Maternity Exam 3 Ch 22-25

The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them:

"Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns."

While assessing the newborn, the nurse should be aware that the average expected apical pulse range for a full-term, quite, alert newborn is:

120 - 160 bpm

In most healthy newborns, blood glucose levels stabilize at _________ mg/dL during the first hours after birth:

50 to 60

Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them about pumping, storing, and transporting the milk needs to assess their knowledge of lactation. What statement is valid?

A premature infant more easily digests breast milk than formula.

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)?

Breast tenderness Warmth in the breast An area of redness on the breast often resembling the shape of a pie wedge Fever and flu like symptoms

What are mode of heat loss in the newborn (select all that apply)

Convection Radiation Conduction

What is the PRIORITY teaching tip the nurse should provide about bottle-feeding?

Hold infant semiupright while feeding.

As the nurse assists a new mother with breastfeeding, the client asks, "If formula I prepared to meet the nutritional need of the newborn, what is in the breast milk that makes it better?" The nurse's best response is that it contains:

Important immunoglobulins

Which action of a breastfeeding mother indicates the need for further instruction?

Leans forward to bring breast toward the baby.

The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a:

Moro reflex.

Which laboratory test result would be a cause for concern if exhibited by an Rh-positive newborn 12 hours after birth?

Rapid Plasma Reagin (RPR)/Venereal Disease Research Laboratories (VDRL): reactive

The nurse is caring for an infant born at 28 weeks of gestation. Which complication could the nurse expect to observe during the course of the neonate's hospitalization? (Select all that apply.)

Respiratory distress syndrome Periventricular hemorrhage Patent ductus arteriosus

Which TORCH infection could be contracted by the infant because the mother owned a cat?

Toxoplasmosis

Which of these statements are helpful and accurate nursing advice concerning bathing the new baby. (Select all that apply.)

Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. Powders are not recommended because the infant can inhale powder.

Which statement regarding infant weaning is correct?

Weaning can be mother or infant initiated.

Concerning congenital abnormalities involving the central nervous system, nurses should be aware that:

a major preoperative nursing intervention for a neonate with myelomeningocele is to protect the protruding sac from injury.

the term that means "inflammation of the amnion" is :

amnionitis

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae:

are benign if they disappear within 48 hours of birth

the prefix pre- means:

before

'Stillborn" refers to

being born dead

Vitamin K is given to the newborn to:

enhance ability of blood to clot

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern since the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by:

explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements.

The unborn offspring from the beginning of the 9th week of pregnancy to birth is called

fetus

the combing form meaning pregnancy is

gravid/o

When caring for a newborn, the nurse must be alert for signs of cold stress, including:

increased respiratory rate

At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as________.

9

The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Many regional and ethnic cultures can be found within the United States. One cannot assume generalized observations about any cultural group will hold for all members of the group. Which statement related to cultural practices influencing infant feeding practice is correct?

A common practice among Mexican women is known as los dos.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include:

Abdominal distention, temperature instability, and grossly bloody stools.

What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge?

Apical heart rate of 90 beats/min, slightly irregular, when awake and active

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot?

Babinski

The nurse administers vitamin K to the newborn for what reason?

Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.

Which of these statements indicate the effect of breastfeeding on the family or society at large. (Select all that apply.)

Breastfeeding requires fewer supplies and less cumbersome equipment. Breastfeeding saves families money Breastfeeding benefits the environment. Breastfeeding results in reduced annual health care costs.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?

Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.

A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who:

Has at least six to eight wet diapers per day

The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. This intervention:

Helps infants to interact directly with their parents and enhances their temperature regulation.

The nurse is caring for a preterm infant who needs to have gavage feedings started and requires the insertion of a nasogastric (NG) tube. Place in correct order the steps for insertion of a nasogastric tube in a preterm infant.

Lubricate the tip of the tube with sterile water. Place infant in supine position. Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus. Check placement of the NG tube by aspirating gastric contents. Gently insert the NG tube through the mouth or nose.

The nurse is caring for an infant who is suspected to have neonatal sepsis. Which neonatal risk factor for an infant with suspected neonatal sepsis would the nurse expect to observe?

Multiple gestation and low birth weight

The process whereby parents awaken the infant to feed every 3 hours during the day and at least every 4 hours at night is:

Necessary during the first 24 to 48 hours after birth

The newborn's nurse should alert the health care provider when which newborn reflex assessment findings are seen? (Select all that apply.)

Newborn turns head toward stimulus when eliciting rooting reflex.

Antidepressant medication is the mainstay treatment for maternal depression, with selective serotonin reuptake inhibitors (SSRIs) being the first line of pharmacotherapy. Reports of cardiac defects have been associated with the use of which SSRI?

Paroxetine

As part of their teaching function at discharge, nurses should tell parents that the baby's respiratory status should be protected by the following procedures: (Select all that apply.)

Prevent exposure to people with upper respiratory tract infections Keep the infant away from secondhand smoke Avoid loose bedding, waterbeds, and beanbag chairs Keep a bulb suction available at home

An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise?

Slow, small, warm bolus feedings over 30 minutes

The nurse should include which instructions when teaching a mother about the storage of breast milk? (Select all that apply.)

Wash hands before expressing breast milk. Milk thawed in the refrigerator can be stored for 24 hours.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include

abdominal distention, temperature instability, and grossly bloody stools.

In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that:

alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.

An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver:

alerts the physician that the infant has a dislocated hip.

With regard to the long-term consequences of infant feeding practices, the nurse should instruct the obese client that the best strategy to decrease the risk for childhood obesity for her infant is:

breastfeeding

The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should:

cleanse eyes from inner to outer canthus before administration.

which of the following is a pregnancy outside of the uterus

ectopic pregnancy

The birth weight of a breastfed newborn was 8 lbs, 4 oz. On the third day the newborn's weight was 7 lbs, 12 oz. On the basis of this finding, the nurse should:

encourage the mother to continue breastfeeding since it is effective in meeting the newborn's nutrient and fluid needs.

Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. The nurse should tell the parents to:

expect a yellowish exudate to cover the glans after the first 24 hours.

With regard to hemolytic diseases of the newborn, nurses should be aware that:

he indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.

With regard to the classification of neonatal bacterial infection, nurses should be aware that:

health care-associated infection can be prevented by effective handwashing; early onset cannot.

An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of:

hypoglycemia.

A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action is to:

listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.

When planning care for an infant with a fractured clavicle, the nurse should recognize that, in addition to gentle handling

no special treatment is necessary.

which of the following terms means "before birth" with reference to the newborn

prenatal

When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, the nurse should:

prewarm the radiant heat warmer and place the undressed newborn under it

the suffix -rrhexis means

rupture

Which of the following is a congenital defect of the vertebral column

spina bifida

A newborn male, estimated to be 39 weeks of gestation, would exhibit:

testes descended into scrotum.

By knowing about variations in infants' blood count, nurses can explain to their clients that:

the early high white blood cell (WBC) count is normal at birth and should decrease rapidly

With regard to umbilical cord care, nurses should be aware that:

the stump can easily become infected.

A newborn is placed under a radiant heat warmer. The nurse knows that thermoregulation presents a problem for newborns because:

they have a relatively thin layer of subcutaneous fat that provides poor insulation.

Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to:

use a rear-facing car seat

Congenital heart defects (CHDs) are anatomic abnormalities in the heart that are present at birth, although they may not be diagnosed immediately. The most common type of CHD is:

ventricular septal defect (VSD).

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is:

vision

An episiotomy is an incision into the

vulva

The nurse taught new parents the guidelines to follow regarding the bottle-feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse's instructions if they:

wash the top of the can and can opener with soap and water before opening the can.

When weighing a newborn, the nurse should:

weigh the newborn at the same time each day for accuracy.

In helping the breastfeeding mother position the baby, nurses should keep in mind that:

whatever the position used, the infant is "belly to belly" with the mother