MB Exam II

A postpartum nurse is caring for a client who received epidural anesthesia during her labor and delivery. The nurse should advise the woman that she may experience which of the following side effects of the medication during the postpartum period? 1. Backache. 2. Light-headedness. 3. Hypertension. 4. Footdrop.

1. Backache.

The nurse is caring for a baby diagnosed with developmental dysplasia of the hip (DDH). Which of the following therapeutic interventions should the nurse expect to perform? 1. Maintain the baby's legs in abduction. 2. Administer pain medication as needed. 3. Assist with bilateral leg casting. 4. Monitor pedal pulses bilaterally.

1. Maintain the baby's legs in abduction.

A baby exhibits weak rooting and sucking reflexes. Which of the following nursing diagnoses would be appropriate? 1. Risk for deficient fluid volume. 2. Activity intolerance. 3. Risk for aspiration. 4. Feeding self-care deficit.

1. Risk for deficient fluid volume.

The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? 1. "Okay. I must be palpating your uterus." 2. "I understand but I still would like you to try to urinate." 3. "You still must be numb from the local anesthesia." 4. "That is a problem. I will have to catheterize you."

2. "I understand but I still would like you to try to urinate."

The nurse assessed four newborns in the neonatal nursery. The nurse called the neonatologist for a cardiology consult on the baby who exhibited which of the following signs/symptoms? 1. Setting sun sign. 2. Anasarca. 3. Flaccid extremities. 4. Polydactyly.

2. Anasarca. systemic edema

A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? 1. Hemolysis of neonatal red blood cells by the maternal antibodies. 2. Physiological destruction of fetal red blood cells during the extrauterine period. 3. Pathological liver function resulting from hypoxemia during the birthing process. 4. Delayed meconium excretion resulting in the production of direct bilirubin.

2. Physiological destruction of fetal red blood cells during the extrauterine period.

The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

2. Well-approximated edges.

Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? 1. Hematocrit, 39%. 2. White blood cell count, 16,000 cells/mm 3 . 3. Red blood cell count, 5 million cells/mm 3 . 4. Hemoglobin, 15 grams/dL

2. White blood cell count, 16,000 cells/mm

The nurse is caring for a newborn male with hypospadias. His parents ask if circumcision is an option. Which is the nurse's best response? 1. "Circumcision is a fading practice and is now contraindicated in most children." 2. "Circumcision in children with hypospadias is recommended because it helps prevent infection." 3. "Circumcision is an option, but it cannot be done at this time." 4. "Circumcision can never be performed in a child with hypospadias."

3. "Circumcision is an option, but it cannot be done at this time."

A neonate is in the warming crib for poor thermoregulation. Which of the following sites is appropriate for the placement of the skin thermal sensor? 1. Xiphoid process. 2. Forehead. 3. Abdominal wall. 4. Great toe.

3. Abdominal wall.

A mucousy baby is being left with the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding use of the bulb syringe? 1. Suction the nostrils before suctioning the mouth. 2. Make sure to suction the back of the throat. 3. Insert the syringe before compressing the bulb. 4. Dispose of the drainage in a tissue or a cloth.

4. Dispose of the drainage in a tissue or a cloth. so the nurse can look at it. wtf

Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? Select all that apply. 1. Heart rate. 2. Blood pressure. 3. Temperature. 4. Facial expression. 5. Breathing pattern.

4. Facial expression. 5. Breathing pattern.

Early signs and symptoms of hydrocephalus in infants include which of the following? 1. Confusion, headache, diplopia. 2. Rapid head growth, poor feeding, confusion. 3. Papilledema, irritability, headache. 4. Full fontanels, poor feeding, rapid head growth.

4. Full fontanels, poor feeding, rapid head growth.

A newborn admitted to the nursery has a positive direct Coombs test. Which of the following is an appropriate action by the nurse? 1. Monitor the baby for jitters. 2. Assess the blood glucose level. 3. Assess the rectal temperature. 4. Monitor the baby for jaundice.

4. Monitor the baby for jaundice.

A macrosomic infant of a non-insulin dependent diabetic mother has been admitted to the neonatal nursery. The baby's glucose level on admission to the nursery is 30 mg/dL, and after a feeding of the mother's expressed breast milk it is 35 mg/dL. Which of the following actions should the nurse take at this time? 1. Nothing, because the glucose level is normal for an infant of a diabetic mother. 2. Administer intravenous glucagon slowly over five minutes. 3. Feed the baby a bottle of dextrose and water and reassess the glucose level. 4. Notify the neonatologist of the abnormal glucose levels.

4. Notify the neonatologist of the abnormal glucose levels.

A G2 P2002 who is postpartum 6 hours from a spontaneous vaginal delivery is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary healthcare provider.

4. Notify the woman's primary healthcare provider. heavy bleeding!!!!!

The staff on the maternity unit is developing a protocol for nurses to follow after a baby is delivered who fails to breathe spontaneously. Which of the following should be included in the protocol as the first action for the nurse to take? 1. Prepare epinephrine for administration. 2. Provide positive pressure oxygen. 3. Administer chest compressions. 4. Rub the back and feet of the baby.

4. Rub the back and feet of the baby.

The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed? 1. The client states that the pain has decreased. 2. The nurse hears the baby swallow after each suck. 3. The baby's jaws move up and down once every second. 4. The baby's cheeks move in and out with each suck.

4. The baby's cheeks move in and out with each suck. doesn't mean baby is feeding right

A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select all that apply. 1. Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs. 2. Gently adduct and abduct the baby's thighs. 3. Palpate the trochanter during hip rotation. 4. Place the baby in a fetal position. 5. Compare the lengths of the baby's legs.

1,2,3,5

A nurse is performing a postpartum assessment on a client who delivered by cesarean section. Which of the following actions will the nurse perform? Select all that apply. 1. Auscultate the abdomen. 2. Palpate the fundus. 3. Assess the nipple integrity. 4. Assess the central venous pressure. 5. Auscultate the lung fields.

1,2,4,5

A nurse is providing anticipatory guidance to a couple regarding the baby's immunization schedule. Which of the following statements by the parents shows that the teaching by the nurse was successful? Select all that apply. 1. The first hepatitis B injection is given by 1 month of age. 2. The first polio injection will be given at 2 months of age. 3. The measles, mumps, and rubella (MMR) immunization should be administered before the first birthday. 4. Three diphtheria, tetanus, and acellular pertussis (DTaP) shots will be given during the first year of life. 5. The Varivax (varicella) immunization will be administered after the baby turns one year of age.

1,2,4,5

A client asks whether or not there are any foods that she must avoid eating while breastfeeding. Which of the following responses by the nurse is appropriate? 1. "No, there are no foods that are strictly contraindicated while breastfeeding." 2. "Yes, the same foods that were dangerous to eat during pregnancy should be avoided." 3. "Yes, foods like onions, cauliflower, broccoli, and cabbage make babies very colicky." 4. "Yes, spices from hot and spicy foods get into the milk and can bother your baby."

1. "No, there are no foods that are strictly contraindicated while breastfeeding."

The nurse is caring for a Seventh Day Adventist woman who delivered a baby boy by cesarean section. Which of the following questions should be asked regarding this woman's care? 1. "Would you like me to order a vegetarian diet for you?" 2. "Is there anything special you will need for your Sabbath on Sunday?" 3. "Would you like to telephone your clergy to set up a date for the baptism?" 4. "Will a rabbi be performing the circumcision on your baby?"

1. "Would you like me to order a vegetarian diet for you?"

A nurse is receiving an infant with myelomeningocele from an outside hospital. Which of the following priority items should be placed at the newborn's bedside? 1. A bottle of normal saline. 2. A rectal thermometer. 3. Extra blankets. 4. A blood pressure cuff.

1. A bottle of normal saline.

The nurse is caring for a newborn with esophageal atresia. When reviewing the mother's history, the nurse would expect to find which of the following? 1. A history of maternal polyhydramnios. 2. A pregnancy that lasted more than 38 weeks. 3. A history of poor nutrition during pregnancy. 4. A history of alcohol consumption during pregnancy.

1. A history of maternal polyhydramnios.

The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the clients who had which of the following deliveries state that they understand why they must receive a RhoGAM injection? Select all that apply. 1. Abortion at 10 weeks' gestation. 2. Amniocentesis at 16 weeks' gestation. 3. Fetal demise at 24 weeks' gestation. 4. Birth of Rh-negative twins at 35 weeks' gestation. 5. Delivery of a 40-week-gestation, Rh-positive baby.

1. Abortion at 10 weeks' gestation. 2. Amniocentesis at 16 weeks' gestation. 3. Fetal demise at 24 weeks' gestation. 5. Delivery of a 40-week-gestation, Rh-positive baby.

A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see? 1. Baby is showing signs of hunger and frustration. 2. Baby is starting to whimper and cry. 3. Baby is wide awake and attending to a picture. 4. Baby is asleep and breathing rhythmically.

1. Baby is showing signs of hunger and frustration.

A nurse who is caring for a mother/newborn dyad on the maternity unit has identified the following nursing diagnosis: Effective breastfeeding. Which of the following would warrant this diagnosis? 1. Baby's lips are flanged when latched. 2. Baby feeds every 4 hours. 3. Baby lost 12% of weight since birth. 4. Baby's tongue stays behind the gum line.

1. Baby's lips are flanged when latched.

A 42-week-gestation baby, 2,400 grams, whose mother had no prenatal care is admitted into the NICU. The neonatologist orders blood work. Which of the following laboratory findings would the nurse expect to see? 1. Blood glucose 30 mg/dL. 2. Leukocyte count 1,000 cells/mm 3 . 3. Hematocrit 30%. 4. Serum pH 7.8.

1. Blood glucose 30 mg/dL.

A child born with Down syndrome should be evaluated for what associated cardiac manifestation? 1. CHD. 2. Systemic hypertension. 3. Hyperlipidemia. 4. Cardiomyopathy.

1. CHD.

Four babies with the following conditions are in the well-baby nursery. The baby with which of the conditions is at high risk for physiological jaundice? 1. Cephalhematoma. 2. Caput succedaneum. 3. Harlequin coloring. 4. Mongolian spotting.

1. Cephalhematoma.

The nurse is conducting a state-mandated evaluation of a neonate's hearing. Infants are assessed for deficits because hearing-impaired babies are at high risk for which of the following? 1. Delayed speech development. 2. Otitis externa. 3. Poor parental bonding. 4. Choanal atresia.

1. Delayed speech development.

A 2-day-old baby's blood values are: Blood type, O- (negative). Direct Coombs, negative. Hematocrit, 50%. Bilirubin, 1.5 mg/dL. The mother's blood type is A+. What should the nurse do at this time? 1. Do nothing because the results are within normal limits. 2. Assess the baby for opisthotonic posturing. 3. Administer RhoGAM to the mother per doctor's order. 4. Call the doctor for an order to place the baby under bili-lights.

1. Do nothing because the results are within normal limits.

A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate? 1. Do nothing because this is a normal weight loss. 2. Notify the neonatologist of the significant weight loss. 3. Advise the mother to bottle feed the baby at the next feed. 4. Assess the baby for hypoglycemia with a glucose monitor.

1. Do nothing because this is a normal weight loss.

A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time? 1. Encourage the parents to bond with their baby. 2. Notify the neonatologist of the finding. 3. Perform the gestational age assessment. 4. Place the baby under the overhead warmer.

1. Encourage the parents to bond with their baby.

A baby admitted to the nursery was diagnosed with galactosemia from an amniocentesis. Which of the following actions must the nurse take? 1. Feed the baby a specialty formula. 2. Monitor the baby for central cyanosis. 3. Do hemoccult testing on every stool. 4. Monitor the baby for signs of abdominal pain.

1. Feed the baby a specialty formula.

A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply. 1. Fever. 2. Flank pain. 3. Dark-colored urine. 4. Nausea. 5. Polycythemia.

1. Fever. 2. Flank pain. 3. Dark-colored urine.

The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? Select all that apply. 1. Gently massage the areas toward the nipple, especially during feedings. 2. Apply warmth to the areas during feedings. 3. Alternate bottle feedings with breast feedings. 4. Apply lanolin ointment to the areas after each and every breastfeeding. 5. Feed from the affected breast first.

1. Gently massage the areas toward the nipple, especially during feedings. 2. Apply warmth to the areas during feedings. 5. Feed from the affected breast first.

Which of the following laboratory findings would the nurse expect to see in a baby diagnosed with erythroblastosis fetalis? 1. Hematocrit 24%. 2. Leukocyte count 45,000 cells/mm 3 . 3. Sodium 125 mEq/L. 4. Potassium 5.5 mEq/L.

1. Hematocrit 24%.

A newborn in the nursery is exhibiting signs of neonatal abstinence syndrome. Which of the following signs/symptoms is the nurse observing? Select all that apply. 1. Hyperphagia. 2. Lethargy. 3. Prolonged periods of sleep. 4. Hyporeflexia. 5. Persistent shrill cry.

1. Hyperphagia. 5. Persistent shrill cry.

A baby was just born to a mother who had positive vaginal cultures for group B streptococci. The mother was admitted to the labor room 2 hours before the birth. For which of the following should the nursery nurse closely observe this baby? 1. Hypothermia. 2. Mottling. 3. Omphalocele. 4. Stomatitis

1. Hypothermia.

The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? Select all that apply. 1. Hypothyroidism. 2. Sickle cell disease. 3. Galactosemia. 4. Cerebral palsy. 5. Cystic fibrosis.

1. Hypothyroidism. 2. Sickle cell disease. 3. Galactosemia. 5. Cystic fibrosis.

A full-term, 36-hour-old neonate's bilirubin level is 13 mg/dL. Which of the following signs and symptoms would the nurse expect to see? Select all that apply. 1. Lethargy. 2. Jaundice. 3. Polyphagia. 4. Diarrhea. 5. Excessive yawning.

1. Lethargy. 2. Jaundice.

Which of the following complementary therapies can a nurse suggest to a multiparous woman who is complaining of severe afterbirth pains? 1. Lie prone with a small pillow cushioning her abdomen. 2. Contract her abdominal muscles for a count of ten. 3. Slowly ambulate in the hallways. 4. Drink ice tea with lemon or lime.

1. Lie prone with a small pillow cushioning her abdomen.

To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do? 1. Maintain the infant's temperature above 97.7°F/36.5°C. 2. Feed the infant glucose water every 3 hours until breastfeeding well. 3. Assess blood glucose levels every 3 hours for the first twelve hours. 4. Encourage the mother to breastfeed every 4 hours.

1. Maintain the infant's temperature above 97.7°F/36.5°C. prevents cold stress-- which causes hypoglycemia

A nurse is inserting a gavage tube into a preterm baby who is unable to suck and swallow. Which of the following actions must the nurse take during the procedure? 1. Measure the distance from the tip of the ear to the nose. 2. Lubricate the tube with an oil-based solution. 3. Insert the tube quickly if the baby becomes cyanotic. 4. Inject a small amount of sterile water to check placement.

1. Measure the distance from the tip of the ear to the nose.

The client in labor is diagnosed with pregnancy-induced hypertension and has preeclampsia. Which interventions should the nurse implement? Select all that apply. 1. Monitor the intravenous (IV) magnesium sulfate. 2. Check the client's telemetry monitor. 3. Assess the client's deep tendon reflexes. 4. Administer furosemide (Lasix) intravenous push (IVP). 5. Notify the nursery when delivery is imminent or has occurred.

1. Monitor the intravenous (IV) magnesium sulfate. 3. Assess the client's deep tendon reflexes. 5. Notify the nursery when delivery is imminent or has occurred.

The nurse must initiate discharge teaching with the couple regarding the need for an infant car seat for the day of discharge. Which of the following responses indicates that the nurse acted appropriately? The nurse discussed the need with the couple: 1. On admission to the labor room. 2. In the client room after the delivery. 3. When the client put the baby to the breast for the first time. 4. The day before the client and baby are to leave the hospital.

1. On admission to the labor room.

A baby born addicted to cocaine is being given oral morphine. The nurse knows that which of the following are the main reasons for its use? Select all that apply. 1. Oral morphine contains no alcohol. 2. Oral morphine helps to correct the diarrhea. 3. Oral morphine is nonsedating. 4. Oral morphine improves respiratory effort. 5. Oral morphine helps to control seizures.

1. Oral morphine contains no alcohol. 2. Oral morphine helps to correct the diarrhea. 5. Oral morphine helps to control seizures.

Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? 1. Pain. 2. Bleeding. 3. Warmth. 4. Redness.

1. Pain.

A neonate is being assessed for necrotizing enterocolitis (NEC). Which of the following actions by the nurse is appropriate? Select all that apply. 1. Perform hemoccult test on stools. 2. Monitor for an increase in abdominal girth. 3. Measure gastric contents before each feed. 4. Assess bowel sounds before each feed. 5. Assess for anal fissures daily.

1. Perform hemoccult test on stools. 2. Monitor for an increase in abdominal girth. 3. Measure gastric contents before each feed. 4. Assess bowel sounds before each feed.

The labor and delivery nurse is performing a vaginal examination and assesses a prolapsed cord. Which intervention should the nurse implement first? 1. Place the client in the Trendelenburg position. 2. Ask the father to leave the delivery room. 3. Request the client not to push during contractions. 4. Prepare the client for an emergency C-section.

1. Place the client in the Trendelenburg position.

A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following prn medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Demerol (meperidine). 3. Seconal (secobarbital). 4. Benadryl (diphenhydramine).

1. Reglan (metoclopramide).

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. Remove wet blankets.

An Asian client's temperature 10 hours after delivery is 100.2°F but, when encouraged, she refuses to drink her ice water. Which of the following nursing actions is most appropriate? 1. Replace the ice water with hot water. 2. Notify the client's healthcare provider. 3. Reassess the temperature in one-half hour. 4. Remind the client that drinking is very important.

1. Replace the ice water with hot water.

The nurse suspects that a newborn in the nursery has a clubbed right foot because the foot is plantar flexed as well as which of the following? 1. Right foot that will not move into alignment. 2. Positive Ortolani sign on the right. 3. Shortened right metatarsal arch. 4. Positive Babinski reflex on the right.

1. Right foot that will not move into alignment.

A client is on magnesium sulfate via IV pump for severe pre-eclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks.

1. Serial grip strengths. assesses for mag toxicity

A mother tells the nurse that because of family history she is afraid her baby son will develop colic. Which of the following colic management strategies should the parents be taught? Select all that apply. 1. Small, frequent feedings. 2. Prone sleep positioning. 3. Tightly swaddling the baby. 4. Rocking the baby while holding him face down on the forearm. 5. Maintaining a home environment that is cigarette smoke-free.

1. Small, frequent feedings. 3. Tightly swaddling the baby. 4. Rocking the baby while holding him face down on the forearm 5. Maintaining a home environment that is cigarette smoke-free.

A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a cesarean delivery, fetal position LMA, under epidural anesthesia. Which of the following physiological findings would the nurse expect to see? 1. Soft pulmonary rales. 2. Absent bowel sounds. 3. Depressed Moro reflex. 4. Positive Ortolani sign.

1. Soft pulmonary rales.

A 42-week gravida is delivering her baby. A nurse and pediatrician are present at the birth. The amniotic fluid is green and thick. The baby fails to breathe spontaneously. Which of the following actions should the nurse take next? Select all that apply. 1. Stimulate the baby to breathe. 2. Assess neonatal heart rate. 3. Prepare to assist with intubation. 4. Place the baby in the prone position. 5. Place the baby under the overhead warmer.

1. Stimulate the baby to breathe. 3. Prepare to assist with intubation. 5. Place the baby under the overhead warmer.

A neonate is being given intravenous fluids through the dorsal vein of the wrist. Which of the following actions by the nurse is essential? 1. Tape the arm to an arm board. 2. Change the tubing every 24 hours. 3. Monitor the site every 5 minutes. 4. Infuse the fluid intermittently.

1. Tape the arm to an arm board.

During a postpartum assessment, it is noted that a G1 P1001 woman who delivered vaginally over an intact perineum has a cluster of hemorrhoids. Which of the following would be appropriate for the nurse to include in the woman's health teaching? Select all that apply. 1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 3. The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. 4. The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. 5. The client should apply topical anesthetic as a relief measure.

1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 5. The client should apply topical anesthetic as a relief measure.

A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse's response? 1. The client's obstetric status is optimal for receiving the vaccine. 2. The client's immune system is highly responsive during the postpartum period. 3. The client's baby will be high risk for acquiring rubella if the woman does not receive the vaccine. 4. The client's insurance company will pay for the shot if it is given during the immediate postpartum period.

1. The client's obstetric status is optimal for receiving the vaccine.

The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation? 1. The mother reports a pain level of 4 on a 5-point scale. 2. The baby has been suckling for over 10 minutes. 3. The mother uses the cross-cradle hold while feeding. 4. The baby lies with the chin touching the under part of the breast.

1. The mother reports a pain level of 4 on a 5-point scale.

Which action by the nurse warrants intervention by the charge nurse on the postpartum unit? 1. The nurse offers the Muslim client a ham sandwich and salad for lunch. 2. The nurse asks the Seventh Day Adventist client if she needs anything for her Sabbath on Saturday. 3. The nurse offers the Asian client who is febrile hot water instead of cold water. 4. The nurse explains to the Jehovah's Witness client who is Rh-negative that Rhogam is a blood product.

1. The nurse offers the Muslim client a ham sandwich and salad for lunch.

A bottle feeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that the teaching was successful? Select all that apply. 1. The woman gently strokes and pats her baby's back. 2. The woman positions the baby in a sitting position on her lap. 3. The woman waits to burp the baby until the baby's feeding is complete. 4. The woman states that a small amount of regurgitated formula is acceptable. 5. The woman remarks that the baby does not need to burp after trying for one full minute.

1. The woman gently strokes and pats her baby's back. 2. The woman positions the baby in a sitting position on her lap. 4. The woman states that a small amount of regurgitated formula is acceptable.

A baby whose mother was addicted to heroin during pregnancy is in the NICU. Which of the following nursing actions would be appropriate for the nurse to perform? 1. Tightly swaddle the baby. 2. Place the baby prone in the crib. 3. Provide needed stimulation to the baby. 4. Feed the baby half-strength formula.

1. Tightly swaddle the baby. helps control hyperreflexia

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O negative. 2. Type A negative. 3. Type B positive. 4. Type AB positive.

1. Type O negative.

A mother is told that she should bottle feed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply. 1. Untreated, active tuberculosis (TB). 2. Hepatitis B surface antigen positive. 3. Human immunodeficiency virus positive. 4. Chorioamnionitis. 5. Mastitis.

1. Untreated, active tuberculosis (TB). 3. Human immunodeficiency virus positive.

A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? Select all that apply. 1. "Babies have a poorly developed sense of smell until they are 2 months old." 2. "Babies respond to all forms of taste well, but they prefer to eat sweet things like breast milk." 3. "Babies are especially sensitive to being touched and cuddled." 4. "Babies are nearsighted with blurry vision until they are about 3 months of age." 5. "Babies respond to many sounds, especially to the high-pitched tone of the female voice."

2. "Babies respond to all forms of taste well, but they prefer to eat sweet things like breast milk." 3. "Babies are especially sensitive to being touched and cuddled." 5. "Babies respond to many sounds, especially to the high-pitched tone of the female voice."

The nurse is caring for a newborn with a cleft lip and palate. The mother states, "I will not be able to breastfeed my baby." Select the nurse's best response. 1. "It sounds like you are feeling discouraged. Would you like to talk about it?" 2. "Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?" 3. "Although breastfeeding is not an option, you have the option of pumping your milk and then feeding it to your baby with a special nipple." 4. "We usually discourage breastfeeding babies with cleft lip and palate as it puts them at an increased risk for aspiration."

2. "Sometimes breastfeeding is still an option for babies with a cleft lip and palate. Would you like more information?"

A client who delivered a 3,900-gram baby vaginally over a right mediolateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fiber foods and drink fluids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."

2. "Your stitches are actually far away from your rectal area."

A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following needles should the nurse choose for the injection? 1. 5/8 inch, 18 gauge. 2. 5/8 inch, 25 gauge. 3. 1 inch, 18 gauge. 4. 1 inch, 25 gauge.

2. 5/8 inch, 25 gauge.

The nurse is caring for a newborn who has just been diagnosed with tracheoesophageal atresia and is scheduled for surgery. Which of the following should the nurse expect to do in the preoperative period? 1. Keep the child in a monitored crib, obtain frequent vital signs, and allow the parents to visit but not hold their infant. 2. Administer intravenous fluids and antibiotics. 3. Place the infant on 100% oxygen via a non-rebreather mask. 4. Have the mother feed the infant slowly in a monitored area, stopping all feedings 4 to 6 hours before surgery.

2. Administer intravenous fluids and antibiotics.

The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action? 1. Meconium is filled with enteric bacteria. 2. Amniotic fluid may contain harmful viruses. 3. The high alkalinity of fetal urine is caustic to the skin. 4. The baby is at high risk for infection and must be protected.

2. Amniotic fluid may contain harmful viruses.

A baby is born with erythroblastosis fetalis. Which of the following signs/ symptoms would the nurse expect to see? 1. Ruddy complexion. 2. Anasarca. 3. Alopecia. 4. Erythema toxicum.

2. Anasarca.

A postpartum nurse notes that a woman who took fluoxetine (Prozac) daily for depression throughout her pregnancy has an order from the primary healthcare provider for the medication to be continued postdelivery. The woman wishes to breastfeed her baby. Which of the following actions is appropriate for the nurse to make at this time? 1. Inform the neonatalogist regarding the antenatal medication so that an autism assessment will be performed on the baby. 2. Ask the client's primary healthcare provider if the woman could take a different antidepressant medication postdelivery. 3. Advise the client that it would be unsafe for her to breastfeed her child. 4. Praise the client for understanding her need to take an antidepressant.

2. Ask the client's primary healthcare provider if the woman could take a different antidepressant medication postdelivery.

A Roman Catholic couple has just delivered a baby with an Apgar score of 1 at 1 minute, 2 at 5 minutes, and 2 at 10 minutes. Which of the following interventions is appropriate at this time? 1. Advise the parents that they should pray very hard so that everything turns out well. 2. Ask the parents whether they would like the nurse to baptize the baby. 3. Leave the parents alone to work through their thoughts and feelings. 4 . Inform the parents that a priest will listen to their confessions whenever they are ready.

2. Ask the parents whether they would like the nurse to baptize the baby.

A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz, 21 inches long, TPR: 96.6°F/35.9°C, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following nursing actions is of highest importance? 1. Swaddle the baby to provide warmth. 2. Assess the glucose level of the baby. 3. Take the baby to the mother for feeding. 4. Administer the neonatal medications.

2. Assess the glucose level of the baby.

Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? 1. Baby with respirations 42, oxygen saturation 96%. 2. Baby with Apgar 9/9, weight 4,660 grams. 3. Baby with temperature 98°F/36.7°C, length 21 inches. 4. Baby with glucose 55 mg/dL, heart rate 121.

2. Baby with Apgar 9/9, weight 4,660 grams. so the baby is overweight and at risk for being hypoglycemic

Which of the following statements is true about breastfeeding mothers as compared to bottle-feeding mothers? 1. Breastfeeding mothers usually involute completely by 3 weeks postpartum. 2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life. 3. Breastfeeding mothers show higher levels of bone density after menopause. 4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.

2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life.

Intravenous magnesium sulfate has been ordered for a 31 weeks' gestation client in preterm labor. The client's vital signs are: TPR 98.6°F /37°C, 92, 22; BP 110/70. The nurse knows that, in addition to its tocolytic action, the rationale for its administration is to prevent which of the following neonatal complications? 1. Hypoxemia. 2. Cerebral palsy. 3. Cold stress syndrome. 4. Necrotizing enterocolitis.

2. Cerebral palsy.

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with povidone-iodine after toileting.

2. Change the peripad at each voiding.

The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? 1. Teach baby-care skills such as diapering. 2. Discuss the labor and birth with the mother. 3. Discuss contraceptive choices with the mother. 4. Teach breastfeeding skills such as pumping.

2. Discuss the labor and birth with the mother.

A baby has been admitted to the neonatal intensive care unit with a diagnosis of symmetrical intrauterine growth restriction (IUGR). Which of the following pregnancy complications would be consistent with this diagnosis? 1. Severe pre-eclampsia. 2. Fetal chromosomal defect. 3. Infarcts in an aging placenta. 4. Preterm premature rupture of the membranes.

2. Fetal chromosomal defect.

A nurse is caring for the following four laboring patients. Which clients should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select all that apply. 1. G1 P0000, delivered a fetal demise at 29 weeks' gestation. 2. G2 P1001, prolonged first stage of labor. 3. G2 P0010, delivered by cesarean section for failure to progress. 4. G3 P0200, delivered vaginally a 42-week, 2,200-gram neonate. 5. G4 P3003, with a succenturiate placenta.

2. G2 P1001, prolonged first stage of labor. 5. G4 P3003, with a succenturiate placenta.

The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible? Select all that apply. 1. Blood in the diaper. 2. Grunting during expiration. 3. Deep red coloring on one side of the body with pale pink on the other side. 4. Lacy and mottled appearance over the entire chest and abdomen. 5. Flaring of the nares during inspiration.

2. Grunting during expiration. 5. Flaring of the nares during inspiration.

A breastfeeding woman, 6 weeks postdelivery, must go into the hospital for a hemorrhoidectomy. Which of the following is the best intervention regarding infant feeding? 1. Have the woman wean the baby to formula. 2. Have the baby stay in the hospital room with the mother. 3. Have the woman pump and dump her milk for two weeks. 4. Have the baby bottle-fed milk that the mother has stored.

2. Have the baby stay in the hospital room with the mother.

A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included? Select all that apply. 1. If their baby is sleeping soundly, they should not awaken the baby for a feeding. 2. If their baby is exposed to the sun, they should put sunscreen on the baby. 3. They should purchase liquid acetaminophen to be used when ordered by the pediatrician. 4. They should notify their pediatrician when the umbilical cord falls off. 5. When strapping their baby into a car seat, they should position the top of the chest clip at the level of the baby's belly button.

2. If their baby is exposed to the sun, they should put sunscreen on the baby. 3. They should purchase liquid acetaminophen to be used when ordered by the pediatrician.

A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6°F, P 72, R 20, BP 150/100, and her reflexes are 4+. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate? 1. Nothing, because the results are normal. 2. Notify the obstetrician of the findings. 3. Discontinue the intravenous immediately. 4. Reassess the client after fifteen minutes.

2. Notify the obstetrician of the findings. signs of preeclampsia

The nurse is caring for a newborn with Erb palsy and a phrenic nerve paralysis. The most effective way to promote respiratory effort is for the nurse to position the newborn in what way? 1. Supine. 2. On the affected side. 3. On the unaffected side. 4. Prone.

2. On the affected side.

A woman who received an intravenous analgesic 4 hours ago has had prolonged late decelerations in labor. She will deliver her baby shortly. Which of the following is the priority action for the delivery room nurse to take? 1. Preheat the overhead warmer. 2. Page the neonatologist on call. 3. Draw up Narcan (naloxone) for injection. 4. Assemble the oral ophthalmic antibiotic.

2. Page the neonatologist on call.

A baby has just been born to a type 1 diabetic mother who has retinopathy and nephropathy. Which of the following neonatal findings would the nurse expect to see? 1. Hyperalbuminemia. 2. Polycythemia. 3. Hypercalcemia. 4. Hypoinsulinemia.

2. Polycythemia. bc placenta isn't functioning as well as it should

A baby is born with caudal agenesis. Which of the following maternal complications is associated with this defect? 1. Poorly controlled myasthenia gravis. 2. Poorly controlled diabetes mellitus. 3. Poorly controlled splenic syndrome. 4. Poorly controlled hypothyroidism.

2. Poorly controlled diabetes mellitus.

A nurse is advising a mother of a neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select all that apply. 1. Place the baby's car seat in the front passenger seat of the car. 2. Position the car seat rear facing until the baby reaches two years of age. 3. Attach the car seat to the car at 2 latch points at the base of the car seat. 4. Check that the installed car seat moves no more than 1 inch side to side or front to back. 5. Make sure that there is at least a 3-inch space between the straps of the seat and the baby's body.

2. Position the car seat rear facing until the baby reaches two years of age. 3. Attach the car seat to the car at 2 latch points at the base of the car seat. 4. Check that the installed car seat moves no more than 1 inch side to side or front to back.

A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make? 1. Integrity of the baby's uvula. 2. Presence of maternal nipple damage. 3. Presence of neonatal tongue injury. 4. The baby's breathing pattern.

2. Presence of maternal nipple damage. tongue tied baby can hurt mom

A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose? 1. Vitamin K. 2. Protamine. 3. Vitamin E. 4. Mannitol.

2. Protamine. vitamin K is for Coumadin

The nurse assesses a 2-day postpartum, breastfeeding client. The nurse notes blood on the mother's breast pad and a crack on the mother's nipple. Which of the following actions should the nurse perform at this time? 1. Advise the woman to wash the area with soap to prevent mastitis. 2. Provide the woman with a tube of topical lanolin. 3. Remind the woman that the baby can become sick if he drinks the blood. 4. Request an order for a topical anesthetic for the mother.

2. Provide the woman with a tube of topical lanolin.

A young woman, age 12, is postpartum from a vaginal delivery. Which of the following actions is appropriate for the nurse to make at this time? 1. Ask the young woman when her boyfriend will be visiting her in hospital. 2. Report the young woman to the local child abuse agency. 3. Strongly advise the young woman always to use birth control in the future. 4. Advise the young woman that she is much too young to be having sex.

2. Report the young woman to the local child abuse agency.

The nurse is discussing the importance of doing Kegel exercises during the postpartum period. Which of the following should be included in the teaching plan? 1. She should repeatedly contract and relax her rectal and thigh muscles. 2. She should practice by stopping the urine flow midstream every time she voids. 3. She should get on her hands and knees whenever performing the exercises. 4. She should be advised that her Kegel exercises should be performed during all bowel movements.

2. She should practice by stopping the urine flow midstream every time she voids.

The nurse caring for an infant with a congenital cardiac defect is monitoring the child for which of the following early signs of congestive heart failure? Select all that apply. 1. Palpitations. 2. Tachypnea. 3. Tachycardia. 4. Diaphoresis. 5. Irritability.

2. Tachypnea. 3. Tachycardia. 4. Diaphoresis.

The nurse working in a women's health clinic is returning telephone calls. Which client should the nurse contact first? 1. The 16-year-old client who is complaining of severe lower abdominal cramping. 2. The 27-year-old primigravida client who is complaining of blurred vision. 3. The 48-year-old perimenopausal client who is expelling dark-red blood clots. 4. The 68-year-old client who thinks her uterus is falling out of her vagina.

2. The 27-year-old primigravida client who is complaining of blurred vision.

A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication? 1. It is administered to prevent the development of neonatal cataracts. 2. The medicine should be placed in the lower conjunctiva from the inner to outer canthus. 3. The medicine must be administered immediately upon delivery of the baby. 4. It is administered to neonates whose mothers test positive for gonorrhea during pregnancy.

2. The medicine should be placed in the lower conjunctiva from the inner to outer canthus.

A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate? 1. Before the procedure, the nurse prepares the sterile field for the physician. 2. The nurse refuses to unclothe the baby until the doctor orders something for pain. 3. The nurse holds the feeding immediately before the circumcision. 4. After the procedure, the nurse monitors the site for signs of bleeding.

2. The nurse refuses to unclothe the baby until the doctor orders something for pain.

A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.

2. The nurse stabilizes the base of the uterus with his or her dependent hand.

A woman with postpartum depression has been prescribed Zoloft (sertraline) 50 mg daily. Which of the following should the client be taught about the medication? 1. Chamomile tea can potentiate the effect of the drug. 2. Therapeutic effect may be delayed a week or more. 3. The medication should only be taken whole. 4. A weight gain of up to ten pounds is commonly seen.

2. Therapeutic effect may be delayed a week or more. most antidepressants take 2-4 weeks

A mother is attempting to latch her newborn baby to the breast. Which of the following actions are important for the mother to perform to achieve effective breastfeeding? Select all that apply. 1. Place the baby on his or her back in the mother's lap. 2. Wait until the baby opens his or her mouth wide. 3. Hold the baby at the level of the mother's breasts. 4. Point the baby's nose to the mother's nipple. 5. Wait until the baby's tongue is pointed toward the roof of his or her mouth.

2. Wait until the baby opens his or her mouth wide. 3. Hold the baby at the level of the mother's breasts. 4. Point the baby's nose to the mother's nipple. 5. Wait until the baby's tongue is pointed toward the roof of his or her mouth.

A breastfeeding mother of a newborn states, "I was good all during my pregnancy. I stopped drinking alcohol and I quit smoking marijuana during my pregnancy. Now that I'm no longer pregnant, one of the first things I'm going to do when I get home is have a joint." Which of the following responses is appropriate for the nurse to give? 1. "I am proud of you for waiting to have those things. It must have been hard for you to abstain for so many months." 2. "You are making the best choice since marijuana is safe while breastfeeding but alcohol is contraindicated." 3. "Because the drug in marijuana does get into breast milk and can alter a baby's development, it is best not to use the drug while breastfeeding." 4. "Both alcohol and marijuana are removed from the body within about two hours. It would be best to wait that long before breastfeeding after consuming either of them."

3. "Because the drug in marijuana does get into breast milk and can alter a baby's development, it is best not to use the drug while breastfeeding."

A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse that when she and her husband had intercourse for the first time after the delivery, "I couldn't stand it. It was so painful. The doctor must have done something terrible to my vagina." Which of the following responses by the nurse is appropriate? 1. "After a delivery the vagina is always very tender. It should feel better the next time you have intercourse." 2. "Does your baby have thrush? If so, you should be assessed for a yeast infection in your vagina." 3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort." 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in to be checked?"

3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort."

Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist? 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. 2-day-old baby who is breathing irregularly at 70 breaths per minute.

The following four babies are in the neonatal nursery. The nurse should report to the neonatologist that which of the babies should be seen? 1. 1-day-old, HR 100 beats per minute, in deep sleep. 2. 2-day-old, T 97.7°F/36.5°C, slightly jaundiced. 3. 3-day-old, breastfeeding every 4 hours, jittery. 4. 4-day-old, crying, papular rash on an erythematous base.

3. 3-day-old, breastfeeding every 4 hours, jittery. think hypoglycemia

A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure? 1. Cover the foot with an iced wrap for one minute prior to the procedure. 2. Avoid puncturing the lateral heel to prevent damaging sensitive structures. 3. Allow the site to dry after rubbing it with an alcohol swab. 4. Firmly grasp the calf of the baby during the procedure to prevent injury.

3. Allow the site to dry after rubbing it with an alcohol swab.

A client on the postpartum unit is preparing to breastfeed her Down syndrome baby. Which of the following actions by the nurse is appropriate at this time? 1. To prevent the baby from becoming obese, educate the mother to allow the baby to breastfeed for only 30 minutes at each feeding. 2. Provide the mother with the same breastfeeding advice that the nurse gives to all breastfeeding mothers. 3. Assist the mother to latch her baby to the breast and educate her regarding how to assess for effective milk transfer. 4. To prevent the baby from becoming anemic, remind the mother to administer iron supplements to the baby every day.

3. Assist the mother to latch her baby to the breast and educate her regarding how to assess for effective milk transfer.

A medication order reads: Methergine (ergonovine) 0.2 mg PO q 6 h × 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia flow. 3. Blood pressure. 4. Episiotomy.

3. Blood pressure.

A client who is post-cesarean section for severe pre-eclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first? 1. Give two breaths. 2. Discontinue medications. 3. Call a code. 4. Check the carotid pulse.

3. Call a code.

An infant in the neonatal nursery has low-set ears, Simian creases, and slanted eyes. The nurse should monitor this infant carefully for which of the following signs/symptoms? 1. Blood-tinged urine. 2. Hemispheric paralysis. 3. Cardiac murmur. 4. Hemolytic jaundice.

3. Cardiac murmur. occurs more often in down syndrome babies

During an interview, the pregnant client at the women's health clinic hesitantly tells the nurse, "I think I should let someone know that I can't stop eating dirt. I crave it all the time." Which action should the nurse implement first? 1. Explain that the behavior is normal. 2. Ask whether the client is taking the prenatal vitamins. 3. Check the client's hemoglobin and hematocrit (H&H). 4. Determine whether there is a history of pica in the family.

3. Check the client's hemoglobin and hematocrit (H&H).

A neonate who is being admitted into the well-baby nursery is exhibiting each of the following assessment findings. Which of the findings should the nurse report to the primary healthcare provider? Select all that apply. 1. Harlequin sign. 2. Extension of the toes when the lateral aspect of the sole is stroked. 3. Elbow moves past the midline when the scarf sign is assessed. 4. Slightly curved pinnae of the ears that are slow to recoil. 5. Telangiectatic nevi.

3. Elbow moves past the midline when the scarf sign is assessed. 4. Slightly curved pinnae of the ears that are slow to recoil.

A neonate is to receive the hepatitis B vaccine in the neonatal nursery. Which of the following must the nurse have available before administering the injection? 1. Hepatitis B immune globulin in a second syringe. 2. Sterile water to dilute the vaccine before injecting. 3. Epinephrine in case of severe allergic reactions. 4. Oral syringe because the vaccine is given by mouth.

3. Epinephrine in case of severe allergic reactions.

A 6-month-old child developed kernicterus immediately after birth. Which of the following tests should be done to determine whether or not this child has developed any sequelae to the illness? 1. Blood urea nitrogen and serum creatinine. 2. Alkaline phosphatase and bilirubin. 3. Hearing testing and vision assessment. 4. Peak expiratory flow and blood gas assessments.

3. Hearing testing and vision assessment.

The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary healthcare provider? 1. White blood cells, 12,500 cells/mm 3 . 2. Red blood cells, 4,500,000 cells/mm 3. Hematocrit, 26%. 4. Hemoglobin, 11 g/dL

3. Hematocrit, 26%.

The blood glucose of a client with type 1 diabetes 12 hours after delivery is 96 mg/ dL. The client has received no insulin since delivery. The drop in serum levels of which of the following hormones of pregnancy is responsible for the glucose level? 1. Estrogen. 2. Progesterone. 3. Human placental lactogen (hPL). 4. Human chorionic gonadotropin (hCG).

3. Human placental lactogen (hPL). insulin antagonist!!!!

A full-term baby's bilirubin level is 12 mg/dL on day 3. Which of the following neonatal behaviors would the nurse expect to see? 1. Excessive crying. 2. Increased appetite. 3. Lethargy. 4. Hyperreflexia.

3. Lethargy.

A woman who wishes to breastfeed advises the nurse that she had a breast reduction one year earlier. Which of the following responses by the nurse is appropriate? 1. Advise the woman that unfortunately she will be unable to breastfeed. 2. Examine the woman's breasts to see where the incision was placed. 3. Monitor the baby's daily weights for excessive weight loss. 4. Inform the woman that reduction surgery rarely affects milk transfer.

3. Monitor the baby's daily weights for excessive weight loss.

There is a baby in the neonatal intensive care unit (NICU) who is exhibiting signs of neonatal abstinence syndrome. Which of the following medications is contraindicated for this neonate? 1. Morphine. 2. Methadone. 3. Narcan. 4. Phenobarbital.

3. Narcan.

A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.

3. Normal postpartum behavior.

A neonate whose mother is HIV positive is admitted to the NICU. A nursing diagnosis: Risk for infection related to perinatal exposure to HIV/AIDS is made. Which of the following interventions should the nurse make in relation to the diagnosis? 1. Monitor daily viral load laboratory reports. 2. Check the baby's viral antibody status. 3. Obtain an order for antiviral medication. 4. Place the baby on contact precautions.

3. Obtain an order for antiviral medication.

A baby has been admitted to the neonatal nursery whose mother is hepatitis B-surface antigen positive. Which of the following actions by the nurse should be taken at this time? 1. Monitor the baby for signs of hepatitis B. 2. Place the baby on contact isolation. 3. Obtain an order for the hepatitis B vaccine and the immune globulin. 4. Advise the mother that breastfeeding is absolutely contraindicated.

3. Obtain an order for the hepatitis B vaccine and the immune globulin.

A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks? 1. Skim milk. 2. Ginger ale. 3. Orange juice. 4. Chamomile tea.

3. Orange juice.

A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery with complaints of burning on urination. 2. PP2 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO4 from cesarean delivery with complaints of firm and painful breasts.

3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL.

The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement? 1. Maintain the client in left lateral recumbent position. 2. Teach sitz bath use on second postoperative day. 3. Perform active range-of-motion exercises until ambulating. 4. Assess central venous pressure during first postoperative day.

3. Perform active range-of-motion exercises until ambulating. prevents VTE

A neonate has intrauterine growth restriction secondary to placental insufficiency. Which of the following signs/symptoms should the nurse expect to observe at delivery? Select all that apply. 1. Thrombocytopenia. 2. Neutropenia. 3. Polycythemia. 4. Hypoglycemia. 5. Hyperlipidemia.

3. Polycythemia. 4. Hypoglycemia.

Which of the following neonates is at highest risk for cold stress syndrome? 1. Infant of diabetic mother. 2. Infant with Rh incompatibility. 3. Postdates neonate. 4. Down syndrome neonate.

3. Postdates neonate.

A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is at much less high risk for? 1. Pruritus. 2. Nausea. 3. Postural headache. 4. Respiratory depression.

3. Postural headache.

The nurse is caring for a 1-month-old term infant who experienced an anoxic episode at birth. The health-care team suspects that the infant is developing NEC. Which of the following would the nurse expect to be included in the plan of care? 1. Immediately remove the feeding NGT from the infant. 2. Obtain vital signs every 4 hours. 3. Prepare to administer antibiotics intravenously. 4. Change feedings to half-strength and administer slowly via a feeding pump.

3. Prepare to administer antibiotics intravenously.

Which outcome is expected in a breast-fed newborn? 1. Voids spontaneously within 12 hours of life. 2. Loses 10% of body weight in the first 5 days. 3. Regains birth weight by the 10th day of life. 4. Awakens spontaneously for all feedings.

3. Regains birth weight by the 10th day of life.

The nurse in the labor and delivery department is caring for a client whose abdomen remains hard and rigid between contractions and the fetal heart rate is 100. Which client problem is priority? 1. Alteration in comfort. 2. Ineffective breathing pattern. 3. Risk for fetal demise. 4. Fluid and electrolyte imbalance.

3. Risk for fetal demise.

A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with "latch on" and recommends that the mother do which of the following? 1. Use a nipple shield at each breastfeeding. 2. Cleanse the nipples with soap 3 times a day. 3. Rotate the baby's positions at each feed. 4. Bottle feed for 2 days then resume breastfeeding.

3. Rotate the baby's positions at each feed.

A nurse takes a Spanish-speaking Mexican woman her baby to breastfeed. The woman refuses to feed and makes motions that she wants to bottle feed. Which of the following is a likely explanation for the woman's behavior? 1. She has decided not to breastfeed. 2. She thinks she must give formula before the breast. 3. She believes that colostrum is bad for the baby. 4. She thinks that she should bottle feed.

3. She believes that colostrum is bad for the baby.

A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal factors would predispose the baby to this diagnosis? Select all that apply. 1. Hyperopia. 2. Gestational diabetes. 3. Substance abuse. 4. Chronic hypertension. 5. Advanced maternal age.

3. Substance abuse. 4. Chronic hypertension. 5. Advanced maternal age.

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 the child in an isolette. 2. Administer oxygen. 3. Swaddle the baby in a blanket. 4. Apply pulse oximeter.

3. Swaddle the baby in a blanket.

An infant at 12 hours of age has a positive Coombs test result and a bilirubin level of 18 mg/dL. The provider has ordered an exchange transfusion for the infant. As the transfusion is proceeding, the nurse should watch for which sign? 1. Increasing jaundice. 2. Lethargy. 3. Temperature instability. 4. Irritability

3. Temperature instability.

15. A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information? 1. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide. 2. The mother covers the glans with antifungal ointment after rinsing off any discharge. 3. The mother squeezes soapy water from the wash cloth over the glans. 4. The mother replaces the dry sterile dressing before putting on the diaper.

3. The mother squeezes soapy water from the wash cloth over the glans.

When administering the neonatal screening for critical congenital heart defects (CCHD) on a baby in the well baby nursery, the nurse should perform which of the following actions? Select all that apply. 1. Obtain parental consent before performing the screen. 2. Take the baby's electrocardiogram. 3. Wait until the baby is at least 24 hours old. 4. Record the baby's heart rate fluctuations for one full minute. 5. Report pulse oximetry readings of 96% on the hand and 92% on the foot.

3. Wait until the baby is at least 24 hours old. 5. Report pulse oximetry readings of 96% on the hand and 92% on the foot.

A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? 1. "That is very concerning. I will request that your physician order an enema for you." 2. "Two days is not that bad. Some patients go four days or longer without a movement." 3. "You have been taking antibiotics through your intravenous. That is probably why you are constipated." 4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."

4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."

The parents of a newborn diagnosed with a cleft lip and palate ask the nurse when their child's lip and palate will most likely be repaired. Select the nurse's best response. 1. "The palate and the lip are usually repaired in the first few weeks of life so that the baby can grow and gain weight." 2. "The palate and the lip are usually not repaired until the baby is approximately 6 months old so that the mouth has had enough time to grow." 3. "The lip is repaired in the first few months of life, but the palate is not usually repaired until the child is 3 years old." 4. "The lip is repaired in the first few weeks of life, but the palate is not usually repaired until the child is 18 months old."

4. "The lip is repaired in the first few weeks of life, but the palate is not usually repaired until the child is 18 months old."

The nurse is teaching feeding techniques to new parents. The nurse emphasizes the importance of slowly warming the formula and testing the temperature prior to feed- ing the infant. The parent of a newborn asks, "Will my baby spit out the formula if it is too hot or too cold?" Select the nurse's best response. 1. "Babies have a tendency to reject hot fluids but not cold fluids, which could result in abdominal discomfort." 2. "Babies have a tendency to reject cold fluids but not hot fluids, which could result in esophageal burns." 3. "Your baby would most likely spit out formula that was too hot, but your baby could swallow some of it, which could result in a burn." 4. "Your baby is too young to be physically capable of spitting out fluids and will automatically swallow anything."

4. "Your baby is too young to be physically capable of spitting out fluids and will automatically swallow anything."

The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend? 1. ½ cup raw celery dipped in 1 ounce cream cheese. 2. 8 ounces yogurt mixed with 1 medium banana. 3. 12 ounces strawberry milk shake. 4. 1½ cups raw broccoli.

4. 1½ cups raw broccoli.

The nurse observes a healthy woman from Africa expressing breast milk into her baby's eyes. Which of the following responses by the nurse is appropriate at this time? 1. Report the abusive behavior to the social worker. 2. Advise the mother that her action is potentially dangerous. 3. Observe the mother for other signs of irrational behavior. 4. Ask the woman about other cultural traditions.

4. Ask the woman about other cultural traditions.

The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? 1. Provide the client with a nutritious meal. 2. Encourage the client to take a nap. 3. Assist the client with activities of daily living. 4. Assure the client that she is an excellent mother.

4. Assure the client that she is an excellent mother.

When examining a neonate in the well-baby nursery, the nurse notes that the sclerae of the baby's eyes are visible above the iris of the eyes. Which of the following assessments is highest priority for the nurse to make next? 1. Babinski and tonic neck reflexes. 2. Evaluation of bilateral eye coordination. 3. Blood type and Coombs test results. 4. Circumferences of the head and chest.

4. Circumferences of the head and chest. assess for hydrocephalus

A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottle feed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.

4. Discuss the action of breastfeeding hormones. normal response r/t oxytocin

The nurse is providing discharge teaching to the parents of a baby born with a cleft lip and palate. Which of the following should be included in the teaching? 1. Correct technique for the administration of a gastrostomy feeding. 2. Need to watch for the appearance of blood-stained mucus from the nose. 3. Optimal position for burping after nasogastric feedings. 4. Need to give the baby sufficient time to rest during each feeding.

4. Need to give the baby sufficient time to rest during each feeding.

The nurse is teaching a couple about the special healthcare needs of their newborn child with Down syndrome. The nurse knows that the teaching was successful when the parents state that the child will need which of the following? 1. Yearly three-hour glucose tolerance testing. 2. Immediate intervention during bleeding episodes. 3. A formula that is low in lactose and phenylalanine. 4. Prompt treatment of upper respiratory infections.

4. Prompt treatment of upper respiratory infections. hypotonia of respiratory mm

A physician writes in a breastfeeding mother's chart, "Ampicillin 500 mg q 6 h po. Baby should be bottle-fed until medication is discontinued." What should be the nurse's next action? 1. Follow the order as written. 2. Call the doctor and question the order. 3. Follow the antibiotic order but ignore the order to bottle feed the baby. 4. Refer to a text to see whether the antibiotic is safe while breastfeeding.

4. Refer to a text to see whether the antibiotic is safe while breastfeeding.

A nurse determines that which of the following is an appropriate short-term goal for a full-term, breastfeeding neonate? 1. The baby will regain birth weight by 4 weeks of age. 2. The baby will sleep through the night by 4 weeks of age. 3. The baby will stool every 2 to 3 hours by 1 week of age. 4. The baby will urinate 6 to 10 times per day by 1 week of age.

4. The baby will urinate 6 to 10 times per day by 1 week of age

The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching by the nurse in the hospital was successful? 1. The client is breastfeeding her baby every two hours. 2. The client is using a diaphragm for family planning. 3. The client is taking her temperature every morning. 4. The client is seeking care for a recent weight loss.

4. The client is seeking care for a recent weight loss.

The charge nurse has received laboratory results for clients on the postpartum unit. Which client would warrant intervention by the nurse? 1. The client whose white blood cell count is 18,000 mm3. 2. The client whose serum creatinine level is 0.8 mg/dL. 3. The client whose platelet count is 410,000 mm3. 4. The client whose serum glucose level is 280 mg/dL.

4. The client whose serum glucose level is 280 mg/dL.

A rubella nonimmune, breastfeeding client has just received the rubella vaccine. Which of the following side effects should the nurse warn the client about? 1. The baby may develop a rash a week after the shot. 2. The baby may temporarily reject the breast milk. 3. The mother's milk supply may decrease precipitously. 4. The mother's joints may become painful and stiff.

4. The mother's joints may become painful and stiff.

A woman who wishes to breastfeed advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate? 1. Breast implants often contaminate the milk with toxins. 2. The glandular tissue of women who need implants is often deficient. 3. Babies often have difficulty latching to the nipples of women with breast implants. 4. Women who have implants are often able to breastfeed exclusively.

4. Women who have implants are often able to breastfeed exclusively.

A baby, 30 weeks' gestation, is admitted to the neonatal intensive care unit. The mother had been treated with the tocolytic, intravenous magnesium sulfate, for the preceding 10 days. For which of the following laboratory findings should the nurse assess the neonate? 1. Hypocalcemia. 2. Hyperkalemia. 3. Hypochloremia. 4. Hypernatremia.

Hypocalcemia r/t mom getting mag sulfate