OB exam 1

A newborn in the observational nursery demonstrates signs of neonatal abstinence syndrome. What findings would correlate with this diagnosis? Select all that apply.

high-pitched cry frequent yawning and sneezing loose, watery stools

A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply.

lethargy cyanosis jitteriness

During a postbirth home visit, the nurse asks the client to complete the Edinburgh Depression Scale. What information will the nurse learn from this scale? Select all that apply.

To identify client at risk for perinatal depressions To identify clients at risk for suicide

A nurse has been handed a newborn term infant who is not crying and has decreased tone. In which order should the following actions be accomplished? All options must be used.

Transfer the newborn to a preheated radiant warmer. Dry the newborn. Clear the airway. Stimulate the newborn by rubbing the back. Check the heart rate.

Four weeks before the birth of a client's already large child, the health care provider has told the client that if the baby gets bigger and the baby's lungs are ready, a cesarean birth is preferred. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse?

"As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress."

The nurse is preparing to administer an intramuscular injection to a newborn. The nurse will ensure the maximum amount per injection is what?

0.5 ml

Which nursing interventions are provided to the newborn utilizing phototherapy via a fiberoptic blanket? Select all that apply.

Assess the newborn's skin. Increase fluid intake. Maintain protective cover around infant. Remove the infant to feed and change.

The nurse is conducting a breast exam on a postpartum mother on the second day following delivery. What findings would the nurse determine to be normal? Select all that apply.

Breasts feel slightly firm. Flattened nipple on the right breast Breasts are non-painful

A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client? Select all that apply.

Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow.

A client who gave birth 18 hours ago is experiencing a change in lochia flow from scant to moderate. Prioritize the actions the nurse would take to assess the client's fundus. Use all options.

Determine the site of bleeding. Palpate the fundus. Massage the fundus if boggy. Increase IV oxytocin or breastfeed the newborn. Assess blood pressure. Notify the primary care provider.

The nursery head nurse is conducting a staff in-service on prevention of hypoglycemia. What information would she share with this group? Select all that apply.

Encourage breastfeeding mothers to nurse immediately after delivery. Keep the newborns warm in the nursery and covered with a blanket. Initiate early feedings for all bottle-fed newborns.

A postpartum mother calls the nurse in and tells her that her right calf hurts whenever she walks around the room or in the hall. What other data needs to be collected in assessing this client for a DVT? Select all that apply.

Feel the right calf for increased warmth. Note any reddened areas on the right calf. Measure the diameter of both calves.

The nurse is bathing a newborn for the first time. Place in order how the nurse would perform these tasks during the bathing procedure. Use all options.

Fill a tub with warm water and add a mild soap. Using a soft washcloth, wash the newborn all over. Comb the hair to remove any dried blood. Take the newborn's axillary temperature. Cover the head with a cap, apply a diaper and dress the newborn. Swaddle in a warm blanket and place in an open crib.

What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply.

Fundal height level of one fingerbreadth above the umbilicus Temperature of 101.8°F (38.8°C)

A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply.

Fundus one finger-breadth below the umbilicus Moderate saturation of peripad every 3 hours

An Rh-negative mother delivered an Rh-positive infant. What information would the nurse need to gather prior to administering Rho (D) immune globulin injection? Select all that apply.

Has the mother ever been sensitized to Rh-positive blood? Has the mother had any previous pregnancies? Has the mother experienced any miscarriages or abortions?

A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on which information? Select all that apply.

Labor of 1 1/2 hours Labor induction with oxytocin Forceps birth

Upon examination of the skin, which assessment findings would the nurse recognize as normal findings for a full-term newborn at 3 hours of age? Select all that apply.

Lanugo on the back Milia Acrocyanosis

A newborn has been diagnosed with a group B streptococcus infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which cause?

Mother's birth canal

A postpartum woman is concerned about constipation following delivery. What factor(s) contribute to this problem? Select all that apply.

Perineal pain Hemorrhoidal discomfort Iron supplements

The primigravida client is surprised by the continued uterine contractions while holding her new baby. Which explanation by the nurse will best explain these contractions?

Seals off the blood vessels at the site of the placenta

A mother who is 4 days postpartum and is breastfeeding expresses to the nurse that her breast seems to be tender and engorged. Which suggestions should the nurse give to the mother to relieve breast engorgement? Select all that apply.

Take warm-to-hot showers to encourage milk release. Express some milk manually before breastfeeding. Apply warm compresses to the breasts prior to nursing.

Which interventions would the nurse take to reduce the incidence of infection in a postpartum woman? Select all that apply.

Teach proper positioning of the infant for breastfeeding. Encourage intake of fluids following delivery and after discharge. Wash her hands before and after caring for the client.

After teaching a group of new mothers about the physiologic jaundice in breastfed and bottle-fed newborns, the nurse determines that the teaching was successful when the mothers state which information?

The decline in bilirubin levels occurs more quickly in bottle-fed newborns.

A woman delivered her infant 24 hours ago by cesarean section. Which assessment findings should be reported to the assigned nurse? Select all that apply.

Uterus feels boggy. The client reports breakthrough pain level of 7-8.

It has been 2 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's uterine fundus, the nurse would expect to find it at:

between the umbilicus and symphysis pubis.

What are common risk factors for developing newborn jaundice? Select all that apply.

fetal-maternal blood group incompatibility prematurity breastfeeding certain drugs maternal gestational diabetes

A nurse is preparing a presentation about changes in the various body systems during the postpartum period and their effects for a group of new mothers. The nurse explains which event as influencing a postpartum woman's ability to void? Select all that apply.

generalized swelling of the perineum decreased bladder tone from regional anesthesia use of oxytocin to augment labor

A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn?

newborn who is type A, mother who is type O

After teaching a group of nurses during an in-service program about risk factors associated with postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which risk factors? Select all that apply.

placenta previa hydramnios labor augmentation

A nurse is assessing a preterm newborn for possible sepsis. The nurse suspects an early onset infection based on which risk factors? Select all that apply.

preterm labor prolonged rupture of membranes maternal fever

A nurse is explaining to a new mother that her newborn is susceptible to both dehydration and overhydration. The nurse integrates knowledge of which aspect as the underlying mechanism for this risk? Select all that apply.

reduced glomerular filtration rate limited concentration ability

A nurse is caring for a large-for-gestational age infant whose mother had gestational diabetes. What assessment findings would the nurse be alert for?

ruddy skin color poor feeding facial nerve paralysis tremors

Which client should the postpartum nurse assess first after receiving shift report

the 2-day postpartum client who has a blood pressure of 138/90 mm Hg

A nurse is preparing a presentation about ways to minimize heat loss in the newborn. Which measure would the nurse include to prevent heat loss through convection?

working inside an isolette as much as possible.