Maternity Week 11 Practice Questions

5. What is the clinical finding most likely to be exhibited in an infant diagnosed with erythroblastosis fetalis? a.Edema b.Immature red blood cells c.Enlargement of the heart d.Ascites

. b.Immature red blood

3. What is the highest priority nursing intervention for an infant born with myelomeningocele? a.Protect the sac from injury. b.Prepare the parents for the childs paralysis from the waist down. c.Prepare the parents for closure of the sac when the child is approximately 2 years of age. d.Assess for cyanosis.

ANS: A A major preoperative nursing intervention for a neonate with a myelomeningocele is the protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system (CNS) infection. The long-term prognosis in an affected infant can be determined to a large extent at birth, with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. A myelomeningocele should be surgically closed within 24 hours. Although the nurse should assess for multiple potential problems in this infant, the major nursing intervention is to protect the sac from injury.

10. The abuse of which substance during pregnancy is a significant cause of mental retardation in the United States? a.Alcohol b.Tobacco c.Marijuana d.Heroin

ANS: A Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. Alcohol is a teratogen; maternal ethanol abuse during gestation can lead to identifiable fetal alcohol spectrum disorders that include alcohol-related neurodevelopmental disorders. Cigarette smoking is linked to adverse pregnancy outcomes. The risk for placenta previa, abruption, and premature rupture of membranes is twice that of nonsmokers. Marijuana is the most common illicit drug used by pregnant women. Marijuana crosses the placenta, and its use during pregnancy can result in shortened gestation and a higher incidence of intrauterine growth restriction (IUGR). Heroin crosses the placenta and often results in IUGR, stillbirth, and congenital anomalies.

2. Which infant is most likely to express Rh incompatibility? a.Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor b.Infant who is Rh negative and a mother who is Rh negative c.Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor d.Infant who is Rh positive and a mother who is Rh positive

ANS: A If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, then all the offspring of this union will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. Only the Rh-positive offspring of an Rh-negative mother are at risk. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, a 50% chance exists that each infant born of this union will be Rh positive, and a 50% chance exists that each will be born Rh negative. No risk for incompatibility exists if both the mother and the infant are Rh positive. DIF: Cognitive Level: Understand REF: p. 883 TOP: Nursing Process: Planning

10. The condition, hypospadias, encompasses a wide range of penile abnormalities. Which information should the nurse provide to the anxious parents of an affected newborn? a.Mild cases involve a single surgical procedure. b.Infant should be circumcised. c.Repair is performed as soon as possible after birth. d.No correlation exists between hypospadia and testicular cancer.

ANS: A Mild cases of hypospadias are often repaired for cosmetic reasons, and repair involves a single surgical procedure, enabling the male child to urinate in a standing position and to have an adequate sexual organ. These infants are not circumcised; the foreskin will be needed during the surgical repair. Repair is usually performed between 1 and 2 years of age. A correlation between hypospadias and testicular cancer exists; therefore, these children will require long-term follow-up observation. DIF: Cognitive Level: Apply REF: p. 902

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: a.Are benign if they disappear within 48 hours of birth b.Result from increased blood volume c.Should always be further investigated d.Usually occur with forceps delivery

ANS: A Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation, the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

A careful review of the literature on the various recreational and illicit drugs reveals that: a.More, longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs b.Heroin and methadone cross the placenta; marijuana, cocaine, and PCP do not c.Mothers should get off heroin (detoxification) any time they can during pregnancy d.Methadone withdrawal for infants is less severe and shorter than heroin withdrawal

ANS: A Studies on the effects of marijuana and cocaine use by mothers are somewhat contradictory. More, longer-range studies are needed. Just about all of these drugs cross the placenta, including marijuana, cocaine, and PCP. Drug withdrawal is accompanied by fetal withdrawal, which can lead to fetal death. Therefore, detoxification from heroin is not recommended, particularly later, in pregnancy. Methadone withdrawal is more severe and more prolonged than heroin withdrawal.

6. Which statement regarding congenital anomalies of the cardiovascular and respiratory systems is correct? a.Cardiac disease may demonstrate signs and symptoms of respiratory illness. b.Screening for congenital anomalies of the respiratory system need only be performed for infants experiencing respiratory distress. c.Choanal atresia can be corrected with the use of a suction catheter to remove the blockage. d.Congenital diaphragmatic hernias are diagnosed and treated after birth.

ANS: A The cardiac and respiratory systems function together; therefore, initial findings will be related to respiratory illness. Screening for congenital respiratory system anomalies is necessary, even for infants who appear normal at birth. All newborns should have critical congenital heart disease (CCHD) screening performed before discharge. Choanal atresia requires emergency surgery. Congenital diaphragmatic hernias are prenatally discovered on ultrasound.

7. A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. Based on her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a.Alcohol b.Cocaine c.Heroin d.Marijuana

ANS: A The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction (IUGR). The infant may have a shrill cry and sleep cycle disturbances and may present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.

During a prenatal examination a woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman questions the nurse as to why, the nurse's best response is: a."Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." b."You and your baby can be exposed to HIV in your cats' feces." c."It's just gross. You should make your husband clean the litter boxes." d."Cat feces are known to carry Escherichia coli, which can cause a severe infection in you and your baby."

ANS: A Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. About 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. Human immunodeficiency virus (HIV) is not transmitted by cats. Although this may be a valid statement, it is not appropriate, does not answer the client's question, and is not the nurse's best response. E. coli is found in normal human fecal flora. It is not transmitted by cats.

The most important nursing action in preventing neonatal infection is: a.Good handwashing b.Isolation of infected infants c.Separate gown technique d.Standard Precautions

ANS: A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of health care-associated infection in nursery units. Overcrowding must be avoided in nurseries, and infants with infectious processes should be isolated; however, the most important nursing action for preventing neonatal infection is effective handwashing. Separate gowns should be worn in caring for each infant. Soiled linens should be disposed of in an appropriate manner; however, the most important nursing action for preventing neonatal infection is effective handwashing. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. The most important nursing action for preventing neonatal infection is effective handwashing.

During the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. In this situation, which condition should the nurse suspect? a. Hypovolemia and/or shock b. Excessively cool environment c. Central nervous system (CNS) injury d. Pending renal failure

ANS: A Other symptoms might include hypotension, prolonged capillary refill, and tachycardia, followed by bradycardia. Intervention is necessary. Preterm infants are susceptible to temperature instability. The goal of thermoregulation is to provide a neutral thermal environment. Hypoglycemia is likely to occur if the infant is attempting to conserve heat. CNS injury is manifested by hyperirritability, seizures, and abnormal movements of the extremities.

OOO The nurse is caring for a woman who experienced a perinatal loss. The nurse finds that the woman is experiencing an intense stage of grieving. What observation did the nurse find in the client? a. The woman weeps when she experiences leakage of breast milk. b. The woman notes the date of birth of the stillborn child. c. The woman cries suddenly and becomes emotional. d. The woman looks at the ultrasound photos of the fetus.

ANS: A Weeping on leakage of breast milk is a sign that the woman is slowly getting through the pain and is adjusting to the life without the expected child. This behavior is observed when the woman is experiencing intense grief. Noting the date of birth of a stillborn child is characteristic of the reorganization phase. Preserving and looking at memorabilia, like the ultrasound pictures of the fetus, show that the woman is cherishing the memories of her pregnancy. This is also a sign of the reorganization phase. If the nurse finds that the woman is emotional and cries spontaneously, the woman is said to be in an acute phase of grief.

An infant at 26 weeks of gestation arrives intubated from the delivery room. 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 saturation of 80%. The prescribed saturations are 92%. What is the nurse's most appropriate action at this time? a. Listening to breath sounds, and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician b. Continuing to observe and making no changes until the saturations are 75% c. Continuing with the admission process to ensure that a thorough assessment is completed d. Notifying the parents that their infant is not doing well

ANS: A, Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygen saturation should be maintained above 92%, and oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determining fetal status.

A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate? a. Meconium aspiration, hypoglycemia, and dry, cracked skin b. Excessive vernix caseosa covering the skin, lethargy, and RDS c. Golden yellow to green-stained skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat d. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance

ANS: A, Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa, lethargy, and RDS are consistent with a very premature infant. The skin may be meconium stained, but the infant will most likely have long hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST is indicative of hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents? a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b. "The drug keeps your baby from requiring too much sedation." c. "Surfactant is used to reduce episodes of periodic apnea." d. "Your baby needs this medication to fight a possible respiratory tract infection."

ANS: A, Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With the administration of an artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with RDS is to stimulate the production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

With regard to skeletal injuries sustained by a neonate during labor or birth, nurses should be aware that: a.A newborn's skull is still forming and fractures fairly easily b.Unless a blood vessel is involved, linear skull fractures heal without special treatment c.Clavicle fractures often need to be set with an inserted pin for stability d.Other than the skull, the most common skeletal injuries are to leg bones

ANS: B About 70% of neonatal skull fractures are linear. Because the newborn skull is flexible, considerable force is required to fracture it. Clavicle fractures need no special treatment. The clavicle is the bone most often fractured during birth.

9. Most congenital anomalies of the CNS result from defects in the closure of the neural tube during fetal development. Which factor has the greatest impact on this process? a.Maternal diabetes b.Maternal folic acid deficiency c.Socioeconomic status d.Maternal use of anticonvulsant

ANS: B All of these environmental influences may affect the development of the CNS. Maternal folic acid deficiency has a direct bearing on the failure of neural tube closure. As a preventative measure, folic acid supplementation (0.4 mg/day) is recommended for all women of childbearing age.

3. When planning care for an infant with a fractured clavicle, the nurse should recognize that in addition to gentle handling: a.Prone positioning facilitates bone alignment b.No special treatment is necessary c.Parents should be taught range-of-motion exercises d.The shoulder should be immobilized with a splint

ANS: B Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. Movement should be limited, and the infant should be gently handled. It is not necessary to perform range of motion exercises on the infant. A fractured clavicle does not require immobilization with a splint.

1. To explain hemolytic disorders in the newborn to new parents, the nurse who cares for the newborn population must be aware of the physiologic characteristics related to these conditions. What is the most common cause of pathologic hyperbilirubinemia? a.Hepatic disease b.Hemolytic disorders c. Postmaturity d. Congenital heart defect

ANS: B Hemolytic disorders in the newborn are the most common cause of pathologic hyperbilirubinemia (jaundice). Although hepatic damage, prematurity, and congenital heart defects may cause pathologic hyperbilirubinemia, they are not the most common causes. DIF: Cognitive Level: Apply REF: p. 882 TOP: Nursing Process: Diagnosis

18. With regard to the understanding and treatment of infants born to mothers who are substance abusers, nurses should be aware that: a.Infants born to addicted mothers are also addicted b.Mothers who abuse one substance likely will use or abuse another, compounding the infant's difficulties c.The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself d. No laboratory procedures can identify the intrauterine drug exposure of the infant

ANS: B Multiple substance use (even alcohol and tobacco) makes it difficult to assess the problems of the exposed infant, particularly with regard to withdrawal manifestations. Infants of substance-abusing mothers may have some of the physiologic signs but are not addicted in the behavioral sense. "Drug-exposed newborn" is a more accurate description than "addict." The NNNS is designed to assess the neurologic, behavioral, and stress/abstinence function of the neonate. Newborn urine, hair, or meconium sampling may be used to identify an infant's intrauterine drug exposure.

The nurse is caring for a client whose pregnancy ended in a stillbirth. The client has breast engorgement associated with breast milk production. What information will the nurse first provide to the client? a. Various methods of suppressing lactation b. Importance of a visit to the lactation consultant c. Procedures for expressing and donating breast milk d. Explaining that this problem would disappear in due time

ANS: B Clients who have experienced stillbirth may have varied reactions to this traumatic experience. A client whose pregnancy ended in a stillbirth would still be able to produce breast milk. In this situation, the nurse should explain to the client the importance of visiting a lactation counselor. The lactation counselor would listen to the preferences of the client regarding suppressing the production of breast milk or donating breast milk. The nurse needs to find out whether the client wants to suppress lactation or donate breast milk and, accordingly, give suggestions. Breast milk production may take a long time to cease. Thus, breast milk should either be donated or milk production should be suppressed

6. Parents have asked the nurse about organ donation after that infant's death. Which information regarding organ donation is important for the nurse to understand? a. Federal law requires the medical staff to ask the parents about organ donation and then to contact their state's organ procurement organization (OPO) to handle the procedure if the parents agree. b. Organ donation can aid grieving by giving the family an opportunity to see something positive about the experience. c. Most common donation is the infant's kidneys. d. Corneas can be donated if the infant was either stillborn or alive as long as the pregnancy went full term.

ANS: B Evidence indicates that organ donation can promote healing among the surviving family members. The federal Gift of Life Act made state OPOs responsible for deciding whether to request a donation and for making that request. The most common donation is the cornea. For cornea donation, the infant must have been born alive at 36 weeks of gestation or later.

11. Which finding would indicate to the nurse that the grieving parents have progressed to the reorganization phase of grieving? a. The parents say that they "feel no pain." b. The parents are discussing sex and a future pregnancy c. The parents have abandoned those moments of "bittersweet grief." d. The parents' questions have progressed from "Why?" to "Why us?"

ANS: B Many couples have conflicting feelings about sexuality and future pregnancies. A little pain is always present, certainly beyond the first year when recovery begins to peak. Bittersweet grief describes the brief grief response that occurs with reminders of a loss, such as anniversary dates. Most couples never abandon these reminders. Recovery is ongoing. Typically, a couple's search for meaning progresses from "Why?" in the acute phase to "Why me?" in the intense phase to "What does this loss mean to my life?" in the reorganizational phase

13. A client gives birth to a stillborn infant. At first, she appears stunned by the news, cries a little, and then asks the nurse to call her mother. What is the proper term for the phase of bereavement that this client is experiencing? a. Anticipatory grief b. Acute distress c. Intense grief d. Reorganization

ANS: B The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal. However, a lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Anticipatory grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant's possible death, although he or she clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

2. A newborn in the neonatal intensive care unit (NICU) is dying of a massive infection. The parents speak to the neonatologist, who informs them of their son's prognosis. When the father sees his son, he says, "He looks just fine to me. I can't understand what all this is about." What is the most appropriate response or reaction by the nurse at this time? a. "Didn't the physician tell you about your son's problems?" b. "This must be a difficult time for you. Tell me how you're doing." c. Quietly stand beside the infant's father. d. "You'll have to face up to the fact that he is going to die sooner or later."

ANS: B The phase of intense grief can be very difficult, especially for fathers. Parents should be encouraged to share their feelings during the initial steps in the grieving process. This father is in a phase of acute distress and is reaching out to the nurse as a source of direction in his grieving process. Shifting the focus is not in the best interest of the parent. Nursing actions may help the parents actualize the loss of their infant through a sharing and verbalization of their feelings of grief. Telling the father that his son is going to die sooner or later is dispassionate and an inappropriate statement on the part of the nurse.

10. During a follow-up home visit, the nurse plans to evaluate whether parents have progressed to the second stage of grieving (phase of intense grief). Which behavior would the nurse not anticipate finding? a. Guilt, particularly in the mother b. Numbness or lack of response c. Bitterness or irritability d. Fear and anxiety, especially about getting pregnant again

ANS: B The second phase of grieving encompasses a wide range of intense emotions, including guilt, anger, bitterness, fear, and anxiety. What the nurse would hope not to see is numbness or unresponsiveness, which indicates that the parents are still in denial or shock.

In appraising the growth and development potential of a preterm infant, the nurse should be cognizant of the information that is best described in which statement? a. Tell the parents that their child will not catch up until approximately age 10 years (for girls) to age 12 years (for boys). b. Correct for milestones, such as motor competencies and vocalizations, until the child is approximately 2 years of age. c. Know that the greatest catch-up period is between 9 and 15 months postconceptual age. d. Know that the length and breadth of the trunk is the first part of the infant to experience catch-up growth.

ANS: B, Corrections are made with a formula that adds gestational age and postnatal age. Whether a girl or boy, the infant experiences catch-up body growth during the first 2 to 3 years of life. Maximum catch-up growth occurs between 36 and 40 weeks of postconceptual age. The head is the first to experience catch-up growth.

With regard to infants who are diagnosed with both small gestational age (SGA) and intrauterine growth restriction (IUGR), the nurse should be aware of which information? a. In the first trimester, diseases or abnormalities result in asymmetric IUGR. b. Infants with asymmetric IUGR have the potential for normal growth and development. c. In asymmetric IUGR, weight is slightly larger than SGA, whereas length and head circumference are somewhat less than SGA. d. Symmetric IUGR occurs in the later stages of pregnancy.

ANS: B, IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; infants who are SGA have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th percentile. Infants with asymmetric IUGR have the potential for normal growth and development.

In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Bronchopulmonary dysplasia (BPD). d. Intraventricular hemorrhage (IVH)

ANS: B, ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is caused by the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. What are generalized signs and symptoms of this condition? a. Hypertonia, tachycardia, and metabolic alkalosis b. Abdominal distention, temperature instability, and grossly bloody stools c. Hypertension, absence of apnea, and ruddy skin color d. Scaphoid abdomen, no residual with feedings, and increased urinary output

ANS: B, Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.

A newborn was admitted to the neonatal intensive care unit (NICU) after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until the premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. What is the nurse's most appropriate action? a. Wait quietly at the newborn's bedside until the parents come closer. b. Go to the parents, introduce him or herself, and gently encourage them to meet their infant. Explain the equipment first, and then focus on the newborn. c. Leave the parents at the bedside while they are visiting so that they have some privacy. d. Tell the parents only about the newborn's physical condition and caution them to avoid touching their baby

ANS: B, The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents see the infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant's condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant's appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents to avoid touching their baby is inappropriate and unhelpful.

A multipara, 26 weeks' gestation and accompanied by her husband, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? a. Encourage the parents to pray for the baby's soul. b. Advise the parents that it is better for the baby to have died than to have had to live with a defect. c. Provide opportunities for grieving parents and family members to spend time with the baby d. Advise the parents to refrain from discussing the baby's death with their other children.

ANS: C

14. With regard to central nervous system injuries to the infant during labor and birth, nurses should be aware that: a.Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant b.Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia c.In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests d.Spinal cord injuries almost always result from forceps-assisted deliveries

ANS: C Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomography (CT) scan might reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants, it is a result of hypoxia. Spinal cord injuries are almost always from breech births; they are rare today because cesarean birth often is used for breech presentation.

Infants of mothers with diabetes are at higher risk for developing: a.Anemia b.Hyponatremia c.Respiratory distress syndrome d.Sepsis

ANS: C IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. Infants of diabetic mothers (IDMs) are not at risk for anemia. They are at risk for polycythemia. IDMs are not at risk for hyponatremia. They are at risk for hypocalcemia and hypomagnesemia. IDMs are not at risk for sepsis.

11. The nurse is instructing a family how to care for their infant in a Pavlik harness to treat DDH. What information should be included in the teaching? a.Apply lotion or powder to minimize skin irritation. b.Remove the harness several times a day to prevent contractures. c.Return to the clinic every 1 to 2 weeks. d.Place a diaper over the harness, preferably using an absorbent disposable diaper.

ANS: C Infants have a rapid growth pattern. Therefore, the child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness, and the harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

19. Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: a.Pharmacologic treatment b.Reduction of environmental stimuli c.Neonatal abstinence syndrome scoring d.Adequate nutrition and maintenance of fluid and electrolyte balance

ANS: C Neonatal abstinence syndrome (NAS) describes the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates central nervous system (CNS), metabolic, vasomotor, respiratory, and gastrointestinal (GI) disturbances. This evaluation tool enables the health care team to develop an appropriate plan of care. The infant is scored throughout the length of stay and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays central nervous system disturbances. Poor feeding is one of the GI symptoms common to this client population. Fluid and electrolyte balance must be maintained and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.

12. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, how should the nurse respond? a.Traction is tried first. b.Surgical intervention is needed. c.Frequent, serial casting is tried first. d.Children outgrow this condition when they learn to walk.

ANS: C Serial casting, the preferred treatment, is begun shortly after birth and before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are frequently repeated (every week) to accommodate the rapid growth of early infancy. Surgical intervention is performed only if serial casting is not successful. Children do not improve without intervention. DIF: Cognitive Level: Understand REF: p. 901 TOP: Nursing Process: Planning

plan of care for an infant experiencing symptoms of drug withdrawal should include: a.Administering chloral hydrate for sedation b.Feeding every 4 to 6 hours to allow extra rest c.Swaddling the infant snugly and holding the baby tightly d.Playing soft music during feeding

ANS: C The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music), because this will increase activity and potentially increase CNS irritability.

12. A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds: a."It is an eye ointment to help your baby see you better." b."It is to protect your baby from contracting herpes from your vaginal tract." c."Erythromycin is given prophylactically to prevent a gonorrheal infection." d."This medicine will protect your baby's eyes from drying out over the next few days."

ANS: C With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision. Erythromycin is used to prevent an infection caused by gonorrhea, not herpes. Erythromycin is given to prevent infection, not for lubrication.

A newborn with hypoplastic heart syndrome died after 12 hours of resuscitation. The nurse allows the parents to take the newborn's pictures, and provides a certificate along with the identification band. The nurse also refers the client to memorial services. Which behavior of the parents a month after the loss is an indication of positive outcomes of the above nursing intervention? a. The parents have reduced spiritual distress. b. The parents try not to dwell on the loss. c. The parents do not have intense longing and yearning. d. The parents are trying to have another child

ANS: C Allowing the parents to take the pictures of the newborn and providing a birth certificate to the family helps the parents accept the reality of death and complete their grieving process. Therefore, it helps to prevent the accumulation of grief and symptoms of complicated grief such as intense longing and yearning. The nurse should refer the client to memorial services in order to prevent isolation and risk of complicated grieving. Facilitating spiritual rituals or referral to a religious figure helps to reduce spiritual distress in the parents, but the nurse's actions are not specific to this purpose. If the parents are trying not to dwell on the loss it could be an indication that they are not allowing themselves to grieve, but it is not an indication that the nurse's interventions helped. If the parents are trying to have another child it does not necessarily mean the nurse helped them through their grief.

9. Which options for saying "good-bye" would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? a. The nurse should not discuss any options at this time; plenty of time will be available after the baby is born. b. "Would you like a picture taken of your baby after birth?" c. "When your baby is born, would you like to see and hold her?" d. "What funeral home do you want notified after the baby is born?"

ANS: C Mothers and fathers may find it helpful to see their infant after delivery. The parents' wishes should be respected. Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. The initial intervention should be directly related to the parents' wishes concerning seeing or holding their dead infant. Although information about funeral home notification may be relevant, this information is not the most appropriate option at this time. Burial arrangements can be discussed after the infant is born.

When assisting the mother, father, and other family members to actualize the loss of an infant, which action is most helpful? a. Using the words lost or gone rather than dead or died b. Making sure the family understands that naming the baby is important c. Ensuring the baby is clothed or wrapped if the parents choose to visit with the baby d. Setting a firm time for ending the visit with the baby so that the parents know when to let go

ANS: C Presenting the baby as nicely as possible stimulates the parents' senses and provides pleasant memories of their baby. Baby lotion or powder can be applied, and the baby should be wrapped in a soft blanket, clothed, and have a cap placed on his or her head. Nurses must use the words dead and died to assist the bereaved in accepting the reality. Although naming the baby can be helpful, creating the sense that the parents have to name the baby is not important. In fact, some cultural taboos and religious rules prohibit the naming of an infant who has died. Parents need different times with their baby to say "good-bye." Nurses need to be careful not to rush the process.

A pregnant client experiences severe bleeding at 30 weeks of gestation. While performing the ultrasound, the nurse discovers that the fetus is dead. How does the nurse present this information to the client? a. "Your baby has left us." b. "You have lost your baby." c. "The baby has no heartbeat." d. "The baby has passed away."

ANS: C The nurse should be very careful while informing a client about fetal death and should convey this information without any ambiguity. Telling the client that the fetus has no heartbeat clearly indicates that the fetus has died. Telling the client that the baby has left us or that the client has lost her baby may not give a clear indication that the fetus is dead. Saying that the baby has passed away may also be somewhat ambiguous. Therefore, the nurse should not use euphemisms to convey messages about fetal death.

The nurse is caring for a client who lost her newborn 8 hours after the birth. The nurse interacts with the client in an isolated room, identifies the client's perception and feelings about death, and refers the client to counseling. What is the rationale behind these interventions? a. To reduce spiritual distress in the client b. To improve the client's relationship with the family c. To improve and maintain the client's self-esteem d. To reduce the client's risk of complicated grieving

ANS: C The nurse should provide the client private time for expression of feelings through therapeutic communication and active listening. This helps the client express her feelings openly without any judgment, thereby promoting self-esteem. The client will exhibit positive self-comments as evidence of her decreasing sense of failure. In order to reduce spiritual distress, the nurse should assess the client's spiritual preference and facilitate spiritual rituals. In order to improve the client's relationship with family members, the nurse should encourage the partners to talk about their loss. In order to reduce the risk of complicated grieving, the nurse should allow the client to hold and view the infant and refer appropriate support groups.

Which statement is accurate with regard to the emotional state of grief? A. It is a static concept applied to loss. B. Aspects of grief occur simultaneously across family units. C. Time limit for grief experiences is variable among individuals. D. It represents a linear process.

ANS: C There is no prescribed time limit for the expression of grief. Grief is a dynamic concept involving complex emotions. The expression of grief is individualized and may not occur simultaneously across family units. The process of grief represents an iterative process.

Where should a nurse remove a child's lock of hair for the parents' memorabilia in the event of perinatal loss? a. The back of the head b. The forehead c. The nape of the neck d. The top of the head

ANS: C To remove a lock of hair for memorabilia, the nurse should select an area that does not disrupt the appearance of the baby. The nape of the neck is considered the most appropriate area to take a hair lock for the memorabilia. The hair lock should not be taken from the areas such as the back of the head, the forehead, or the top of the head. Taking a hair lock from these areas would make the lack of hair in that area noticeable.

12. Which statement most accurately describes complicated grief? a. Occurs when, in multiple births, one child dies and the other or others live b. Is a state during which the parents are ambivalent, as with an abortion c. Is an extremely intense grief reaction that persists for a long time d. Is felt by the family of adolescent mothers who lose their babies

ANS: C Parents showing signs of complicated grief should be referred for counseling. Multiple births, in which not all of the babies survive, create a complicated parenting situation but not complicated bereavement. Abortion can generate complicated emotional responses, but these responses do not constitute complicated bereavement. Families of lost adolescent pregnancies may have to deal with complicated issues, but these issues are not complicated bereavement.

3. During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. What is the nurse's role at this time? a. To take over as much as possible to relieve the pressure b. To encourage the grandparents to take over c. To ensure that the parents, themselves, approve the final decisions d. To leave them alone to work things out

ANS: C The nurse is always the client's advocate. Nurses can offer support and guidance and yet leave room for the same from grandparents. In the end, however, nurses should let the parents make the final decisions. For the nurse to be able to present options regarding burial and autopsy, among other issues, in a sensitive and respectful manner is essential. The nurse should assist the parents in any way possible; however, taking over all arrangements is not the nurse's role. Grandparents are often called on to help make the difficult decisions regarding funeral arrangements or the disposition of the body because they have more life experiences with taking care of these painful yet required arrangements. Some well-meaning relatives may try to take over all decision-making responsibilities. The nurse must remember that the parents, themselves, should approve all of the final decisions. During this time of acute distress, the nurse should be present to provide quiet support, answer questions, obtain information, and act as a client advocate.

An infant is to receive gastrostomy feedings. Which intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? a. Rapid bolusing of the entire amount in 15 minutes b. Warm cloths to the abdomen for the first 10 minutes c. Slow, small, warm bolus feedings over 30 minutes d. Cold, medium bolus feedings over 20 minutes

ANS: C, Feedings by gravity are slowly accomplished over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Applying warm cloths to the abdomen would not be appropriate because the environment is not thermoregulated. In addition, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

With regard to an eventual discharge of the high-risk newborn or the transfer of the newborn to a different facility, which information is essential to provide to the parents? a. Infants stay in the NICU until they are ready to go home. b. Once discharged to go home, the high-risk infant should be treated like any healthy term newborn. c. Parents of high-risk infants need special support and detailed contact information. d. If a high-risk infant and mother need to be transferred to a specialized regional center, then waiting until after the birth and until the infant is stabilized is best.

ANS: C, High-risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high-risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Simply because high-risk infants are eventually discharged does not mean they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

A nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. Which statement regarding this intervention is most appropriate? a. Kangaroo care was adopted from classical British nursing traditions. b. This intervention helps infants with motor and CNS impairments. c. Kangaroo care helps infants interact directly with their parents and enhances their temperature regulation. d. This intervention gets infants ready for breastfeeding.

ANS: C, Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent's bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits. Kangaroo care was established in Bogota, Colombia, assists the infant in maintaining an organized state, and decreases pain perception during heelsticks. Even premature infants who are unable to suckle benefit from kangaroo care. This practice fosters increased vigor and an enhanced breastfeeding experience as the infant matures.

For clinical purposes, the most accurate definition of preterm and postterm infants is defined as what? a. Preterm: Before 34 weeks of gestation if the infant is appropriate for gestational age (AGA); before 37 weeks if the infant is small for gestational age (SGA) b. Postterm: After 40 weeks of gestation if the infant is large for gestational age (LGA); beyond 42 weeks if the infant is AGA c. Preterm: Before 37 weeks of gestation and postterm beyond 42 weeks of gestation; no matter the size for gestational age at birth d. Preterm: Before 38 to 40 weeks of gestation if the infant is SGA; postterm, beyond 40 to 42 weeks gestation if the infant is LGA

ANS: C, Preterm and postterm are strictly measures of time—before 37 weeks and beyond 42 weeks, respectively—regardless of the size for gestational age.

An infant is being discharged from the NICU after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including RDS, mild bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP), requiring surgical treatment. During discharge teaching, the infant's mother asks the nurse if her baby will meet developmental milestones on time, as did her son who was born at term. What is the nurse's most appropriate response? a. "Your baby will develop exactly like your first child." b. "Your baby does not appear to have any problems at this time." c. "Your baby will need to be corrected for prematurity." d. "Your baby will need to be followed very closely."

ANS: C, The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant's responses are accordingly evaluated against the norm expected for the corrected age of the infant. The baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing. Although predicting with complete accuracy the growth and development potential of each preterm infant is impossible, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. Development needs to be evaluated over time. The growth and developmental milestones are corrected for gestational age until the child is approximately years old.

By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. Which significant symptoms will the infant display when experiencing cold stress? a. Decreased respiratory rate b. Bradycardia, followed by an increased heart rate c. Irritability with central cyanosis d. Increased physical activity

ANS: C, The infant has minimal-to-no fat stores. During times of cold stress, the skin becomes mottled and acrocyanosis develops, progressing to cyanosis.

An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths per minute with significant substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure (CPAP). What level of partial pressure of arterial oxygen (PaO2) indicates hypoxia? a. 67 mm Hg b. 89 mm Hg c. 45 mm Hg d. 73 mm Hg

ANS: C, The laboratory value of PaO2 of 45 mm Hg is below the range for a normal neonate and indicates hypoxia in this infant. The normal range for PaO2 is 60 to 80 mm Hg; therefore, PaO2 levels of 67 and 73 mm Hg fall within the normal range, and a PaO2 of 89 mm Hg is higher than the normal range.

13. Which statement regarding hemolytic diseases of the newborn is most accurate? a.Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother. b.ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. c.Exchange transfusions are frequently required in the treatment of hemolytic disorders. d.The indirect Coombs test is performed on the mother before birth; the direct Coombs test is performed on the cord blood after birth.

ANS: D An indirect Coombs test may be performed on the mother a few times during pregnancy. Only the Rh-positive child of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers infrequently are needed because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

7. When attempting to screen and educate parents regarding the treatment of developmental dysplasia of the hip (DDH), which intervention should the nurse perform? a.Be able to perform the Ortolani and Barlow tests. b.Teach double or triple diapering for added support. c.Explain to the parents the need for serial casting. d.Carefully monitor infants for DDH at follow-up visits.

ANS: D Because DDH often is not detected at birth, infants should be carefully monitored at follow-up visits. The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. Double or triple diapering is not recommended because it promotes hip extension, thus worsening the problem. Serial casting is recommended for clubfoot, not DDH. DIF: Cognitive Level: Apply REF: p. 899 TOP: Nursing Process: Planning

4. Which nursing diagnosis is most appropriate for a newborn diagnosed with a diaphragmatic hernia? a.Risk for impaired parent-infant attachment b.Imbalanced nutrition, related to less than body requirements c.Risk for infection d.Impaired gas exchange

ANS: D Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. Although imbalanced nutrition, related to less than body requirements, may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. The nutritional needs of this infant may be a clearly identified need; however, at this time the nurse should be most concerned about impaired gas exchange. This infant is at risk for infection, especially once the surgical repair has been performed. The extent of the herniation may have hindered normal development of the lungs in utero, resulting in respiratory distress.

16. What bacterial infection is definitely decreasing because of effective drug treatment? a.Escherichia coli infection b.Tuberculosis c.Candidiasis d.Group B streptococci (GBS) infection

ANS: D Penicillin has significantly decreased the incidence of GBS infection. E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Tuberculosis is increasing in the United States and in Canada. Candidiasis is a fairly benign fungal infection.

9. Human immunodeficiency virus (HIV) may be perinatally transmitted: a.Only in the third trimester from the maternal circulation b.From the use of unsterile instruments c.Only through the ingestion of amniotic fluid d.Through the ingestion of breast milk from an infected mother

ANS: D Postnatal transmission of HIV through breastfeeding may occur. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases. This is highly unlikely because most health care facilities must meet sterility standards for all instrumentation. Transmission of HIV may occur through the placenta from the mother to the fetus or through breast milk postnatally.

8. The nurse is assigned a home care visit of a 5-day-old infant for the treatment of jaundice. A thorough assessment is completed, and a health history is obtained. Which sign or symptom indicates that the infant may be displaying the initial phase of encephalopathy? a.High-pitched cry b.Severe muscle spasms (opisthotonos) c.Fever and seizures d.Hypotonia, lethargy, and poor suck

ANS: D The early and most subtle symptoms of bilirubin encephalopathy include hypotonia, lethargy, poor suck, and a depressed or absent Moro reflex. Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or an arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase of encephalopathy. Medical attention is immediately necessary. Symptoms may progress from the subtle indications of the first phase to fever and seizures in as few as 24 hours. Only approximately one half of these infants survive, and those that do will have permanent sequelae, including auditory deficiencies, intellectual deficits, and movement abnormalities.

5. A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, the cause of this newborn's distress is most likely: a.Hypoglycemia b.Phrenic nerve injury c.Respiratory distress syndrome d.Sepsis

ANS: D The prolonged rupture of membranes and the tachypnea (before and after birth) suggest sepsis. A differential diagnosis can be difficult because signs of sepsis are similar to noninfectious problems such as anemia and hypoglycemia. Phrenic nerve injury is usually the result of traction on the neck and arm during birth and is not applicable to this situation. The earliest signs of sepsis are characterized by lack of specificity (i.e., lethargy, poor feeding, and irritability), not respiratory distress syndrome.

A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lb, 6 oz). The nurse's most appropriate action is to: a.Leave the infant in the room with the mother b.Take the infant immediately to the nursery c.Perform a gestational age assessment to determine whether the infant is large for gestational age d.Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia

ANS: D This infant is macrosomic (more than 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. Macrosomic infants need to be observed closely. This can be achieved in the mother's room with nursing interventions, depending on the condition of the infant. It may be more appropriate for observation to occur in the nursery. Observation of the macrosomic infant may occur in the nursery or in the mother's room, depending on the condition of the infant. Regardless of gestational age, this infant is macrosomic. Macrosomia is defined as fetal weight over 4000 g. Hypoglycemia affects many macrosomic infants. Blood glucose levels should be observed closely.

The nurse is caring for clients in a maternity unit. Which client is most likely to experience isolation during the grieving period? a. A client who is on bed rest for a high risk pregnancy b. A client whose newborn was born with a cleft palate c. A client who lost her newborn 6 hours after birth d. A client who had a miscarriage at 6 weeks of gestation

ANS: D A client who miscarries during early pregnancy may experience loss and suffer from isolation, because it may be difficult to discuss the loss with friends and family who may not have known about the pregnancy yet. A client who is on bed rest for a high-risk pregnancy may experience fear and boredom, but it is not experiencing a loss. A client whose newborn has a cleft palate may be depressed, but she does not necessarily experience isolation and loss. A client who lost her newborn 6 hours after birth may have the support of family and friends who were ready for the birth. Therefore, the client may be less likely to experience isolation.

7. Which statement is the most appropriate for the nurse to make when caring for bereaved parents? a. "This happened for the best." b. "You have an angel in heaven." c. "I know how you feel." d. "What can I do for you?"

ANS: D Acknowledging the loss and being open to listening is the best action that the nurse can do. No bereaved parent would find the statement "This has happened for the best" to be comforting in any way, and it may sound judgmental. Nurses must resist the impulse to speak about the afterlife to people in pain. They should also resist the temptation to give advice or to use clichés. Unless the nurse has lost a child, he or she does not understand how the parents feel.

1. A family is visiting two surviving triplets. The third triplet died 2 days ago. What action indicates that the family has begun to grieve for the dead infant? a. Refers to the two live infants as twins b. Asks about the dead triplet's current status c. Brings in play clothes for all three infants d. Refers to the dead infant in the past tense

ANS: D Accepting that the infant is dead (in the past tense of the word) demonstrates an acceptance of the reality and that the family has begun to grieve. Parents of multiples are challenged with the task of parenting and grieving at the same time. Referring to the two live infants as twins does not acknowledge an acceptance of the existence of their third child. Bringing in play clothes for all three infants indicates that the parents are still in denial regarding the death of the third triplet. The death of the third infant has imposed a confusing and ambivalent induction into parenthood for this couple. If the two live infants are referred to as twins and/or if play clothes for all three infants are still considered, then the family is clearly still in denial regarding the death of one of the triplets

5. Parents are often asked if they would like to have an autopsy performed on their infant. Nurses who are assisting parents with this decision should be aware of which information? a. Autopsies are usually covered by insurance. b. Autopsies must be performed within a few hours after the infant's death. c. In the current litigious society, more autopsies are performed than in the past. d. Some religions prohibit autopsy.

ANS: D Some religions prohibit autopsies or limit the choice to the times when it may help prevent further loss. The cost of the autopsy must be considered; it is not covered by insurance and can be very expensive. There is no rush to perform an autopsy unless evidence of a contagious disease or maternal infection is present at the time of death. The rate of autopsies is declining, in part because of a fear by medical facilities that errors by the staff might be revealed, resulting in litigation.

4. A nurse caring for a family during a loss might notice that a family member is experiencing survivor guilt. Which family member is most likely to exhibit this guilt? a. Siblings b. Mother c. Father d. Grandparents

ANS: D Survivor guilt is sometimes felt by grandparents because they feel that the death is out of order; they are still alive, while their grandchild has died. They may express anger that they are alive and their grandchild is not. The siblings of the expired infant may also experience a profound loss. A young child will respond to the reactions of the parents and may act out. Older children have a more complete understanding of the loss. School-age children are likely to be frightened, whereas teenagers are at a loss on how to react. The mother of the infant is experiencing intense grief at this time. She may be dealing with questions such as, "Why me?" or "Why my baby?" and is unlikely to be experiencing survival guilt. Realizing that fathers can be experiencing deep pain beneath their calm and quiet appearance and may need help acknowledging these feelings is important. This need, however, is not the same as survivor guilt.

8. After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die?" What is the nurse's most appropriate response? a. "That's an old wives' tale; lots of women are around paint during pregnancy, and this doesn't happen to them." b. "That's not likely. Paint is associated with elevated pediatric lead levels." c. Silence. d. "I can understand your need to find an answer to what caused this. What else are you thinking about?"

ANS: D The statement "I can understand your need to find an answer to what caused this. What else are you thinking about?" is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. In addition, trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feeling does not help the process of grieving. Silence would probably increase the mother's feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and then listening with care. The nurse should encourage the mother to express her thoughts.

Which condition might premature infants who exhibit 5 to 10 seconds of respiratory pauses, followed by 10 to 15 seconds of compensatory rapid respiration, be experiencing? a. Suffering from sleep or wakeful apnea b. Experiencing severe swings in blood pressure c. Trying to maintain a neutral thermal environment d. Breathing in a respiratory pattern common to premature infants

ANS: D, Breathing in a respiratory pattern is called periodic breathing and is common to premature infants. This pattern may still require nursing intervention of oxygen and/or ventilation. Apnea is the cessation of respirations for 20 seconds or longer and should not be confused with periodic breathing.

When providing an infant with a gavage feeding, which infant assessment should be documented each time? a. Abdominal circumference after the feeding b. Heart rate and respirations before feeding c. Suck and swallow coordination d. Response to the feeding

ANS: D, Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Abdominal circumference is not measured after a gavage feeding. Although vital signs may be obtained before feeding, the infant's response to the feeding is more important. Similarly, some older infants may be learning to suck; the most important factor to document would still be the infant's response to the feeding, including the attempts to suck

On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they may hold their infant during his next gavage feeding. Considering that this newborn is physiologically stable, what response should the nurse provide? a. "Parents are not allowed to hold their infants who are dependent on oxygen." b. "You may only hold your baby's hand during the feeding." c. "Feedings cause more physiologic stress; therefore, the baby must be closely monitored. I don't think you should hold the baby." d. "You may hold your baby during the feeding."

ANS: D, Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the caregiving responsive to the needs of both the parents and the infant. Allowing the parents to hold their baby is the most appropriate response by the nurse. Parental interaction by holding should be encouraged during gavage feedings; nasal cannula oxygen therapy allows for easy feedings and psychosocial interactions. The parent can swaddle the infant or provide kangaroo care while gavage feeding their infant. Both swaddling and kangaroo care during feedings provide positive interactions for the infant and help the infant associate feedings with positive interactions.

When evaluating the preterm infant, the nurse understands that compared with the term infant, what information is important for the nurse to understand? a. Few blood vessels visible through the skin b. More subcutaneous fat c. Well-developed flexor muscles d. Greater surface area in proportion to weight

ANS: D, Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.

Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a. Delayed growth and development b. Ineffective thermoregulation c. Ineffective infant feeding pattern d. Risk for infection

ANS: D, The nurse needs to understand that decreased immune functioning increases the risk for infection. Growth and development, thermoregulation, and feeding may be affected, although only indirectly.

15. Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of: a.Gonorrhea b.Herpes simplex virus (HSV) infection c.Congenital syphilis d.Human immunodeficiency virus (HIV)

C This rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. This rash is not an indication that the neonate has contracted gonorrhea. The neonate with gonorrheal infection might present with septicemia, meningitis, conjunctivitis, and scalp abscesses. Infants affected with HSV display growth restriction, skin lesions, microcephaly, hypertonicity, and seizures. Typically the HIV-infected neonate is asymptomatic at birth. Most often the infant develops an opportunistic infection and rapid progression of immunodeficiency.

1. ____________________, a synthetic opiate, has been the therapy of choice for heroin addiction. It crosses the placenta, leading to significant neonatal abstinence syndrome after birth. A. Morphine B. Nalaxone C. Levothyroxine D. Methadone

D. Methadone Methadone withdrawal is more severe and prolonged than withdrawal from heroin. Signs of withdrawal include tremors, irritability, hypertonicity, vomiting, nasal stuffiness, and disturbed sleep patterns. This infant is also at increased risk for sudden infant death syndrome (SIDS).

3. The nurse is caring for an infant with DDH. Which clinical manifestations should the nurse expect to observe? (Select all that apply.) a.Positive Ortolani click b.Unequal gluteal folds c.Negative Babinski sign d.Trendelenburg sign e.Telescoping of the affected limb

correct answer is: A, B A positive Ortolani test and unequal gluteal folds are clinical manifestations of DDH observed from birth to 2 to 3 months of age. A negative Babinski sign, Trendelenburg sign, and telescoping of the affected limb are not clinical manifestations of DDH. DIF: Cognitive Level: Apply REF: p. 900 TOP: Nursing Process: Planning

2. The most widespread use of postnatal testing for genetic disease is the routine screening of newborns for inborn errors of metabolism (IEM). Which conditions are considered metabolic disorders? (Select all that apply.) a.Phenylketonuria (PKU) b.Galactosemia c.Hemoglobinopathy d.Cytomegalovirus (CMV) e. Rubella

correct answer is: A, B, C PKU is an IEM that can be diagnosed with newborn screening. Galactosemia is a metabolic defect that falls under the category of an IEM. Sickle cell disease and thalassemia are hemoglobinopathies that can be detected by newborn screening. CMV and rubella cannot be detected by newborn screening and are not metabolic disorders; rather, they are viruses contracted by the fetus. DIF: Cognitive Level: Understand REF: p. 904 TOP: Nursing Process: Planning

Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. What are possible causes of early miscarriage? (Select all that apply.) a. Chromosomal abnormalities b. Nausea and vomiting in early pregnancy c. Endocrine imbalance d. Systemic disorders e. Varicella

correct answer is: A, B, C, D, E Although most N/V in early pregnancy is not likely to relate to miscarriage, severe dehydration can reduce uterine circulation severely enough to impact a pregnancy

According to the CDC, which of the following are significant causes of maternal death in the United States? (Select all that apply). a. hemorrhage b. cardio-vascular disease c. non-cardiovascular conditions d. street drug use e. ski accidents f. hypertensive disorders

correct answer is: A, B, C, F

Yolanda is 6 weeks pregnant by dates and is considering abortion. What options might be appropriate for her at this point? (Select all that apply). a. medical abortion with mifepristone and misopristol b. emergency contraception c. surgical abortion with aspiration d. it is too late for her to have an abortion

correct answer is: A, C

1. Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from the failure of the primary palate to fuse. Multiple genetic and, to a lesser extent, environmental factors may lead to the development of a cleft lip or palate. Which factors are included? (Select all that apply.) a.Alcohol consumption b.Female gender c.Use of some anticonvulsant medications d.Maternal cigarette smoking e.Antibiotic use in pregnancy

correct answer is: A, C, D Factors associated with the potential development of cleft lip or palate are maternal infections, alcohol consumption, radiation exposure, corticosteroid use, use of some anticonvulsant medications, male gender, Native-American or Asian descent, and maternal smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate. DIF: Cognitive Level: Understand REF: p. 895 TOP: Nursing Process: Planning

What are some causes of perinatal loss? Select all that apply. a. Stillbirth b. Fertility c. Infertility d. Miscarriage e. Intrauterine fetal death (IUFD) f. Death of live-born infant soon after birth

correct answer is: A, C, D, E, F Some causes of perinatal loss include: stillbirth, infertility, miscarriage, intrauterine fetal death (IUFD), and death of live-born infant soon after birth. Fertility is not a cause of perinatal loss.

The nurse is caring for a client whose pregnancy ended in stillbirth 2 months ago. The nurse finds that the client experiences feelings of loneliness, emptiness, and yearning. What additional symptoms of grief may the nurse find in the client? Select all that apply. a. Guilt b. Shock c. Numbness d. Resentment e. Disorganization

correct answer is: A, D, E Pregnancy loss can lead to intense grief and feelings of loneliness, emptiness, and yearning. The client may feel guilty and blame herself for the fetal death, because she may assume that she was responsible for the fetal well-being. The client experiences helplessness because she could not save her fetus and, therefore, has resentment. The client experiences disorganization and depression due to the loss. The client experiences shock and numbness in the acute phase of distress, but not while experiencing intense grief.

1. Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (choose all that apply): a.Amphetamine b.Heroin c.Nicotine d.PCP e.Morphine

correct answers is: A, B, C, D Use of amphetamines, heroin, nicotine, and PDP is contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication often used to treat neonatal abstinence syndrome.

The nurse is caring for a client who lost her baby immediately after birth. The client blames herself for the loss. Which nursing interventions are designed to promote feelings of self-worth in the client? Select all that apply. a. Attending the memorial services and funeral b. Helping the client identify positive coping mechanisms c. Giving the client the newborn's photograph and footprints d. Encouraging the client to share her feelings with her partner e. Identifying the client's perception and feeling about fetal death

the correct answer is: B, E Clients may experience low self-esteem related to fetal death due to a sense of failure to become a mother. The nurse should help the client identify and follow positive coping skills because it improves the client's self-esteem and self-worth. The nurse should identify the client's perception and feelings about fetal death and should correct any misconceptions and alleviate guilt. This promotes feelings of self-worth. The nurse may attend memorial services and the funeral to support the parents, but this intervention does not promote feelings of self-worth. The nurse would provide photographs and footprints in order to make the client acknowledge the reality of death. The nurse should encourage the client to share her feelings with her partner in order clarify possible effects on the family