talking about the labor and birth C. Touching the baby with her fingertips D. Being involved with her own need to eat and sleep

A The mother has moved into the taking-hold phase when she takes control and becomes actively involved with her infant and calls the infant by name. She has completed the taking-in phase when her own needs no longer predominate.

A woman who is 1 day postpartum, is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? A. Urine output 200 mL for the past 8 hours B. Weight decrease of 2 pounds since delivery C. Drop in hematocrit of 2% since admission D. Pulse rate of 68 beats per minute

A The nurse must divide the amount of urine output by the number of hours. The output in this scenario is equal to 25 mL/hr. This is well below the accepted output of 30 mL/hr. Plus, because this is a postpartum client, the nurse would expect high urinary outputs. All other findings are within normal limits.

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

A When a woman receives RhoGAM, she receives passive Rh antibodies. If any Rh antigen is circulating the mother's blood stream, the antibodies will destroy it. As a result, there will be no antigen in the mother's body to stimulate her mast cells to have an active antibody response. In essence, therefore, RhoGAM is injected to inhibit the client's immune response.

A woman's chart indicates she has a second-degree laceration. When assessing this patient, the nurse plans to observe which of the following structures? Select all that apply: A. Vaginal mucosa B. Perineal skin C. Peritoneal muscle D. Anus E. Rectum

A, B, C A second-degree perineal laceration includes vaginal mucosa, perineal skin, and peritoneal muscle. A third-degree laceration involves the anus, while a fourth-degree laceration includes the rectum.

Nurses must be aware of the conditions that increase the risk of hemorrhage, one of the most common complications of the puerperium. What are these conditions? (Select all that apply.) a. Uterine fibroids b. Rapid or prolonged labor c. Preeclampsia d. Primipara e. Overdistention of the uterus

A, B, C, E

The nurse assesses a woman's episiotomyor perineal laceration using the acronym REEDA. What factors does this include? A. Redness B. Edema C. Approximation D. Depth E. Discharge

A, B, C, E The acronym REEDA indicates redness, edema, ecchymosis or bruising, discharge and approximation. Depth is not a consideration with this acronym.

Medications used to manage postpartum hemorrhage include which of the following? Select all that apply. A. Pitocin B. Methergine C. Terbutaline D. Hemabate E. Magnesium Sulfate

A, B, D Pitocin, Methergine, and Hemabate are all used to manage PPH. Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.

A bottle-feeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that the teaching was successful: Select all that apply. A. The woman gently strokes and pats the baby's back B. The woman positions the baby in a sitting position on her lap C. The woman waits to burp the baby until the baby's feeding is complete D. The woman states that a small amount of regurgitated formula is acceptable E. The woman remarks that the baby does not need to burp after trying for one full minute

A, B, D Stroking and patting the baby's back are very effective ways of burping. Babies can be burped in many different positions, including over the shoulder, lying flat across the lap, and in sitting position. When placing the baby in the sitting position, themother should carefully support the baby's chin. Positioning the baby face down on the lap can be very effective and some mothers feel more secure using this position because the baby is unlikely to be dropped from this position. A small amount of "spitup" is within normal limits. Breastfed babies often spit up bits of their feeds.

During a postpartum assessment, the nurse assesses the calves of a woman's legs. The nurse is checking for which of the following signs and symptoms? A. Pain B. Warmth C. Discharge D. Ecchymosis E. Redness

A, B, E Postpartum women are high risk for deep vein thrombosis (DVT). At each postpartum assessment, the nurse assesses the calves for signs of the complication, i.e., those seen in any inflammatory response: pain, warmth, redness, and edema. If the signs/symptoms are noted, the nurse should request an order from the primary healthcare provider for diagnostic tests to be performed.

The nurse who elects to practice in the area of obstetrics learn about the "Five Ps". What are the five P's? A. Powers B. Pain C. Passenger D. Psyche E. Passage

A, C, D, E Powers: the two powers of labor are uterine contractions and pushing efforts. Passenger: this is the fetus plus the membranes and placenta. Fetal lie, attitude, presentation, and position are all factors that affect the fetus as passenger. Psyche: the psych is a crucial part of childbirth. Marked anxiety, fear, or fatigue decreases the woman's ability to cope. Passage: the passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the successful outcome of labor because bones and joints do not yield as readily to the forces of labor. Pain is not one of the P's.

The nurse explain to the student that which of the following factors increase a woman's risk for thrombosis? (Select all that apply.) a. Prolonged bedrest during or after labor and delivery b. Maternal age greater than 30 years of age c. Adherence to a strict vegetarian diet d. Excessive sweating during labor e. Use of stirrups for a prolonged period of time

A, D, E

A nurse is advising the parents of a newborn regarding when they should call their pediatrician. Which of the following responses show that the teaching was effective? A. If the baby repeatedly refuses to feed B. If the baby's breathing is irregular C. If the baby has no tears when he cries D. If the baby is repeatedly difficult to awaken E. If the baby's temperature is above 100.4 degrees F

A, D, E If a baby refuses to eat, it may mean that the baby is seriously ill. Newborns normally breathe irregularly. Apnea of 10 seconds or less is normal. Newborns do not tear when the cry. If a baby does tear, he or she may have a blocked lacrimal duct. Although babies who are in the deep sleep state are difficult to arouse, the deep sleep state lasts no more than an hour. If the baby continues to be nonarousable, the pediatrician should be notified. A temperature of 100.4 F is a febrile state for a newborn and the pediatrician should be notified.

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

B

A nurse receives handoff report. Which newborn should the nurse assess first? a. Temperature 97.7° F (36.5° C) b. Respiratory rate 78 breaths/minute c. Pulse 144 beats/minute d. Glucose reading 58 mg/dL

B

After giving birth the nurse suggests that the woman place the infant to her breast within 15 minutes. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the a. transition period. b. first period of reactivity. c. second period of reactivity. d. organizational stage.

B

If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the patient has a. been lying on her right side too long. b. a distended bladder. c. a normal involution. d. stretched ligaments that are unable to support the uterus.

B

To prevent heat loss from convection in a newborn, which action by the nurse is best? a. Wrap the baby in warmed blankets. b. Move infant away from blowing fan. c. Place the baby in a warmer. d. Dry the baby after a bath.

B

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

B

What instructions should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications? A. Palpate the fundus daily to ensure that it is soft B. Notify the physician of a return to bright red bleeding C. Report any decrease in the amount of brownish red lochia D. The passage of clots as large as an orange can be expected

B An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication. The fundus should stay firm. Large clots after discharge are a sign of complications and should be reported.

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

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

The nurse determines teaching has been effective when a laboring client makes which statement? A. Effacement is the opening of my cervix B. My cervix will probably efface before it dilates because this is my first pregnancy C. Effacement is measured from 0 to 10 centimeters D. My cervix will efface and dilate at the same time because this is my first pregnancy

B Effacement is the thinning of the cervix from 0 to 100%. The opening of the cervix from 0 to 10 cm is called dilation. In primigravidas, effacement usually precedes dilation while in multigravidas these processes usually occur concurrently.

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

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

When the tongue stays behind the gum line, the baby is unable to propel milk from the breast.In order prevent nipple trauma, the nurse should teach the new mother to: A. Limit the feeding time to less than 5 minutes B. Position the infant so the nipple is far back in the mouth C. Assess the nipples before each feeding D. Wash the nipples daily with mild soap and water

B If the infant's mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, causing trauma to the area. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. Assessing the nipples for traumais important, but it will not prevent sore nipples. Soap can be drying to the nipples and should be avoided during breastfeeding.

The student nurse learns that the hormone necessary for milk production is: A. Estrogen B. Prolactin C. Progesterone D. Lactogen

B Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Progesterone decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced.

A nurse on the postpartum unit is assessing several patients. Which clinical finding requires and immediate investigation? A. An inflamed episiotomy B. A slow-trickle of blood from the vagina C. An estimated blood loss of 500 ml during a vaginal birth D. A boggy uterine fundus that becomes firm after prolonged massage

B Steady vaginal bleeding may be an early sign of hemorrhage; hypovolemic shock can develop. An inflamed episiotomy is an expected finding; ice packs help resolve the inflammation. An expected blood loss for a vaginal birth is 300 to 500 mL. A fundus that hasbeen overstretched or is multiparous may require prolonged massage until it becomes firm.

A patient tells the nurse that the first day of her last menstrual period was July 22nd, 2016. What is the estimated date of delivery? A. May 7, 2017 B. April 29, 2017 C. April 22nd, 2017 D. March 6th 2017

B The Naegele rule is an indirect, noninvasive method for estimating the date of delivery: EDD = last menstrual period +1 year -3 months + 7 days.

During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant? A. Anticipatory B. Formal C. Informal D. Personal

B The major task of the formal stage of role attainment is getting acquainted with the infant. The anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes. The informal stage begins once the parents have learned appropriate responses to their infant's cues. The personal stage is attained when parents feel a sense of harmony in their role.

A new mother asks, "Why are you doing a gestational age assessment on my baby? I delivered on time." The nurse's best response is: A. This must be done to meet insurance requirements B. It helps us identify infants who are at risk for any problems C. The gestational age determines how long the infant will be hospitalized D. It was ordered by your doctor

B The nurse should provide the mother with accurate information about various procedures performed on the newborn. A gestational age assessment helps identify at-risk infants. It is not done for insurance requirements or to determine hospital days. Assessing gestational age is a nursing assessment and does not have to be ordered.

A woman at 35 weeks' gestation asks a nurse why her breathing has become more difficult. How should the nurse respond? A. "Your lower rib cage is more restricted." B. "Your diaphragm has been displaced upward." C. "There is an increase in the size of your lungs." D. "There is an increase in the height of your rib cage."

B The pressure of the enlarging fetus causes upward displacement of the diaphragm, which results in thoracic breathing; this limits the descent of the diaphragm on inspiration.

A nurse is about to administer the ophthal micpreparation to a newly born neonate. Which of the following is the correct statement regarding the medication? A. It is administeredto prevent the development of neonatal cataracts B. The medication should be placed in the lower conjunctiva from the inner to outer canthus C. This medication must be administered immediately upon delivery of the baby D. It is administered to neonates whose mothers test positive for gonorrhea during pregnancy

B This is the correct method of instillation of the ophthalmic prophylaxis. The ophthalmic preparation is administered to prevent opthalmia neonatorum, which is caused by gonorrhea and/or chlamydia infections. It is not given to prevent cataracts. The medication can be delayed until the baby has had his or her first feeding and has begun the bonding process. Ophthalmic prophylaxis is given to all neonates at birth whether or not their mothers are positive for gonorrhea.

A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion? (Select all that apply.) a. A small white blister on the tip of the nipple b. Breast tenderness c. Fever and flulike symptoms d. An area of redness on the breast often resembling the shape of a pie wedge e. Warmth in the breast

B, C, D, E

The nurse is planning to teach a class of expectant parents about the cardinal movements, or changes in position, that occur as the fetus passes through the birth canal. The nurse plans to teach the positional changes in the sequence in which they occur when the fetus is in a cephalic presentation. Place the cardinal movements in the correct sequence: A Expulsion B Descent C Flexion D External rotation E Internal rotation

B, C, E, D, A The cardinal movements (position changes) of the fetus occur in the order of engagement, descent, flexion, internal rotation, extension, external rotation, & expulsion.

Which are examples of appropriate techniques to wake a sleepy infant for breastfeeding? (Select all that apply.) a. Apply a cold towel to the infant's abdomen. b. Unwrap the infant. c. Slap the infant's hands and feet. d. Change the diaper. e. Talk to the infant.

B, D, E

A nurse is planning a prenatal class about the changes that occur during pregnancy. Which cardiovascular compensatory mechanisms should the nurse explain will occur? Select all that apply. A. Systematic vasodilation B. Increased blood volume C. Elevated blood pressure D. Increased cardiac output E. Enlargement of the heart F. Decreased erythrocyte production

B, D, E Blood volume is increased to meet the metabolic demands of pregnancy. In increased cardiac output is necessary to accommodate the increased blood volume needed to meet the demands of the growing fetus. Cardiac hypertrophy is a result of the demands made by the increased blood volume and cardiac output. Systematicvasodilation is not expected. There is little variation in blood pressure with a slight decrease during the second trimester. Erythrocyte production increases; because the plasma volume increases more than the RBCs, the hematocrit is lower.

According to the recommendations of the American Academy of Pediatrics (AAP) on infant nutrition a. Infants fed on formula should be started on solid food sooner than breastfed infants. b. If infants are weaned from breast milk before 12 months, they should receive cow's milk, not formula. c. Infants should be given only human milk for the first 6 months of life. d. After 6 months, mothers should shift from breast milk to cow's milk.

C

To prevent breast engorgement, the new breastfeeding mother should be instructed to a. feed her infant no more than every 4 hours. b. apply cold packs to the breast before feeding. c. breastfeed frequently and for adequate lengths of time. d. limit her intake of fluids for the first few days.

C

To promote bonding and attachment immediately after delivery, what action by the nurse is most important? a. Allow the mother quiet time with her infant. b. Assist the mother in feeding her baby. c. Assist the mother in assuming an en face position with her newborn. d. Teach the mother about the concepts of bonding and attachment.

C

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Stepping b. Tonic neck c. Babinski d. Plantar grasp

C

Which type of formula is not diluted before being administered to an infant? a. Modified cow's milk b. Concentrated c. Ready-to-use d. Powdered

C

During a physical in the prenatal clinic, the patient's vaginal mucosa is observed to have a bluish discoloration. What sign should the nurse document in the patients clinical record? A. Hegar B. Goodell C. Chadwick D. Preparatory contractions

C A bluish color results from the increased vascularity and blood vessel engorgement of the vagina. The Hegar sign is softening of the lower uterine segment. The Goodell sign is softening of the cervix. After the fourth month of pregnancy, uterine contraction can be felt through the abdominal wall. They are irregular and painless, and they increase blood flow to the placenta.

What should a nurse include in nutritional planning for a pregnant woman of average height weighing 145 pounds who has just entered her 2nd trimester? A. A decrease of 100 calories per day B. A decrease of 200 calories per day C. An increase of 300 calories per day D. An increase of 500 calories per day

C An increase of 300 calories per day is the recommended caloric increase for adult women to meet theincreased metabolic demands of pregnancy

The maternal newborn nurse would use which description of the fetal position when explaining to the mother the occurrence of a frank breech position? A. The hips and the knees are flexed B. The hips are extended and the knees are flexed C. The hips are flexed and the knees are extended D. Both the hips and the knees are extended

C Frank breech presentation is when the sacrum of the baby is presenting, the hips are flexed, and the feet are extended upward toward the fetal head. Both hip and knee flexion occurs with a complete breech. Hip extension with knee flexion is characteristic of a kneeling breech and both hip and knee extension occur with a double footling breach

The nurse reads the history of a newborn admitted to the nursery and discovers that the infant's mother was listed as gravida 1, para 1 before the baby was born. How should the nurse use these data to gather more information? A. Determine whether there were fetal losses B. Determine whether there are twins at home C. Consider that someone recorded the gravida and para incorrectly D. Consider that the current birth means that there were two pregnancies

C Gravida refers to pregnancies, and para refers to pregnancies terminated (by whatever means) after the age of viability. If this is the mother'sonly pregnancy, she could not have had a previous pregnancy that terminated after the age of viability. Para cannot exceed gravida. One pregnancy is gravida 1. A twin pregnancy is still one delivery terminated after the age of viability. Because the documentation of the mother is gravida 1, it cannot be assumed that it is the woman's second pregnancy.A) Determine whether there were fetal losses;

A woman, 37 weeks' gestation, has been advised that she is positive for group B streptococci. Which of the following comments by the nurse is appropriate at this time? A. The doctor will prescribe intravenous antibiotics for you. A visiting nurse will administer them to you in your home B. You are very high risk for an intrauterine infection. It is important for you to check your temperature every day C. The bacteria are living in your vagina. They will not hurt your but we will give you medicine in labor to protect your baby from getting sick D. This bacteria causes scarlet fever. If you notice that your tongue becomes very red and that your feel feverish, you should call the doctor immediately.

C Group B strep bacteria are normal for this woman, she does not need to take her temperature. Antibiotics will be given during labor since GroupB strep is very dangerous for newborns. Group B strep does not cause Scarlett fever. Group A strep causes scarlet fever and strep pharyngitis.

To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD): A. Is the "baby blues" plus the woman has a visitwith a counselor or psychologist B. Does not affect the father who can then care for the baby C. Is distinguished by pervasive sadness that lasts at least 2 weeks D. Will disappear on its own without outside help

C PPD is characterized by a persistent depressed state. The woman is unable to feel pleasure or love although she may be able to care for her infant. She often experiences generalized fatigue, irritability, little interest in food and sleep disorders. PPD is more serious and persistent than postpartum baby blues. Fathers are often affected. Most women need professional help to get through PPD, including pharmacologic intervention.

A newborn who is large for gestational age (LGA) is _______ percentile for weight. A. Below the 90th B. Less than the 10th C. Greater than the 90th D. Between the 10th and 90th

C The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. An infant between the 10th and 90th percentiles is average for gestational age. An infant less than the 10th percentile is small for gestational age.

A pregnant patient is making her first antepartum visit. She has a 2-year-old son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-year-old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, what does the nurse document about the patient's obstetric history? A. G4 T3 P2 A1 L4 B. G5 T2 P2 A1 L4 C. G5 T2 P1 A1 L4 D. G4 T3 P1 A1 L4

C The acronym GTPAL reflects, G, gravidity; T, term birth; P, preterm birth; A, abortions; and L, living children. G5 T2 P1 A1 L4 indicates that there have been 5 pregnancies (including current pregnancy), twins count as 1 delivery. Therefore, we have 2 term deliveries (2-year old, and 5-year-old delivered after 37 weeks, 1 preterm delivery of twins at less than 37 weeks gestation, 1 abortion and currently 4 living children: a 2-year-old, a 5-year-old, and 7-year-old twins.

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

C The green drainage may be a sign of infection. The cord should become driedand shriveled. There is controversy in the literature regarding what should be used to clean the umbilical cord, but hydrogen peroxide is not one of the recommended agents. Some research actually indicates that nothing should be applied to the umbilical cord. The cord should fall off on its own. This usually happens 7 to 10 days after birth. There is no need to cover the umbilicus.

How many ounces will a 1-week-old formula-fed infant who is on a 4-hour feeding schedule need to consume at each feeding to meet daily caloric needs? A. 0.5 to 1 B. 1 to 2 C. 2 to 3 D. 4

C The newborn requires approximately 2 to 3 ounces per feeding within 1 week after birth

The nurse is reviewing results from a woman's initial prenatal visit and notes that the urine contained an increased number of white blood cells, nitrates, and greater than 10,000 bacteria/mL of urine. These findings may lead to the nurse to suspect which of the following? A. Renal insufficiency B. Contamination of the urine with amniotic fluid C. Urinary tract infection D. Nothing unusual, this is a normal finding in pregnancy

C The presence of nitrites, white bloods cells, and bacteria are all indicative of a urinary tract infection. Renal insufficiency would show an increase in blood urea nitrogen and creatinine. Contamination of the urine with amniotic fluidis not realistic. Stating that the results are a normal finding in pregnancy is false because the urine should be sterile, not containing bacteria.

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

C Tickling the baby's lips with the nipple is the recommended method of encouraging a baby to open his or her mouth for feeding. The enface position is an ideal position for interacting with a baby who is in the quiet alert behavioral state, but not to encourage a baby to open wide for feeding. Although sometimes needed, it is not routinely recommended that mothers push down on their baby's lower jaw to encourage the baby to open his or her mouth. Bottles should not be used to entice babies to breastfeed.

A patient who is 24 weeks pregnant has been diagnosed with syphilis. She asks the nurse how the infection will affect the baby. The nurse's response should be based on which of the following? A. She is at high risk for premature rupture of the membranes B. The baby will be born with congenital syphilis C. Penicillin therapy will reduce the risk to the fetus D. The fetus will likely be born with a cardiac defect

C Usually a single shot of penicillin administered to the mother, will cure her and protect the baby. If treated early, there likely will be no pregnancy of fetal damage noted. If treated the baby will not be born with congenital syphilis. The woman is past the first trimester when the major organ systems are developed.

A nurse is teaching a primigravida about how she can identify the onset of labor. What clinical indicator of labor would necessitate the client to call her health care provider? A. Bloody show and back pressure occur B. Contractions become regular or get stronger C. Membranes rupture or contractions are 5 to 8 minutes apart D. Contractions are 10 to 12 minutes apart and last about 30 seconds

C When the membranes rupture, the potential for infection is increased, and when the contractions are 5 to 8 minutes apart, they are usually of sufficient force to warrant professional supervision. Blood show and back pressure may be early signs of labor or signs of posterior fetal position; it is too early to notify the health care provider. When contractions become regular or get stronger is too early; the woman should remain with her family and keep moving around at home. When contractions are 10-12 minutes apart, lasting about 30 seconds, it is too early.

The nurse explains to the nursing student that one mechanism for the diaphoresis and diuresis experienced during the early postpartum period is which of the following? A. Elevated temperature caused by postpartum infection B. Increased basal metabolic rate after giving birth C. Loss of increased blood volume associated with pregnancy D. Increased venous pressure in the lower extremities

C Within 12 hours of birth, women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid. An elevated temperature causes chills and may cause dehydration, not diaphoresis and diuresis. Diaphoresis and diuresis are not caused by an increase in metabolic rate. Postpartal diuresis may be caused by removal of increased venous pressure in the lower extremities.

A neonate who is being admitted into the well-baby nursery, is exhibiting each of the following assessment findings. Which of the findings should the nurse report to the primary health care provider? Select all that apply. A. Harlequin sign B. Extension of the toes when the lateral aspect of the sole is stroked C. Elbow moves past the midline when the scarf sign is assessed D. Slightly curved pinnae of the ears that are slow to recoil E. Telangiectatic nevi

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

A nurse is administering vitamin K to an infant shortly after birth. The parents ask why their baby needs a shot. The nurse explains that vitamin K is a. important in the production of red blood cells. b. necessary in the production of platelets. c. responsible for the breakdown of bilirubin and prevention of jaundice. d. not initially synthesized because of a sterile bowel at birth.

D

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

D

An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called a. nevus flammeus. b. vascular nevi. c. lanugo. d. mongolian spots.

D

Nurses can help parents deal with the issue and fact of circumcision if they explain a. that circumcision is rarely painful and that any discomfort can be managed without medication. b. that the American Academy of Pediatrics (AAP) recommends that all newborn males be routinely circumcised. c. that the infant will likely be alert and hungry shortly after the procedure. d. the pros and cons of the procedure during the prenatal period.

D

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

D Cephalohematomas are subcutaneous swellings of accumulated blood from the trauma of delivery. The bulges may be one-sided or bilateral and the swellings do not cross suture lines. Molding is characterized by the overlapping of the cranial bones. It is rarely one sided and would feel like a ridge rather than a bulge. Swelling of the tissues of the baby's head occurs over the entire cranium and called caput succedaneum. Positioning usually results in molding.

To check for the presence of Epstein's pearls, the nurse should assess which part of the neonate's body? A. Feet B. Hands C. Back D. Mouth

D Epstein's pearls -small white specks (keratin-containing cysts) -are located on the palate and gums.

What maternal event is abnormal in the early postpartum period? A. Diuresis and diaphoresis B. Flatulence and constipation C. Extreme hunger and thirst D. Lochial changes from rubra to alba

D For the first 3 days after childbirth, lochia is mostly red and is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. Thebody rids itself of increased plasma volume after birth. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days after birth, leading to flatulence and constipation. The new mother is hungry and thirsty because of energy used in labor and fluid restriction during labor.

A nurse is teaching a group of pregnant women about breastfeeding. Which factor that influences the availability of milk in the lactating woman should the nurse include in the teaching? A. Age of the woman at the time of the birth B. Distribution of erectile tissue in the nipples C. Amount of milk products consumed during pregnancy D. Viewpoint of the woman's family toward breastfeeding

D If the woman perceives a negative viewpoint about breastfeeding from significant others, she may be tense and the let-down reflex may not occur; a positive attitude from significant others toward breastfeeding promotes relaxation and the let-down reflex.

If rubella vaccine is indicated for a postpartum patient, instructions to the patient should include: A. Drinking plenty of fluids to prevent fever B. No specific instructions C. Recommendations that she stop breastfeeding for 24 hours after injection D. Explaining the risks of becoming pregnant within 1 month after injection

D Potential risks to the fetus can occur if pregnancy results within 28 days after rubella vaccine administration. Drinking fluids will not prevent a fever. Small amounts of the vaccine do cross the breastmilk, but it is believed that there is no need to discontinue breastfeeding.

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

D The AAP, although acknowledging that there are some advantages to circumcision, states that there is not enough evidence to suggest that all baby boys be circumcised. There is no evidence that circumcision status affects boy's self-image. No official statements have been published regarding the rationality of performing circumcision. The CDC has made no policy statement on circumcision.

When responding to the question, "Will I produce enough milk for my baby as she grows and needs more milk at each feeding? The nurse should explain that: A. The breast milk will gradually become richer to supply additional calories B. As the infant requires more milk, feedings can be supplemented with cow's milk C. Early addition of baby food will meet the infant's needs D. The mother's milk supply will increase as the infant demands more at each feeding

D The amount of milk produced depends on the amount of stimulation of the beast. Increased demand with more frequent and longer breastfeeding sessions results in more milk available for the infant. Mature milk will stay the same. The amounts will increase as the infant feeds for longer times. Supplementation will decrease the amount of stimulation of the breast and decrease the milk production. Solids should not be added until about 4 to 6 months, when the infant's immune system is more mature. This will decrease the chance of allergies.

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data? A. The nurse should notify the neonatologist for this emergency situation B. The neonate must have aspirated surfactant C. If this baby was born vaginally, it could indicate a pneumothorax D. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth

D The condition will resolve itself within a few hours. For this common condition of the newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. There is no need to notify the neonatologist. Surfactant is produced by the lungs, so aspiration is not a concern. Pneumothorax is also not a concern.

A patient who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. When the nurse assesses the neonate 11 hours after birth, the infant's skin appears yellow. What is the most likely cause? A. Neonatal sepsis B. Rh incompatibility C. Physiologic jaundice D. ABO incompatibility

D There is an apparent ABO incompatibility because the mother is O and the infant is B; incompatibility can cause pathological jaundice within the first 24 hours.

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

D To minimize the ingestion of large quantities of air, the bottle should be held so that the nipple is alwaysfilled with formula. Stools in breastfed babies are bright yellow and loose. In bottle feeding babies, they are brownish and pasty. To prevent aspiration, bottle nipples should not be enlarged. Microwaving can overheat the formula, causing burns.

Which statement by a postpartum woman indicates that teaching about thrombus formation has been effective? A. I'll stay in bed for the first 3 days after my baby is born B. I'll keep my legs elevated with pillows C. I'll sit in my rocking chair most of the time D. I'll put my support stockings on every morning before rising.

D Venous congestion begins as soon as the woman stands up. The stockings should be applied before she rises from the bed in the morning. As soon as possible, the woman should ambulate frequently. The mother should avoid knee pillows because the increase pressure on the popliteal space. Sitting in a chair with legs in a dependent position causes pooling of blood in the lower extremities.

A nurse is providing dietary counseling to a patient who is 14 weeks' gestation. The patient is a recent immigrant from Asia, and the nurse explores the foods that the patient usually eats. Which foods does the nurse counsel her to avoid during pregnancy? A. Yogurt B. Oily fish C. Apricots D. Raw shellfish E. Herbal supplements F. Soft-scrambled eggs

D, E, F Yogurt is an excellent source of calcium and is safe to eat during pregnancy. Oily fish have a high level of omega-3 oils and is safe to eat in limited amounts during pregnancy. Apricots are a source of potassium and are safe to eat during pregnancy. Raw shellfish may be contaminated with hepatitis or typhoid. Herbal supplements and teas often have ingredients that are medicinal and should not be taken during pregnancy without consulting a health care provider as to safety. The March of Dimes has included soft-scrambled eggs on its list of food to avoid during pregnancy because they may be contaminated with salmonella.

A pregnant adolescent at 10 weeks' gestation visits the prenatal clinic for the first time. The nutrition interview indicates that her dietary intakes consists mainly of soft drinks, candy, french fries, and potato chips. Why does the nurse consider this diet inadequate? A. Caloric content will result in too great a weight gain B. Ingredients in soft drinks and candy can be teratogenic in early pregnancy C. Salt in this died will contribute to the development of gestational hypertension D. Nutritional composition of the diet places her at risk for a low-birthweight infant

D??