Maternity Nclex questions
The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot when evaluating which reflex? A) Babinski B) Tonic neck C) Stepping D) Plantar grasp
A The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The tonic neck reflex is tested by having the newborn lie on his back and then turn his head to one side. The stepping reflex is elicited by holding the newborn upright and inclined forward with the soles of the feet on a flat surface. The plantar grasp reflex is elicited by placing a finger against the area just below the newborn's toes.
The nurse is reviewing four prenatal charts. Which client would be an appropriate candidate for a contraction stress test (CST)? a)A client with intrauterine growth retardation b)A client with multiple gestation c)A client with an incompetent cervix d)A client with placenta previa
A A contraction stress test (CST) is indicated for a client with intrauterine growth retardation (IUGR), because it will assess the respiratory function of the placenta, which may be adversely affected by the conditions causing IUGR. The CST is contraindicated in third-trimester bleeding from placenta previa or marginal abruptio placentae, previous cesarean with classical incision (vertical incision in the fundus of the uterus), premature rupture of the membranes, incompetent cervix, anomalies of the maternal reproductive organs, history of preterm labor (if being done prior to term), or multiple gestation.
Understanding the transition from intrauterine to extrauterine life, what intervention is most appropriate when working with an infant of a diabetic mother? a)Frequent blood glucose checks b)Obtain lab work to look for infection. c)Administer IV fluids. d)Place under radiant warmer bed immediately.
A Lab work, IV fluids, and the radiant warmer bed may all be required for interventions for the infant of a diabetic mother, if the infant is experiencing signs of respiratory distress or sepsis. Frequent blood glucose checks need to be completed to ensure that blood glucose levels are being maintained.
When counseling a mother about the immunologic properties of breast milk, the nurse would emphasize breast milk as a major source of which immunoglobulin? A) IgA B) IgG C) IgM D) IgE
A A major source of IgA is human breast milk. IgG, found in serum and interstitial fluid, crosses the placenta beginning at approximately 20 to 22 weeks' gestation. IgM is found in blood and lymph fluid and levels are generally low at birth unless there is a congenital intrauterine infection. IgE is not found in breast milk and does not play a major role in defense in the newborn.
After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation? A) Dry the newborn thoroughly. B) Put a hat on the newborn's head. C) Check the newborn's temperature. D) Wrap the newborn in a blanket.
A Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.
A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following? A) Normal progression of behavior B) Probable hypoglycemia C) Physiological abnormality D) Inadequate oxygenation
A From 30 to 120 minutes of age, the newborn enters the second stage of transition, that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.
An LGA newborn has a blood glucose level of 23 mg/dL. Which of the following would the nurse do next? A) Administer intravenous glucose immediately. B) Feed the newborn 2 ounces of formula. C) Initiate blow-by oxygen therapy. D) Place the newborn under a radiant warmer.
A If an LGA newborn's blood glucose level is below 25 mg/dL, the nurse should institute immediate treatment with intravenous glucose regardless of the clinical symptoms. Oral feedings would be used to maintain the newborn's glucose level above 40 mg/dL. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress.
When describing the neurologic development of a newborn to his parents, the nurse would explain that it occurs in which fashion? A) Head-to-toe B) Lateral-to-medial C) Outward-to-inward D) Distal-caudal
A Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center to outside) pattern.
While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen level and duration closely based on the understanding that the newborn is at risk for which of the following? A) Retinopathy of prematurity B) Metabolic acidosis C) Infection D) Cold stress
A Oxygen therapy has been implicated in the pathogenesis of retinopathy of prematurity (ROP). Therefore, the nurse monitors the newborn's oxygen therapy closely. Metabolic acidosis may occur due to anaerobic metabolism used for heat production. Infection may occur for numerous reasons, but they are unrelated to oxygen therapy. Cold stress results from problems due to the preterm newborn's inadequate supply of brown fat, decreased muscle tone, and large body surface area.
Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as: A) A good time to initiate breast-feeding B) The period of decreased responsiveness preceding sleep C) The need to be alert for gagging and vomiting D) Evidence that the newborn is becoming chilled
A The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breast-feeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. There is no indication that the newborn may experience gagging or vomiting. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.
When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8 degrees F, an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes highest priority? A) Hypothermia related to heat loss during birthing process B) Impaired parenting related to addition of new family member C) Risk for deficient fluid volume related to insensible fluid loss D) Risk for infection related to transition to extrauterine environment
A The newborn's heart rate is slightly below the accepted range of 120 to 160 beats/minute; the respiratory rate is at the high end of the accepted range of 30 to 60 breaths per minute. However, the newborn's temperature is significantly below the accepted range of 97.7 to 99.7 degrees F. Therefore, the priority nursing diagnosis is hypothermia. There is no information to suggest impaired parenting. Additional information is needed to determine if there is a risk for deficient fluid volume or a risk for infection.
Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A) How many hours old is this newborn? B) How long ago did this newborn eat? C) What was the newborn's birthweight? D) Is acrocyanosis present?
A The typical heart rate of a newborn ranges from 120 to 160 beats per minute with wide fluctuation during activity and sleep. Typically heart rate is assessed every 30 minutes until stable for 2 hours after birth. The time of the newborn's last feeding and his birthweight would have no effect on his heart rate. Acrocyanosis is a common normal finding in newborns.
Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess? A) Respiratory rate 45, irregular B) Costal breathing pattern C) Nasal flaring, rate 65 D) Crackles on auscultation
A Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and crackles suggest a problem.
When planning the care for a SGA newborn, which action would the nurse determine as a priority? A) Preventing hypoglycemia with early feedings B) Observing for respiratory distress syndrome C) Promoting bonding between the parents and the newborn D) Monitoring vital signs every 2 hours
A With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for respiratory distress, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn.
A nurse is teaching a group of student nurses about amniotic fluid. Which of the following statements by the student nurse reflects an understanding of the fetus's contribution to the quality of amniotic fluid? Select all that apply. a) "The fetus contributes to the volume of amniotic fluid by excreting urine." b) "Approximately 400 mL of amniotic fluid flows out of the fetal lungs each day." c) "The fetus swallows about 600 mL of the fluid in 24 hours." d) "A fetus can move freely and develop normally, even if there is no amniotic fluid."
A, B, C "The fetus contributes to the volume of amniotic fluid by excreting urine." Approximately 400 mL of amniotic fluid flows out of the fetal lungs each day. The fetus swallows about 600 mL of the fluid in 24 hours. A normal volume of amniotic fluid is necessary for good fetal movement. Normal movement is necessary for good musculoskeletal development.
A pregnant client asks why ultrasound is used so frequently during pregnancy. The nurse's response is based on her knowledge that the advantages of ultrasound include which of the following? Select all that apply. a)"It is noninvasive and painless." b)"It can be used to estimate gestational age." c)"Results are immediate." d)"The ultrasound is the only test to determine gender."
A, B, C The ability to establish fetal age accurately by ultrasound is lost in the third trimester because fetal growth is not as uniform as it is in the first two trimesters; however, ultrasound can be used to approximate gestational age within 1-3 weeks' accuracy during the third trimester. A comprehensive ultrasound is used to detect anatomical defects, not gestational age. Ultrasound is not used to determine gender.
The nurse is teaching a prenatal client about chorionic villus sampling (CVS). The nurse correctly teaches the client that risks related to CVS include which of the following? Select all that apply. a)Intrauterine infection b)Rupture of membranes c)Maternal hypertension d)Spontaneous abortion
A, B, D Risks of CVS include failure to obtain tissue, rupture of membranes, leakage of amniotic fluid, bleeding, intrauterine infection, maternal tissue contamination of the specimen, and Rh alloimmunization. CVS testing has a higher rate of spontaneous abortion than amniocentesis. Other complications include fetal limb defects and abnormalities of the fetal face and jaw.
A nurse is teaching a group of first-trimester prenatal clients about the discomforts of pregnancy. A client asks the nurse, "What causes my nausea and vomiting?" The nurse responds indicating which of the following as being contributing factors to first-trimester emesis? Select all that apply. a) Human chorionic gonadotropin b) Estrogen c) Alterations in carbohydrate metabolism d) Prostaglandins
A, C Nausea and vomiting are common during the first trimester because of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. Estrogen stimulates the growth of the uterus and breast tissue. Prostaglandins stimulate uterine contractions.
A prenatal client at 22 weeks gestation is scheduled for an amniocentesis. Which nursing action would apply to any client undergoing this procedure? Select all that apply. a)Assess for bleeding. b)Administer Rh immune globulin to the client. c)Cleanse skin with alcohol. d)Assess vital signs and fetal heart rate.
A, D The skin is cleaned with a betadine solution. The use of a local anesthesia at the needle insertion site is optional. A 22-gauge needle is then inserted into the uterine cavity and amniotic fluid is withdrawn. After 15-20 mL of fluid has been removed, the needle is withdrawn and the site is assessed for streaming (movement of fluid), which is an indication of bleeding. The fetal heart rate and maternal vital signs are then assessed. Rh immune globulin is given only to all Rh-negative women.
What factors influence the outcomes of the at-risk newborn? Select all that apply. a)Birth weight b)Gestational age c)Type and length of newborn illness d)Environmental factors e)Maternal factors
All are correct. Maternal factors such as age and parity, newborn weight, and gestational age also influence outcomes, as do environmental factors such as exposure to environmental dangers (toxic chemicals and illicit drugs). Evaluation; Physiological Integrity; Analysis
At 17 weeks pregnant, a mother asks the nurse questions about the development of her baby. The mother states that it may be too early to visualize any body structures via ultrasound. The nurse's best response in relation to fetal development at 17 weeks is: a) Myelination of the spinal cord has occurred. b) Differentiation of hard and soft palate can be seen. c) The earlobes are soft with little cartilage. d) Hard tissue (enamel) for teeth has developed.
B Differentiation of hard and soft palate are structures developed by 16 weeks gestation. Myelination of the spinal cord begins at 20 weeks gestation. Soft earlobes with little cartilage develop at 36 weeks gestation. Teeth form hard tissue (enamel) at 18 weeks gestation.
A pregnant client is concerned about a blow to the abdomen if she continues to play basketball during her pregnancy. The nurse's response is based upon her knowledge of which of the following facts concerning amniotic fluid? a) The total amount of amniotic fluid during pregnancy is 300 mL. b) Amniotic fluid functions as a cushion to protect against mechanical injury. c) The fetus does not contribute to the production of amniotic fluid. d) Amniotic fluid is slightly acidic.
B During pregnancy, the amniotic fluid protects against injury. After 20 weeks of pregnancy, fluid volume ranges from 700-1000 mL. Some of the amniotic fluid is contributed by the fetus's excreting urine. Amniotic fluid is slightly alkaline.
Identify a complication of the small-for-gestational-age newborn. a)Hyperglycemia b)Cognitive difficulties c)Leukocytosis d)Hyperthermia
B SGA newborns often subsequently exhibit learning disabilities. The disabilities are characterized by hyperactivity, short attention span, and poor fine motor coordination. Some hearing loss and speech defects also occur. The SGA newborn does not exhibit symptoms of high blood sugars, increased temperatures, and high white blood cell counts.
The preterm newborn is experiencing vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea. What is the best explanation for these symptoms? a)Traumatic birth b)Maternal substance abuse c)Sepsis d)Gestational diabetes
B The severity of withdrawal that an infant experiences can be assessed by using a scoring system such as the Finnegan scale. This scale is based on observations and measurement of the responses to neonatal abstinence from substances. It evaluates the infant on potentially life-threatening signs such as vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea.
Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when Ortolani's maneuver is performed. Which of the following would the nurse suspect? A) Slipping of the periosteal joint B) Developmental hip dysplasia C) Normal newborn variation D) Overriding of the pelvic bone
B A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the area. This, along with uneven gluteal creases, suggests developmental hip dysplasia. These findings are not a normal variation and are not associated with slipping of the periosteal joint or overriding of the pelvic bone.
A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? A) "You are lucky to have given birth to a term newborn." B) "We still need to monitor him closely for problems." C) "How do you feel about delivering your baby at 36 weeks?" D) "Your baby is premature and needs monitoring in the NICU."
B A baby born at 36 weeks' gestation is considered a late-preterm newborn. These newborns face similar challenges as those of preterm newborns and require similar care. Telling the mother that close monitoring is necessary can prevent any misconceptions that she might have and prepare her for what might arise. The baby is not considered a term newborn, nor is the baby considered premature. The decision for care in the NICU would depend on the newborn's status. Asking the woman how she feels about the delivery demonstrates caring but does not address the woman's lack of understanding about her newborn.
Just after delivery, a newborn's axillary temperature is 94 degrees F. What action would be most appropriate? A) Assess the newborn's gestational age. B) Rewarm the newborn gradually. C) Observe the newborn every hour. D) Notify the physician if the temperature goes lower.
B A newborn's temperature is typically maintained at 36.5 to 37.5 degrees C (97.7 to 99.7 degrees F). Since this newborn's temperature is significantly lower, the nurse should institute measures to rewarm the newborn gradually. Assessment of gestational age is completed regardless of the newborn's temperature. Observation would be inappropriate because lack of action may lead to a further lowering of the temperature. The nurse should notify the physician of the newborn's current temperature since it is outside normal parameters.
The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings by observing the newborn, which of the following actions would be most appropriate? A) Notify the health care provider immediately. B) Assess the newborn for signs of respiratory distress. C) Reassure the parents that this is an expected pattern. D) Tell the parents not to worry since his color is fine.
B Although periods of apnea of less than 20 seconds can occur, the nurse needs to gather additional information about the newborn's respiratory status to determine if this finding is indicative of a developing problem. Therefore, the nurse would need to assess for signs of respiratory distress. Once this information is obtained, then the nurse can notify the health care provider or explain that this finding is an expected one. However, it would be inappropriate to tell the parents not to worry, because additional information is needed. Also, telling them not to worry ignores their feelings and is not therapeutic.
The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which of the following would the nurse correlate with this gestational age variation? A) Strong, brisk motor skills B) Difficulty in arousing to a quiet alert state C) Birthweight of 7 lb 14 oz D) Wasted appearance of extremities
B LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb 13 oz at term.
Which of the following, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of a LGA newborn? A) Drug abuse B) Diabetes C) Preeclampsia D) Infection
B Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdates gestation, maternal obesity, male fetus, and genetics. Drug abuse is associated with SGA newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth.
A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate? A) "You probably took iron during your pregnancy." B) "This is meconium stool, normal for a newborn." C) "I'll take a sample and check it for possible bleeding." D) "This is unusual and I need to report this."
B Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.
During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: A) Milia B) Mongolian spots C) Stork bites D) Birth trauma
B Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Milia are unopened sebaceous glands frequently found on a newborn's nose. Stork bites are superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling, and possible deformity.
Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: A) Habituation B) Motor maturity C) Orientation D) Social behaviors
B Motor maturity is evidenced by rhythmic, spontaneous movements. Habituation is manifested by the newborn's ability to respond to the environment appropriately. Orientation involves the newborn's response to new stimuli, such as turning the head to a sound. Social behaviors involve cuddling and snuggling into the arms of a parent.
The nurse is teaching a group of students about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed? A) The newborn's skin and that of an adult are similar in thickness. B) The newborn's sweat glands function fully, just like those of an adult. C) Skin development in the newborn is not complete at birth. D) The newborn has fewer fibrils connecting the dermis and epidermis
B The newborn has sweat glands, like an adult, but full adult functioning is not present until the second or third year of life. The newborn and adult epidermis is similar in thickness and lipid composition, but skin development is not complete at birth. Fewer fibrils connect the dermis and epidermis in the newborn when compared with the adult.
When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because of which of the following? A) The newborn should not be sleeping on his back. B) Stuffed animals should not be in areas where infants sleep. C) The bulb syringe should not be kept in the bassinet. D) This newborn should be sleeping in a crib.
B The nurse should instruct the mother to remove all fluffy bedding, quilts, stuffed animals, and pillows from the crib to prevent suffocation. Newborns and infants should be placed on their backs to sleep. Having the bulb syringe nearby in the bassinet is appropriate. Although a crib is the safest sleeping location, a bassinet is appropriate initially.
After teaching a class about hepatic system adaptations after birth, the instructor determines that the teaching was successful when the class identifies which of the following as the process of changing bilirubin from a fat-soluble product to a water-soluble product? A) Hemolysis B) Conjugation C) Jaundice D) Hyperbilirubinemia
B The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is called conjugation. Hemolysis involves the breakdown of blood cells. In the newborn, hemolysis of the red blood cells is the principal source of bilirubin. Jaundice is the manifestation of increased bilirubin in the bloodstream. Hyperbilirubinemia refers to the increased level of bilirubin in the blood.
The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? A) Evaporation B) Conduction C) Convection D) Radiation
B Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.
Which of the following would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A) Avoid using the terms "death" or "dying." B) Provide opportunities for them to hold the newborn. C) Refrain from initiating conversations with the parents. D) Quickly refocus the parents to a more pleasant topic.
B When dealing with grieving parents, nurses should provide them with opportunities to hold the newborn if they desire. In addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn. These interventions help to validate the parents' sense of loss, relive the experience, and attach significance to the meaning of loss. The nurse should use appropriate terminology, such as "dying," "died," and "death," to help the parents accept the reality of the death. Nurses need to demonstrate empathy and to respect the parents' feelings, responding to them in helpful and supportive ways. Active listening and allowing the parents to vent their frustrations and anger help validate the parents' feelings and facilitate the grieving process.
A prenatal client at 30 weeks gestation is scheduled for a nonstress test (NST) and asks the nurse, "What is this test for?" The nurse correctly responds that the test is used to determine which of the following? Select all that apply. a)Fetal lung maturity b)Adequate fetal oxygenation c)Accelerations of fetal heart rate d)Fetal well-being
B, C, D An NST documents fetal well-being by measuring fetal oxygenation and fetal heart rate accelerations, but not fetal lung maturity.
A 28-week-gestation newborn experienced birth asphyxia at the time of delivery. What is a long-term complication of birth asphyxia? a)Necrotizing enterocolitis b)Retinopathy of prematurity c)Intraventricular hemorrhage d)Anemia of prematurity
C Birth asphyxia will cause an insult to the brain, and more often than not will cause a bleed or intraventricular hemorrhage. Birth asphyxia is not directly correlated with NEC, retinopathy of prematurity, or anemia of prematurity. These are common for the premature infant, but not necessarily birth asphyxia.
The physician orders an ultrasound for a prenatal client prior to an amniocentesis. The nurse explains to the client that the purpose of the ultrasound is to: a)Determine the gestational sac volume. b)Measure the fetus's crown-rump length. c)Locate the placenta. d)Measure the fetus's biparietal diameter.
C During an amniocentesis, the physician scans the uterus using ultrasound to identify the fetal and placental positions and to identify adequate pockets of amniotic fluid. Determination of the gestational sac volume, measuring the crown-rump length, and measuring the biparietal diameter are aspects of assessing fetal well-being (biophysical profile, or BPP), and may or may not be done prior to the amniocentesis, depending on gestational age.
A prenatal client at 35 weeks gestation is scheduled for an amniocentesis to determine fetal lung maturity. The nurse expects the lecithin/sphingomyelin (L/S) ratio to be: a)0.5:1 b)1:1 c)2:1 d)3:1
C Early in pregnancy, the sphingomyelin concentration in amniotic fluid is greater than the concentration of lecithin, and so the L/S ratio is low (lecithin levels are low and sphingomyelin levels are high). At about 32 weeks gestation, sphingomyelin levels begin to fall and the amount of lecithin begins to increase. By 35 weeks gestation, an L/S ratio of 2:1 (also reported as 2.0) is usually achieved in the normal fetus.
A client states that she had a spontaneous abortion 12 months ago. The client asks if her hormones may have contributed to the loss of the pregnancy. The nurse's response is based upon her knowledge of which of the following facts? a) Implantation occurs when progesterone levels are low. b) hCG reaches a maximum level at 4 weeks gestation. c) Progesterone decreases the contractility of the uterus. d) Progesterone is only produced by the corpus luteum during pregnancy.
C Progesterone decreases the contractility of the uterus, thus preventing uterine contractions that might cause spontaneous abortion. Progesterone must be present in high levels for implantation to occur. After 10 weeks, the placenta takes over the production of progesterone. hCG reaches its maximum level at 50-70 days gestation.
The nurse is preparing an educational workshop on fetal development. Which statement by the student would require the nurse to explain further? a) "True knots are usually associated with a cord that is too long." b) "The average cord length at term is 22 inches." c) "The umbilical cord normally contains two veins and one artery." d) "The high blood volume and Wharton's jelly content of the umbilical cord prevents compression of the cord."
C Umbilical cords appear twisted or spiraled. This is most likely caused by fetal movement. A true knot in the umbilical cord rarely occurs; if it does, the cord is usually long. More common are so-called false knots, caused by the folding of cord vessels. A nuchal cord is said to exist when the umbilical cord encircles the fetal neck. A normal umbilical cord contains one large vein and two smaller arteries. A specialized connective tissue known as Wharton's jelly surrounds the blood vessels in the umbilical cord. This tissue, plus the high blood volume pulsating through the vessels, prevents compression of the umbilical cord in utero.
When assessing a postterm newborn, which of the following would the nurse correlate with this gestational age variation? A) Moist, supple, plum skin appearance B) Abundant lanugo and vernix C) Thin umbilical cord D) Absence of sole creases
C A postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet.
The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which of the following? A) Inability to clear fluids B) Immature respiratory control center C) Deficiency of surfactant D) Smaller respiratory passages
C A preterm newborn is at increased risk for respiratory distress syndrome (RDS) because of a surfactant deficiency. Surfactant helps to keep the alveoli open and maintain lung expansion. With a deficiency, the alveoli collapse, predisposing the newborn to RDS. An inability to clear fluids can lead to transient tachypnea. Immature respiratory control centers lead to an increased risk for apnea. Smaller respiratory passages led to an increased risk for obstruction.
When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes? A) Gastrointestinal and hepatic B) Urinary and hematologic C) Respiratory and cardiovascular D) Neurological and integumentary
C Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.
When describing the complications that can occur in newborns to a group of pregnant women, which would the nurse include as being at lowest risk? A) Small-for-gestational-age newborns B) Large-for-gestational-age newborns C) Appropriate-for-gestational-age newborns D) Low-birthweight newborns
C Appropriate-for-gestational-age newborns are at the lowest risk for any problems. The other categories all have an increased risk of complications.
The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? A) To aid in maturing the newborn's sucking reflex B) To encourage the development of maternal antibodies C) To facilitate maternal-infant bonding D) To enhance the clearing of the newborn's respiratory passages
C Breast-feeding can be initiated immediately after birth. This immediate mother-newborn contact takes advantage of the newborn's natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn's temperature, blood glucose level, and respiratory rate. It is not associated with maturing the sucking reflex, encouraging the development of maternal antibodies, or aiding in clearing of the newborn's respiratory passages.
While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: A) Molding B) Microcephaly C) Caput succedaneum D) Cephalhematoma
C Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of the skull.
The nurse assesses a 1-day-old newborn. Which finding indicates that the newborn's oxygen needs aren't being met? A) Respiratory rate of 54 breaths/minute B) Abdominal breathing C) Nasal flaring D) Acrocyanosis
C Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.
The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation and intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A) Suggest that the parents stay for just a few minutes to reduce their anxiety. B) Reassure them that their newborn is progressing well. C) Encourage the parents to touch their preterm newborn. D) Discuss the care they will be giving the newborn upon discharge.
C The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated.
A client at 28 weeks gestation is admitted to the labor and birth unit. Which test would most likely be used to assess the client's comprehensive fetal status? a) Ultrasound for physical structure b) Nonstress test (NST) c) Biophysical profile (BPP) d) Amniocentesis
C. Biophysical profile is a comprehensive test that would be used to assess the client's fetal status at 28 weeks gestation. Ultrasound for physical structure is limited to identifying the growth and development of the fetus, and does not assess for other parameters of fetal well-being. Women with a high-risk factor will probably begin having NSTs at 30-32 weeks gestation and at frequent intervals for the remainder of the pregnancy. Amniocentesis late in pregnancy is used to test for lung maturity, not overall fetal status in labor, and when performed earlier it is used to test for specific disorders.
The nurse is preparing a prenatal client for a transvaginal ultrasound. What nursing action should the nurse include in the preparations? Select all that apply. a)Advise the client to empty her bladder. b)Encourage the client to drink 1.5 quarts of fluid. c)Apply transmission gel over the client's abdomen. d)Place client in lithotomy position.
D After having the client void, assist her to a lithotomy position for a transvaginal ultrasound. Preparation for a transabdominal ultrasound includes encouraging the client to drink 1.5 quarts of fluid, maintaining a full bladder, and applying transmission gel over the client's abdomen.
What is the best intervention a nurse can utilize to promote parent-infant attachment? a)Allow for privacy. b)Contact support families that have been through the same diagnosis with their own child and allow time to discuss the situation. c)Provide an extensive handbook with information related to the preterm newborn. d)Encourage rooming in.
D All will help strengthen the attachment bond, but the best answer would be to encourage rooming in. Rooming in can provide a great opportunity for the stable preterm infant and family to get acquainted; it offers both privacy and readily available help.
The nurse in the prenatal clinic assesses a 26-year-old client at 13 weeks gestation. Which presumptive (subjective) signs and symptoms of pregnancy should the nurse anticipate? a) Hegar's sign and quickening b) Ballottement and positive pregnancy test c) Chadwick's sign and uterine souffle d) Excessive fatigue and urinary frequency
D Excessive fatigue and urinary frequency both are presumptive (subjective) signs and symptoms of pregnancy. Hegar's sign, ballottement, a positive pregnancy test, Chadwick's sign, and uterine souffle are probable (objective) signs or symptoms of pregnancy.
The nurse is taking an initial history of a prenatal client. Which of the following, if detected by the nurse practitioner, would indicate a positive, or diagnostic sign of pregnancy? a) Positive pregnancy test b) Goodell's sign c) Uterine enlargement and amenorrhea d) Fetal heartbeat with at Doppler at 11 weeks gestation
D The positive signs of pregnancy are completely objective, cannot be confused with a pathologic state, and offer conclusive proof of pregnancy. The fetal heartbeat can be detected with an electronic Doppler device as early as weeks 10-12 of pregnancy. Pregnancy tests detect the presence of hCG in the maternal blood or urine. These are not considered a positive sign of pregnancy because other conditions can cause elevated hCG levels. Physical changes, like Godell's sign and uterine enlargement, can also have other causes and do not confirm pregnancy. The subjective changes of pregnancy, like amenorrhea, are the symptoms the woman experiences and reports. Because they can be caused by other conditions, they cannot be considered proof of pregnancy.
When performing newborn resuscitation, which action would the nurse do first? A) Intubate with an appropriate-sized endotracheal tube. B) Give chest compressions at a rate of 80 times per minute. C) Administer epinephrine intravenously. D) Suction the mouth and then the nose.
D After placing the newborn's head in a neutral position, the nurse would suction the mouth and then the nose. This is followed by ventilation, circulation (chest compressions), and administration of epinephrine.
The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal? A) Prevent cold stress B) Increase surfactant levels in the lungs C) Promote respiratory stability D) Decrease the serum bilirubin level
D Jaundice reflects elevated serum bilirubin levels; phototherapy helps to break down the bilirubin for excretion. Phototherapy has no effect on body temperature, surfactant levels, or respiratory stability.
The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: A) Have a smaller body surface compared to body mass B) Lose more body heat when they sweat than adults C) Have an abundant amount of subcutaneous fat all over D) Are unable to shiver effectively to increase heat production
D Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.
The nurse is teaching a group of students about the differences between a full-term newborn and a preterm newborn. The nurse determines that the teaching is effective when the students state that the preterm newborn has: A) Fewer visible blood vessels through the skin B) More subcutaneous fat in the neck and abdomen C) Well-developed flexor muscles in the extremities D) Greater surface area in proportion to weight
D Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone.
Which of the following would alert the nurse to the possibility of respiratory distress in a newborn? A) Symmetrical chest movements B) Periodic breathing C) Respirations of 40 breaths/minute D) Sternal retractions
D Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life.
A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds based on the understanding that this most likely is due to which of the following? A) Placing the newborn prone after feeding B) Limited ability of digestive enzymes C) Underdeveloped pyloric sphincter D) Relaxed cardiac sphincter
D The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in their ability to digest complex carbohydrates and fats; this results in fatty stools, not regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric contents.
Which of the following would alert the nurse to suspect that a preterm newborn is in pain? A) Bradycardia B) Oxygen saturation level of 94% C) Decreased muscle tone D) Sudden high-pitched cry
D The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone.
While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first? A) Alert the physician stat and turn the newborn to her right side. B) Administer oxygen via facial mask by positive pressure. C) Lower the newborn's head to stimulate crying. D) Aspirate the oral and nasal pharynx with a bulb syringe.
D The nurse's first action would be to suction the oral and nasal pharynx with a bulb syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the blockage due to secretions. Administering oxygen via positive pressure is not indicated at this time. Lowering the newborn's head would be inappropriate.
When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature? A) Hearing B) Touch C) Taste D) Vision
D Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.
The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales? A) Stop Rh sensitization B) Increase erythopoiesis C) Enhance bilirubin breakdown D) Promote blood clotting
D Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the liver. RhoGAM prevents Rh sensitization. Erythropoietin stimulates erythropoiesis. Phototherapy enhances bilirubin breakdown.
A prenatal client in her second trimester is admitted to the maternity unit with painless, bright red vaginal bleeding. What test might the physician order? a)Alpha-fetoprotein (AFP) b)Contraction stress test (CST) c)Amniocentesis d)Ultrasound
D. An ultrasound for placenta location to rule out placenta previa would be ordered for a client who presents with painless, bright red vaginal bleeding. The ability to see the lower portion of the uterus and cervix with ultrasound is particularly important when vaginal bleeding is noted and placenta previa is the suspected cause. Alpha-fetoprotein (AFP) is a test used to screen for neural tube defects. A contraction stress test is ordered in the third trimester to evaluate the respiratory function of the placenta. Amniocentesis is a procedure used for genetic diagnosis or, in later pregnancy, for lung maturity studies.
