Maternity Test 1 (Modules 1 & 4)
All of the following are signs of respiratory distress in the newborn EXCEPT a) Central cyanosis b) Chest retractions c) Coughing and a respiratory rate above 50 d) Grunting e) Nasal flaring
C-Coughing and a respiratory rate above 50 is good sign, the remainder indicate distress Coughing and sneezing are normal reflexes present in newborns. The expected respiratory rate of newborn is 30 to 60 breaths per minute.
A 14-year-old has delivered and *the newborn needs to have surgery*. Who has the right to give consent for the surgery?
The 14-year-old, since she is the legal mother of the newborn
What are LDR's? What are LDRP's?
What are LDR's? LDR's: Labor, delivery, recovery rooms What are LDRP's? The labor/delivery/recovery/postpartum room setting The room where the mother is with the primary support person and is encouraged to stay until discharge*allows increased parent-infant contact.*
Which of the following would be most effective in reducing pain in the preterm newborn? Select all that apply. a) Removing tape quickly from the skin b) Swaddling the newborn closely c) Offering a pacifier prior to a procedure d) Encouraging kangaroo care during procedures e) Increasing the volume on device alarms f) Using cool blankets to soothe the newborn
b-Swaddling the newborn closely d-Encouraging kangaroo care during procedures c-Offering a pacifier prior to a procedure Explanation: Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation.
A newborn is passing greenish-black stool of tarry consistency. The nursing student correctly identifies this type of stool as which of the following? a) stool of a formula-fed newborn b) meconium stool c) stool of a breast-fed newborn d) transitional stool
meconium stool: Meconium is a newborn's first stool. It is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. Breast-fed newborns will pass stools that are yellow-gold, loose, and stringy to pasty in consistency. A formula-fed newborn will have stools that are yellow, yellow-greeen, or greenish and loose, pasty, or formed in consistency based upon the type of formula.
When assessing infant reflexes the nurse documents a startled response and extension of the arms and legs as which reflex? a) Rooting b) Moro c) Tonic neck d) Fencing
*The moro reflex is also known as the startle reflex* When the infant is startled they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.
A preterm infant born at 33 weeks of gestation is placed in an incubator because:
-preterm infant is at risk for heat loss, the heat-regulating center in the brain is immature. Newborns have very little subcutaneous fat, which offers little insulation against cold. Newborns have ineffective sweat glands and cannot cool themselves through evaporation.
Types of Hyperbilirubinemia
1) Physiologic jaundice (> 24 hr) 2) Breastmilk jaundice (Caused by poor milk intake; onset 2-3 days, peak 2-3 days; treated by frequent breastfeeding, caloric supplements) 3) Breastmilk jaundice (late onset 4-5 days) 4) Pathologic jaundice (hemolytic anemia)- caused by blood antigen incompatibility; onset first 24 hours; peak variable; treated by phototherapy, exchange transfusions
The ways heat is lost from a neonate
1. CONDUCTION to a cold object 2.CONVECTION from warm baby to cool air/liquid 3. RADIATION from warm baby to cold object 4. EVAPORATION from a wet baby *be sure to dry baby after bath to avoid heat loss through evaporation*
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? 1. Remove wet blankets. 2. Assess Apgar score. 3. Insert eye prophylaxis. 4. Elicit the Moro reflex.
1. When newborns are wet they can become hypothermic from heat loss resulting from evaporation. They may then develop cold stress syndrome.
While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? 1. Activate the code blue or emergency system. 2. Do nothing because acrocyanosis is normal in the neonate 3. Immediately take the newborn's temperature according to hospital policy 4. Notify the physician of the need for a cardiac consult
2. Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.
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 in order to prevent heat loss resulting from which of the following? 1. Evaporation. 2. Conduction. 3. Radiation. 4. Convection.
2. Heat loss resulting from conduction occurs when the baby comes in contact with cold objects (hands or stethoscope).
The pediatrician writes the following order for a term newborn: Vitamin K 1 mg IM. Which of the following responses provides a rationale for this order? 1. During the neonatal period... babies absorb fat-soluble vitamins poorly. 2. Breast milk and formula contain insufficient quantities of vitamin K. 3. The neonatal gut is sterile. 4. Vitamin K prevents hemolytic jaundice.
3. It takes about 1 week for the baby to be able to synthesize his or her own vitamin K. The gut, at birth, is sterile.
Four newborns are in the neonatal nursery. Which of the babies should the nurse report to the neonatalogist? 1. 16-hour-old baby who has yet to pass meconium. 2. 16-hour-old baby whose blood glucose is 50 mg/dL. 3. 2-day-old baby who is breathing irregularly at 70 breaths per minute. 4. 2-day-old baby who is excreting a milky discharge from both nipples.
3. Normal neonatal breathing is irregular at 30 to 60 breaths per minute. This baby is tachypneic.
A client has just given birth at 42 weeks' gestation. When assessing the neonate, which physical finding is expected? 1. A sleepy, lethargic baby 2. Lanugo covering the body 3. Peeling and cracking of the skin 4. Vernix caseosa covering the body
3. Peeling, cracking, dryness, and a few visible veins in the skin are expected findings in postdate fetuses. Postdate fetuses lose the vernix caseosa which is the protective coating so the skin may be peeling, cracking, & dry. These neonates are usually very alert. Lanugo (hairyness) is missing in the postdate neonate.
The nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions the nurse compressses at least how many times? 1. 60 times per minute 2. 80 times per minute 3. 100 times per minute 4. 160 times per minute
3. Rationale-In an infant, the rate of chest compressions is at least 100 times per minute.
The nurse notes that a newborn... who is 5 minutes old... exhibits the following characteristics: heart rate 108 bpm... respiratory rate 29 rpm with lusty cry... pink body with bluish hands and feet... some flexion. What does the nurse determine the baby's Apgar score is? 1. 6 2. 7 3. 8 4. 9
3. The baby's Apgar is 8.
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? 1. Place child in isolette. 2. Administer oxygen. 3. Swaddle baby in blanket. 4. Apply pulse oximeter.
3. The baby's extremities are cyanotic as a result of the baby's immature circulatory system. Swaddling helps to warm the baby's hands and feet. Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.
A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: 1. "You infant needs vitamin K to develop immunity." 2. "The vitamin K will protect your infant from being jaundiced." 3. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." 4. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."
3. Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant's bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion.
When performing nursing care for a neonate after a birth, which intervention has the highest nursing priority? 1. Obtain a dextrostix 2. Give the initial bath 3. Give the vitamin K injection 4. Cover the neonates head with a cap
4. Covering the neonates head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate's wet head. Vitamin K can be given up to 4 hours after birth
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? 1. Molding of the baby's skull so that the baby could fit through her pelvis. 2. Swelling of the tissues of the baby's head from the pressure of her pushing. 3. The position that the baby took in her pelvis during the last trimester of her pregnancy. 4. Small blood vessels that broke under the baby's scalp during birth.
4. Small blood vessels that broke under the baby's scalp during birth. Cephalhematomas 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
A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? 1. Lanugo 2. Milia 3. Nevus flammeus 4. Vernix caseous
4. Vernix caseous
A newborn has a strong cry and is actively moving his blue extremities when stimulated. Vital signs are P140, R48. What is his APGAR score?
6
A neonatal patient has a pink color, a pulse rate of 102, and a respiration rate of 27. She grimaces in response to stimuli, has limited muscle movement. This patient has an APGAR score of?
7
The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? a. Flexed posture b. Abundant lanugo c. Smooth, pink skin with visible veins d. Faint red marks on the soles of the feet
A Term infants typically have a flexed posture. (Abundant lanugo usually is seen on preterm infants. Smooth, pink skin with visible veins seen on preterm infants. Faint red marks usually are seen on preterm infants.)
Which statement is true about 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 multivitamin supplements be given to the infant
ANS: A Feedback A Exposure to cow's milk poses a risk of developing allergies, eczema, and asthma. B This is a false statement. Newborns should be fed during the night regardless of feeding method. C Iron is better absorbed from breast milk than from formula. D Commercial formulas are designed to meet the nutritional needs of the infant and to resemble breast milk. No supplements are necessary.
The nurse assessing the fundus of the uterus immediately after delivery would expect to find the uterus: a. Well-contracted with its upper border at or just below the umbilicus b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus c. Relaxed with its upper border level with the umbilicus d. Relaxed with its upper border two or three fingerbreadths below the umbilicus
ANS: A Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus.
The nurse explains that the physician will order RhoGAM in the event that a/an: a. Unsensitized Rh-negative mother has an Rh-positive pregnancy. b. Rh-negative mother becomes sensitized. c. Sensitized infant has a rising bilirubin level. d. Unsensitized infant exhibits no outward signs.
ANS: A The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-positive infant.
Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cures indicating pain, measures should be taken to manage the infant's pain. Examples of nonpharmacologic pain management techniques include (select all that apply) a. Swaddling b. Nonnutritive sucking (pacifier) c. Skin-to-skin contact with the mother d. Sucrose e. Acetaminophen
ANS: A, B, C, D These interventions are all appropriate nonpharmacologic techniques used to manage pain in neonates. Other interventions include soothing music, dim lighting and speaking to the infant in a quiet voice. *note: sucrose is NOT medication* Incorrect: Acetaminophen is a pharmacologic method of treating pain.
Many communities now offer the availability of free-standing birth centers to provide care for low-risk women during pregnancy, birth, and postpartum. When counseling the newly pregnant woman regarding this option, the nurse should be aware that this type of care setting includes which advantages? Select all that apply. a. Less expensive than acute-care hospitals b. Access to follow-up care for 6 weeks postpartum c. Equipped for obstetric emergencies d. Safe, home-like births in a familiar setting e. Staffing by lay midwives
ANS: A, B, D Correct: A, B, D. Women who are at low risk and desire a safe, home-like birth are very satisfied with this type of care setting. The new mother may return to the birth center for postpartum follow-up care, breastfeeding assistance, and family planning information for 6 weeks postpartum. Since birth centers do not incorporate advanced technologies into their services, costs are significantly less than a hospital setting. Incorrect: C, E. The major disadvantage of this care setting is that these facilities are not equipped to handle obstetric emergencies. Should unforeseen difficulties occur, the woman must be transported by ambulance to the nearest hospital. Birth centers are usually staffed by certified nurse-midwives (CNMs); however, in some states lay midwives may provide this service.
The nurse discusses safety-proofing the home with the mother of a 9-month-old. The statement made by the mother that indicates an unsafe behavior is: a. "I put covers on all of the electrical outlets." b. "In the car, she rides in a front-facing car seat." c. "There are locks on all of the cabinets in the house." d. "I have a gate at the top and bottom of the stairs."
ANS: B A rear-facing infant car seat should be used for infants under 1 year of age.
The certified nurse-midwife (CNM) clarifies to the pregnant patient that the CNM's scope of practice includes: a. Practice independent from medical supervision b. Comprehensive prenatal care c. Attendance at all deliveries d. Simple surgical techniques
ANS: B The CMN provides comprehensive prenatal and postnatal care and attends uncomplicated deliveries and assures a back-up physician in case of unforeseen problems. *The nurse-midwife is qualified to deliver infants vaginally in uncomplicated pregnancies.*
When assessing a newborn, the nurse observes nasal flaring, sternal retractions, and expiratory grunting. These findings are indicative of: a. Cold stress b. Postmaturity syndrome c. Apneic episode d.Respiratory distress syndrome
ANS: D Insufficient amounts of surfactant predispose the preterm infant to respiratory distress. The signs manifested by the infant are indicative of respiratory distress.
The mother of a 4-day-old calls the pediatrician's office because she is concerned about her baby's skin. The finding that needs to be reported promptly to the child's pediatrician is: a. The hands and feet feel cooler than the rest of the body. b. Skin is peeling on several parts of the baby's body. c. There is a small pink patch on the left eyelid and one on the neck. d. Today, the baby's skin has a yellowish tinge.
ANS: D *Physiologic jaundice > 24 hr Caused by immature hepatic function* Physiological jaundice becomes evident between the second and third days of life and lasts for about 1 week. Evidence of jaundice is reported and the newborn is evaluated.
To prevent the abduction of newborns from the hospital, the nurse should: a. Instruct the mother not to give her infant to anyone except the one nurse assigned to her that day. b. Apply an electronic and identification bracelet to mother and infant. c. Carry the infant when transporting him or her in the halls. d. Restrict the amount of time infants are out of the nursery.
B -A measure taken by many facilities is to band both the mother and the baby with matching identification bracelets and band the infant with an electronic device that will alarm if the infant is removed from the maternity unit. *Always question anyone walking in the hall with a baby (prevents kidnapping)* Infants should always be transported in their bassinet, for both safety and security reasons. Infants should remain with their parents and spend as little time in the nursery as possible.
The nurse's initial action when caring for an infant with a slightly decreased temperature is to: a. Notify the physician immediately. b. Place a cap on the infant's head and have the mother perform kangaroo care. c. Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d. Change the formula because this is a sign of formula intolerance.
B Keeping the head well covered with a cap will prevent further heat loss from the head, and having the mother place the infant *skin to skin* should increase the infant's temperature. Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary. A slightly decreased temperature can be treated in the mother's room. This would be an excellent time for parent teaching on prevention of cold stress.
A mother is concerned that her 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. d. This condition is also known as "breast milk jaundice."
C is correct *know diff btw path and physio jaundice* A Pathologic jaundice occurs during the first 24 hours of life. B Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocytes, and must be investigated. C Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greater, which occurs when the baby is approximately 3 days old. This finding is within normal limits for the newborn. D Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids.
A new mother told the nurse, "I've been told that the milk I have right after the baby is born is not good for the baby." The nurse should base her answer on the fact that: a. only the first secretion of milk should be discarded. b. the colostrum is low in vitamins and protein. c. the colostrum is high in immunoglobulin A. d. the mother secretes just small amounts of colostrum.
C-Colostrum is high in *immunoglobulin A*, which helps protect the infant's gastrointestinal tract from infection. Colostrum also helps establish the normal flora in the intestines, and its laxative effect speeds the passage of meconium. Colostrum is high in vitamins and protein. *this is why milk from breast is better= immunoglobins!!*
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. Lanugo b. Vascular nevi c. Nevus flammeus d. Mongolian spots
D-Mongolian spots are a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. A Lanugo is the fine, downy hair seen on a term newborn. B A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. C A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face.
When the area below the toes are touched, the infant's toes curl over the nurse's finger is testing which newborn reflex? a. Babinski b. Tonic neck c. Stepping d. Plantar grasp
D-Plantar grasp A Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. B The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. C The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. D Plantar grasp reflex is similar to the palmar grasp reflex: when the area below the toes are touched, the infant's toes curl over the nurse's finger.
When assessing the newborn's umbilical cord, what should the nurse expect to find? a) One smaller artery and two larger veins b) Two smaller veins and one larger artery c) One smaller vein and two larger arteries d) Two smaller arteries and one larger vein
D-Two smaller arteries and one larger vein *Remember "aVa"-2 small arteries 1 large vein* When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities.
