OB Exam 3

Which action will the nurse avoid when performing basic care for a newborn male? Determining the location of the urethral opening Retracting the foreskin over the glans to assess for secretions Palpating if testes are descended into the scrotal sac Inspecting the genital area for irritated skin

Retracting the foreskin over the glans to assess for secretions

Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action? Suction the nose first and then the mouth with a bulb syringe. Using a bulb syringe, suction the mouth then the nose. Place the newborn on its stomach with the head down and gently pat its back. Suction the mouth and then the nose with a suction catheter.

Using a bulb syringe, suction the mouth then the nose.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? a. moderate lochia rubra for the first 24 hours b. clear lung sounds upon auscultation c. temp of 100 F d. CHest pain experienced when ambulating

d. CHest pain experienced when ambulating

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated? Administer vitamin D supplements. Administer 0.5 ml/kg/hr of breast milk enterally. Administer dextrose intravenously. Administer iron supplements.

Administer 0.5 ml/kg/hr of breast milk enterally.

After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? two or three times per week once a week once a day every other day

two or three times per week

The heart rate of the newborn in the first few minutes after birth will be in which range? 80 to 120 bpm 120 to 130 bpm 180 to 220 bpm 110 to 160 bpm

110 to 160 bpm

A mother of a neonate who was born at 32 weeks' gestation is encouraged to perform skin-to-skin (kangaroo) care in the neonatal intensive care unit. What would best correlate with this suggestion? There will be a decrease in episodes of apnea. The infant will adjust better to the environment. Breastfeeding attempts will be enhanced. The infant will have more awake periods.

Breastfeeding attempts will be enhanced.

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for an SGA infant? placental factors age of 30 years blood group incompatibility grand multiparity

placental factors

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as: vernix caseosa. Epstein pearls. oral candidiasis (thrush). milia.

Epstein pearls.

The nurse is caring for a postpartum woman who is diagnosed with endometritis. Which position should the nurse encourage the client to maintain? On her left side Trendelenburg Semi-Fowler Flat in bed

Semi-Fowler

A newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which substance in response to cold exposure? nerves brown fat white fat muscles

brown fat

A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area? legs face trunk arms

face

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns? "The problem is a result of the shortened lifespan of the newborn's red blood cells (RBCs)." "Placing the infant in direct sunlight for short periods helps in eliminating the bilirubin." "Physiologic jaundice usually begins in the first week after birth." "Breastfed babies need supplements of glucose water to help lower bilirubin levels."

"Breastfed babies need supplements of glucose water to help lower bilirubin levels."

When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn? between 2 and 4 days of life after 5 days postpartum often with formula-fed babies during the first 24 hours of life

during the first 24 hours of life

A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article? higher oxygen content of the circulating blood drop in pressure in the neonate's chest precipitous drop in blood pressure higher oxygen levels at the respiratory centers of the brain

higher oxygen content of the circulating blood

The nurse should carefully monitor which neonate for hyperbilirubinemia? neonate with Apgar scores 9 and 10 at 1 and 5 minutes neonate of African descent neonate with ABO incompatibility neonate of an Rh-positive mother

neonate with ABO incompatibility

A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority? Administer vitamin K. Perform the newborn screening. Complete the hearing test. Provide hepatitis B vaccination.

Administer vitamin K.

To confirm a finding of primary syphilis, the nurse would observe which of the following external genitalia? a. highly variable skin rash b. yellow-green vaginal discharge c. nontender, indurated ulcer d. localized gumma formation

c. nontender, indurated ulcer

A Black couple are spending time with their newborn after the nurse brings the newborn back from the transition nursery. The parents note that their newborn's buttocks appear bruised and ask what happened. The nurse should explain this is related to which factor? congenital dermal melanocytosis (slate gray nevi) bruising lanugo vascular nevi

congenital dermal melanocytosis (slate gray nevi)

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding." "Your newborn should finish a bottle in less than 15 minutes." "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed."

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? 24 hours after the newborn's first protein feeding When the infant is 48 hours old 36 hours before the infant is discharged home with its parents Just before discharge home

24 hours after the newborn's first protein feeding

A client arrives in the emergency department accompanied by her husband and new 10-week-old infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear within which time frame after birth? 3 months 4 months 5 months 2 months

3 months

A nurse is assessing the perineum of several postpartum clients using the REEDA score. The nurse initiates interventions to minimize the risk for postpartum infection for the client with which score? 5 9 7 3

9

A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate? Encourage the parent to burp the newborn to get rid of air. Instruct the parent to stop feeding for a few minutes and then restart. Urge the parent to prop the bottle for the rest of the feeding. Suggest the parent stop the feeding because the newborn is full.

Encourage the parent to burp the newborn to get rid of air.

The nurse is assisting with the circumcision of a male infant. Which nursing intervention is priority immediately after the procedure? Apply a petrolatum gauze dressing Monitor the site for bleeding. Administer acetaminophen orally. Assess the newborn for infection.

Monitor the site for bleeding.

A newborn with newly diagnosed hemolytic jaundice is being treated with phototherapy. Which actions should the nurse take? Select all that apply. Supplement breast milk with formula. Tightly swaddle the infant during the phototherapy sessions. Encourage the mother to breastfeed (8 to 12 feedings per day). Expose as much of the newborn's skin as possible. Turn the newborn during phototherapy every 8 hours. Shield the newborn's genitals and eyes during phototherapy sessions.

Shield the newborn's genitals and eyes during phototherapy sessions. Encourage the mother to breastfeed (8 to 12 feedings per day). Supplement breast milk with formula. Expose as much of the newborn's skin as possible.

Which statement is true regarding fetal and newborn senses? A newborn cannot experience pain. The rooting reflex is an example that the newborn has a sense of touch. A newborn does not have the ability to discriminate between tastes. A fetus is unable to hear in utero. A newborn cannot see until several hours after birth.

The rooting reflex is an example that the newborn has a sense of touch.

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately? soft, flat anterior fontanels (fontanelles) intake and output for 8 hours pink skin with noted blue extremities a sudden drop in hematocrit

a sudden drop in hematocrit

A prophylactic agent is instilled in both eyes of all newborns to prevent which of the following conditions? a. gonorrhea and chlamydia b. thrush and enterobacter c. staphylococcus and syphilis d. hepatitis b and herpes

a. gonorrhea and chlamydia

In which of the following infants would the nurse be most alert for the development of transient tachypnea? a. infant born by cesarean section b. neonate who received no sedation c. newborn of a mother with heart disease d. baby who is small for gestational age

a. infant born by cesarean section

A postpartum woman reports hearing voices and says, "The voices are telling me to do bad things to my baby", the clinic nurse interprets these findings as suggesting postpartum a. psychosis b. anxiety disorder c. depression d. blues

a. psychosis

What is a typical feature of a small-for-gestational-age (SGA) newborn that differentiates it from a preterm baby with a low-birth-weight? ability to tolerate early oral feeding face is angular and pinched decreased body temperature decreased muscle mass

ability to tolerate early oral feeding

What action by the nurse provides the neonate with sensory stimulation of a human face? encouraging the mother to view the baby through the isolette dome assisting the mother to position the infant in an en face position having mothers look at the infant through the isolette's porthole teaching parents to maintain a distance of 18 inches (7 cm) from the baby's face

assisting the mother to position the infant in an en face position

Breast cancer that is localized is referred to as a. primary b. in situ c. metastisized d. localized

b. in situ

Which factor in a postpartum woman's history would lead the nurse to monitor the woman closely for an infection? a. hemoglobin of 12 mg/dL b. manually extracted placenta c. labor of 10 hours length d. multiparity of 5 pregnancies

b. manually extracted placenta

When assessing the term newborn, the following are observed: newborn is alert, heart and respiratory rates have stabilized, and meconium has passed. The nurse determines the newborn is exhibiting behaviors indicating the a. initial period of reactivity b. second period of reactivity. c. decreased responsiveness period d. sleep period

b. second period of reactivity.

The nurse documents that a newborn is postterm based on the understanding that he was born after a. 38 weeks b. 40 weeks c. 42 weeks d. 44 weeks

c. 42 weeks

When assessing a term newborn (6 hours old), the nurse auscultates bowel sounds and documents recent passing of meconium. These findings would indicate: a. abnormal gastrointestinal newborn transition that requires reporting b. an intestinal anomaly that needs immediate surgery c. a patent anus with no bowel obstruction and normal peristalsis d. malabosrption syndrome resulting in fatty stools

c. a patent anus with no bowel obstruction and normal peristalsis

The nurse performs a physical examination on a newborn 2 hours after birth. Which findings indicate a need for pediatric consultation? Select all that apply. a. RR of 50 bpm b. Intermittent episodes of apnea lasting less than 10 seconds each c. absent moro reflex when startled d. preauricular skin tag noted on left ear e. white raised bumps noted on nose and face f. yellow blanching of the skin when pressure applied to the nose

c. absent moro reflex when startled f. yellow blanching of the skin when pressure applied to the nose

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which information would be important to collect first? coagulation studies HIV status STI status urinalysis results

coagulation studies

AFter teaching a group of nursing students about thermoregulation and appropriate measures to prevent heat loss by evaporation, which student behavior indicates successful teaching? a. transporting the newborn to an isolette b. maintaining a warm room temperature c. placing the newborn on a warmed surface d. drying the newborn immediately after birth

d. drying the newborn immediately after birth

When assesing a preterm newborn, which of the following findings would be of greatest concern? a. milia over the bridge of the nose b. Thin transparent skin c. poor muscle tone d. heart murmur

d. heart murmur

Because the newborns RBCs break down much sooner than those of an adult, what might result? a. anemia b. bruising c. apnea d. jaundice

d. jaundice

In an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions? vitamin K silver nitrate solution gentamicin ophthalmic ointment erythromycin ophthalmic ointment

erythromycin ophthalmic ointment

A nurse is conducting a class for expectant parents about newborns and the changes that they experience after birth. The nurse discusses the neonatal period, describing it as which time frame? first 36 days of life first 3 weeks of life first 2 months of life first 28 days of life

first 28 days of life

When examining a newborn's eyes, the nurse would expect which assessment? follows your finger a full 180 degrees produces tears when he cries follows a light to the midline has a white rather than a red reflex

follows a light to the midline

On postpartum day 4, a client has a temperature of 101.4°F (38.6°C). Which finding(s) will cause the nurse to suspect endometritis? Select all that apply. fluctuant, perineal mass fever tender uterus swollen, warm breast foul-smelling lochia

foul-smelling lochia tender uterus fever

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. loss of confidence decreased interest in life inability to concentrate bizarre behavior manifestations of mania

inability to concentrate loss of confidence decreased interest in life

A nurse is observing the interaction between a new mother and the neonate. The nurse notes that the neonate moves the head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response? motor maturity orientation self-quieting behavior habituation

orientation

A nurse is preparing to place a skin temperature probe on a neonate who is lying on his back. To ensure an accurate reading, which location would be most appropriate to use for placement? between the scapulae over the liver above the left kidney at the nape of the neck

over the liver

An infant born via a cesarean birth appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant? hyperthermia tachypnea hypoglycemia cardiac murmur

tachypnea

A woman who gave birth 23 hours ago asks the nurse about what causes the holes in the newborn's heart to close. What is the best response by the nurse? "That is a great question and I will remind you to ask your health care provider when you talk next." "The pressure in the atrium of the heart and the chest cause the holes to close." "The holes, or shunts, should close automatically after your baby is born." "To breathe, the holes in the heart must close so the blood is directed away from the lungs."

"The pressure in the atrium of the heart and the chest cause the holes to close."

A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching? "The head of his bed will be elevated to prevent him from aspirating." "We can probably start feeding him with the bottle about a day after the surgery." "He'll need antibiotics for a bit after the surgery to prevent infection." "We can give him a pacifier to help satisfy his need to suck."

"We can probably start feeding him with the bottle about a day after the surgery."

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention? 90 mg/dL (5.00 mmol/L) 53 mg/dL (2.94 mmol/L) 70 mg/dL (3.89 mmol/L) 30 mg/dL (1.67 mmol/L)

30 mg/dL (1.67 mmol/L)

When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voidings per day is a good indicator of adequate fluids? 6 to 8 4 to 6 2 to 4 8 to 10

6 to 8

A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed? 1 month after discharge 1 day after birth After the newborn has completed the antibiotic therapy Before discharge from the hospital

After the newborn has completed the antibiotic therapy

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex? Turn the head to one side without moving the rest of the body. Place a gloved finger in the newborn's mouth. Startle the newborn by letting the head drop back slightly. Gently stroke the newborn's cheek.

Gently stroke the newborn's cheek.

A laboring mother requests that she be allowed to participate in "kangaroo care" following the birth. The nurse understands that this involves what action? Laying the newborn in a radiant warmer for 30 minutes followed by the mother holding the newborn for 30 minutes. Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket. Allowing the mother to cut the cord of the newborn. Wrapping the newborn in a towel and placing it on the mother's abdomen.

Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket.

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? Oxygen is exchanged in the lungs. The oxygen in the blood decreases. Pressure changes occur and result in closure of the ductus arteriosus. Fluid is removed from the alveoli and replaced with air.

Pressure changes occur and result in closure of the ductus arteriosus.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? Escherichia coli group B streptococcus (GBS) Staphylococcus aureus Streptococcus pyogenes (group A strep)

Staphylococcus aureus

A couple is considered infertile after how many months of trying to conceive? a. 6 months b. 12 months c. 18 months d. 24 months

b. 12 months

Which would the nurse expect to include in the plan of care for a woman with mastitis who is receiving antibiotic therapy? a. stop breastfeeding and apply lanolin b. administer analgesics and bind both breasts c. apply warm or cold compresses and administer analgesics d. remove the nursing bra and expose the breast to fresh air

c. apply warm or cold compresses and administer analgesics

A nursing student asks the nursery nurse why they do not bathe the newborn immediately upon admission to the nursery observation area after birth. The nurse states that this would increase the risk of: a. jaundice b. infection c. hypothermia d. anemia

c. hypothermia

A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism? convection evaporation conduction radiation

conduction

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? evaporation radiation conduction convection

conduction

Which condition may cause intrauterine asphyxia? Select all that apply. intrauterine growth restriction (IUGR) cord compression group B streptococcus (GBS) infection gestational diabetes placental abruption (abruptio placentae)

cord compression placental abruption (abruptio placentae) intrauterine growth restriction (IUGR)

A postoperative mastectomy client should be referred to which organization for assistance upon discharge from the hospital a. National Organization for Women b. FDA c. March of Dimes d. REach to recovery

d. REach to recovery

A newborn is designated as very-low-birth-weight. When weighing this newborn, the nurse would expect to find which weight? less than 1,500 g less than 1,000 g approximately 2,500 g more than 4,000 g

less than 1,500 g

When evaluating neurologic maturity to determine gestational age, the nurse understands that which activity is not part of the assessment? rooting square window posture popliteal angle

rooting

A nurse is caring for a baby girl born at 34 weeks' gestation. Which feature should the nurse identify as those of a preterm newborn? shiny heels and palms closely approximated labia paper-thin eyelids scant coating of vernix

shiny heels and palms

The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement? "He needs to get food orally to make vitamin K." "The newborn's gut is sterile at birth." "His stomach can hold approximately 10 ounces." "The muscle opening that leads into the stomach is not mature."

"His stomach can hold approximately 10 ounces."

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status? "When did you last void?" "What time did you last change your pad?" "How much blood was on the two pads?" "Are you in any pain with your bleeding?"

"How much blood was on the two pads?"

The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's intervention? 30 mg/dl (1.67 mmol/l) 50 mg/dl (2.77 mmol/l) 60 mg/dl (3.33 mmol/l) 40 mg/dl (2.25 mmol/l)

30 mg/dl (1.67 mmol/l)

What is the expected range for respirations in a newborn? 30 to 60 breaths per minute 40 to 80 breaths per minute 20 to 40 breaths per minute 10 to 30 breaths per minute

30 to 60 breaths per minute

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? Anesthetic may not be effective during the procedure Lower rate of urinary tract infections Fewer complications than if done later in life Reduced risk of penile cancer

Anesthetic may not be effective during the procedure

The nurse is checking on a newborn who was circumcised 2 hours ago using a Plastibell. Which intervention would be inappropriate for this client? Monitor the amount of bleeding and chart it. Administer analgesics for pain on a scheduled basis. Position the infant on his side for comfort. Apply petroleum gauze to the penis with each diaper change.

Apply petroleum gauze to the penis with each diaper change.

Which assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn? Monitor for fall in temperature, indicative of dehydration. Measure weight once every 2 to 3 days. Assess for decrease in urinary output. Assess for increased muscle tone.

Assess for decrease in urinary output.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? Limit the bathing time to 5 minutes. Postpone breastfeeding until after the initial bath. Bathe the baby under a radiant warmer. Bathe the baby in water between 90 and 93 degrees.

Bathe the baby under a radiant warmer.

Place in order the change of events as fetal circulation transitions to newborn circulation. Use all options. Birth occurs. The ductus arteriosus closes. Pulmonary blood flow increases, and pulmonary venous return to the left side of the heart increases. The foramen ovale closes. An increase in systemic blood pressure occurs with continued increase in blood flow to the lungs.

Birth occurs. Pulmonary blood flow increases, and pulmonary venous return to the left side of the heart increases. The foramen ovale closes. An increase in systemic blood pressure occurs with continued increase in blood flow to the lungs. The ductus arteriosus closes

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? Degree of responsiveness, respiratory rate, fundus location Height, level of orientation, support systems Attachment, lochia color, complete blood cell count Blood pressure, pulse, reports of dizziness

Blood pressure, pulse, reports of dizziness

The nurse is performing an assessment on a neonate. Which assessment finding should the nurse prioritize as suggestive of hypothermia? Hyperglycemia Metabolic alkalosis Shivering Bradycardia

Bradycardia

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? Recommend that the mother pump her breast milk and measure it before feeding. Add cereal to the newborn's feedings twice a day. Breastfeed the infant every 2 to 4 hours on demand. Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day.

Breastfeed the infant every 2 to 4 hours on demand.

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition? Harlequin sign Molding Increased intracranial pressure Caput succedaneum

Caput succedaneum

The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program? Caregivers use this time to rest or complete errands while the visiting nurse takes care of the infant. The nurse can discuss parenting conflicts with the caregivers to determine which style is best. The nurse will complete any procedures the infant was not able to have performed while in the hospital. Caregivers can demonstrate competency in caring for the infant and ask questions.

Caregivers can demonstrate competency in caring for the infant and ask questions.

The nurse notes that a client's uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next? Use semi-Fowler position to encourage uterine drainage. Offer analgesics prescribed by health care provider. Check for bladder distention, while encouraging the client to void. Perform vigorous fundal massage for the client.

Check for bladder distention, while encouraging the client to void.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? Check the lochia. Monitor the pain level. Assess the fundal height. Assess the temperature.

Check the lochia.

It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition? Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour. Client maintains a urinary output greater than 30 ml per hour. Client's temperature remains below 100.4°F (38.8°C) orally. Fundus remains firm and midline with progressive descent.

Client's temperature remains below 100.4°F (38.8°C) orally.

The nurse has admitted a small-for-gestational-age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan? Assess for hyperglycemia. Monitor intake and output. Observe feeding tolerance. Closely monitor temperature.

Closely monitor temperature.

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Call the primary care provider. Document the data. Stimulate the neonate. Inform the charge nurse.

Document the data.

A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition? Mastitis Subinvolution Endometritis Episiotomy infection

Endometritis

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal? Staphylococcus aureus Klebsiella pneumoniae Escherichia coli Gardnerella vaginalis

Escherichia coli

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant? Focus on monitoring and maintaining blood glucose levels. Check blood glucose within 2 hours of birth by reagent test strip. Focus on decreasing blood viscosity by increasing fluid volume. Repeat screening every 2 to 3 hours or before feeds.

Focus on decreasing blood viscosity by increasing fluid volume.

The nurse is preparing to administer the ordered injections to a newborn. After noting the mother tested positive for HbsAG, which nursing intervention should the nurse prioritize for the infant? Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 24 hours of birth Hepatitis B vaccination and 2 doses of hepatitis B immunoglobulin within 24 hours of birth Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth Two doses of the hepatitis B immunoglobulin within 24 hours of birth

Hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth

What is the best rationale for trying to decrease the incidence of cold stress in the neonate? The neonate will stabilize his or her temperature by 8 hours after birth if kept warm and dry. If the neonate becomes cold stressed, he or she will eventually develop respiratory distress. Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. It takes energy to keep warm, so the neonate has to remain in an extended position.

If the neonate becomes cold stressed, he or she will eventually develop respiratory distress.

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply. Offer early feedings. Administer vitamin supplements. Increase the infant's hydration. Stop breastfeeding until jaundice resolves. Initiate phototherapy.

Increase the infant's hydration. Offer early feedings. Initiate phototherapy.

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? Injecting at a 45-degree angle Injecting the medication into the vastus lateralis Using a 21-gauge needle Injecting 1cc of medication

Ineffective airway clearance related to mucus and secretions

The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority? Initiate early oral feedings. Ensure feedings are on demand. Monitor the infant at feedings. Initiate daily newborn weights.

Initiate early oral feedings.

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem? Remove the clamp and replace with another one just above the old one. Notify the doctor to come suture the site of the bleeding. Clean the cord with soap and water, as oozing of blood is a common finding. Inspect the clamp to insure that it is tightly closed and applied correctly.

Inspect the clamp to insure that it is tightly closed and applied correctly.

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding? If the fontanel (fontanelle) feels full, then this is normal. This finding is normal if the pulsation can also be palpated in the posterior fontanel (fontanelle). This is an abnormal finding and needs to be reported immediately. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle).

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle).

The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be sure to include in the presentation? Select all that apply. Seizures Hyperthermia Bradypnea Jitteriness Lethargy

Jitteriness Lethargy Seizures

At birth, a neonate is diagnosed with brachial plexus palsy. The parent asks how the nurse knows the neonate's positioning of the arm is a result of the palsy and not just a preferred position. The nurse would show the parent that the neonate has asymmetry of which neonatal reflex? rooting Moro Babinski stepping

Moro

The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply. Bluish coloration of hands and feet Chest retractions Nasal flaring Respiratory rate of 64 breaths per minute Heart rate of 120 beats per minute

Nasal flaring Respiratory rate of 64 breaths per minute Chest retractions

A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client? Change to a soy-based formula. Increase the newborn's fluid intake. Switch to feeding breast milk. No action is need; this is normal.

No action is need; this is normal.

The LPN is assessing a 1-day-old newborn and notices a large amount of white drainage and redness at the base of the umbilical cord. What is the best response by the nurse? Call the doctor immediately to ask for intravenous antibiotics and document finding. Show the mother how to clean the area with soap and water, and document the intervention. Carefully clean the area with a damp washcloth and cover it with an absorbent dressing and document finding and intervention. Notify the charge nurse, because it represents a possible complication, and document the finding.

Notify the charge nurse, because it represents a possible complication, and document the finding.

Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting? Breastfeeding jaundice. Physiologic jaundice. Bile duct blockage. Pathologic jaundice.

Physiologic jaundice.

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which intervention should the nurse implement at this point? Take a blood sample. Place the infant supine in a radiant heat warmer. Immediately suction the infant's airway. Place the infant in an elevated position.

Place the infant in an elevated position.

When preparing to resuscitate a preterm newborn, the nurse would perform which action first? Hyperextend the newborn's neck. Place the newborn's head in a neutral position. Prepare to insert an endotracheal tube (ETT). Administer epinephrine.

Place the newborn's head in a neutral position.

A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn? Administer antibiotics and total parenteral nutrition as prescribed. Prevent aspiration by elevating the head of the bed, and inserting an NG tube to low suction. Document the amount and color of esophageal drainage. Provide NG feedings only.

Prevent aspiration by elevating the head of the bed, and inserting an NG tube to low suction.

The nurse wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met? Avoid skin-to-skin contact with the mother until the infants are 8 hours old. Avoid bathing the newborn until he or she is 24 hours old. Promote early breastfeeding for the infants. Keep the infant transporter temperature between 80° and 85°F (27° and 29°C).

Promote early breastfeeding for the infants.

A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. Provide warm water to drink. Massage the newborn's back. Provide oxygen supplementation. Observe respiratory status frequently. Ensure the newborn's warmth.

Provide oxygen supplementation. Ensure the newborn's warmth. Observe respiratory status frequently.

A woman arrives at the office for her 4-week postpartum visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client? Risk for impaired breastfeeding related to development of mastitis Risk for fatigue related to chronic bleeding due to subinvolution Risk for infection related to microorganism invasion of episiotomy Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis

Risk for fatigue related to chronic bleeding due to subinvolution

Which intervention(s) will the nurse recommend for a breastfeeding mother diagnosed with mastitis? Select all that apply. Take antibiotics as prescribed Apply warm compresses to the affected breast PRN Do not breastfeed from the affected breast Encourage client to breastfeed the infant every 3 to 4 hours Take acetaminophen as needed for pain Rub expressed breast milk on the nipples after each feeding session

Take antibiotics as prescribed Apply warm compresses to the affected breast PRN Rub expressed breast milk on the nipples after each feeding session Take acetaminophen as needed for pain

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred? The infant may have been exposed to alcohol during pregnancy. The infant's mother must have had a long labor. The infant's mother probably had diabetes. The infant may have experienced birth trauma.

The infant's mother probably had diabetes.

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred? The infant's mother probably had diabetes. The infant may have been exposed to alcohol during pregnancy. The infant's mother must have had a long labor. The infant may have experienced birth trauma.

The infant's mother probably had diabetes.

The NICU nurse is caring for a preterm neonate with respiratory distress syndrome on mechanical ventilation. Which assessment data would alert the nurse that a pneumothorax might have developed? Select all that apply. Neonate is exhibiting nasal flaring and grunting. Oxygen saturation is 92% and heart rate is 130. Chest radiography reveals low lung volume and a ground glass appearance. The neonate's chest is asymmetrical with decreased breath sounds on one side. The neonate's respiratory rate is 68. Neonate's blood pressure is 80/50.

The neonate's respiratory rate is 68. Neonate is exhibiting nasal flaring and grunting. The neonate's chest is asymmetrical with decreased breath sounds on one side

The nurse is assessing the newborn for convection heat loss. Which situation will the nurse address related to this concern? The newborn has urinated without a diaper in place and has a wet blanket. The newborn is laying on a bassinet mattress with a diaper in place. The newborn is being photographed in a diaper next to a window. The newborn is being transported to the nursery wearing a diaper, in a bassinet.

The newborn is being transported to the nursery wearing a diaper, in a bassinet.

Which of the following findings in a newborn would the nurse document as abnormal when assessing the newborn head? a. two soft spots palpated between the cranial bones b. a spongy area of edema outlined on the head c. head circumference 32 cm, chest 34 cm d. asymmetry of the head with overriding bones

c. head circumference 32 cm, chest 34 cm

A client has given birth to a small-for-gestational-age (SGA) newborn. Which finding would the nurse expect to assess? round flushed face brown lanugo body hair head larger than body protuberant abdomen

head larger than body

The Apgar score is based on which 5 parameters? heart rate, breaths per minute, irritability, reflexes, and color heart rate, muscle tone, reflex irritability, respiratory effort, and color heart rate, respiratory effort, temperature, tone, and color heart rate, breaths per minute, irritability, tone, and color

heart rate, muscle tone, reflex irritability, respiratory effort, and color

An obese woman with diabetes has just given birth to a term, large-for-gestational-age (LGA) newborn. Which condition should the nurse most expect to find in this infant? hypoglycemia hypertension hyperglycemia hypotension

hypoglycemia

A neonate undergoing phototherapy treatment must be monitored for which adverse effect? hyperglycemia increased GI transit time increased insensible water loss severe decrease in platelet count

increased insensible water loss

The obstetrical nurse admits a premature, small-for-gestational age infant to the observational unit for assessment. The maternal record reveals an obese 27-year-old homeless woman with limited prenatal, medical, or dental care. Her blood pressure on admission was 170/90 mm Hg. Which factors in the maternal history would have suggested a high-risk pregnancy? Select all that apply. lack of prenatal care periodontal disease homelessness obesity maternal age maternal hypertension

lack of prenatal care homelessness periodontal disease maternal hypertension obesity

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn? meconium aspiration in utero or at birth seizures, respiratory distress, cyanosis, and shrill cry tremors, irritability, and high-pitched cry yellow appearance of the newborn's skin

meconium aspiration in utero or at birth

Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client? oxytocin agent nifedipine indomethacin magnesium sulfate

oxytocin agent

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings? hyperglycemia hypercalcemia hyponatremia polycythemia

polycythemia

Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of: lack of partner support. postpartum blues. postpartum depression. maladjustment to parenting.

postpartum depression.

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate? LGA preterm SGA postterm

postterm

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. general fussiness abdominal distention temperature of 38.3° C (101° F) or higher refuse feeding approximately eight wet diapers a day

temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention

A nurse initiates bag and mask ventilation with an anesthesia bag on a newborn with no spontaneous respiratory effort. What controls the pressure of breaths delivered by an anesthesia bag? the flow rate of air into the inflatable bag on the apparatus the blow-off valve, which limits the pressure in the apparatus the pressure the nurse uses when the hand squeezes against the bag the pressure setting on the dial at the point where the mask connects to the bag

the pressure the nurse uses when the hand squeezes against the bag

A client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client? disseminated intravascular coagulation cervical laceration uterine atony retained placental fragment

uterine atony

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine subinvolution uterine atony uterine contraction uterine prolapse

uterine atony

The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care? "I can continue breastfeeding my infant, but it may be somewhat uncomfortable." "When breastfeeding, it is recommended to begin nursing on the infected breast first." "I am able to pump my breast milk for my baby and throw away the milk." "I will stop breastfeeding until I finish my antibiotics."

"I can continue breastfeeding my infant, but it may be somewhat uncomfortable."

Six hours after birth, a client's first void is 70 ml. What is the nurse's next action? Assess for residual urine. Assess for perineal hematoma. Assess for a urinary tract infection. Assess for dehydration.

Assess for residual urine.

The nurse notes uterine atony in the postpartum client. Which assessment is completed next? Assessment of the lung fields Assessment of the perineal pad Assessment of laboratory data Assessment of bowel function

Assessment of the perineal pad

A newborn's condition is not improving after intubation. What assessment by the nurse would identify a possible problem? Obtain a blood gas. Auscultate breath sounds. Palpate for crepitus. Inspect for retractions.

Auscultate breath sounds.

The nurse is caring for a newborn who was delivered via a planned cesarean birth. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor? Excessive fluid in the infant's lungs, making respiratory adaptation more challenging. Fetal lungs are uninflated and full of amniotic fluid that must be absorbed. Oxygen was cut off when the umbilical cord was clamped, resulting in decreased oxygen and increased carbon dioxide. Much of the fetal lung fluid is squeezed out in cesarean birth.

Excessive fluid in the infant's lungs, making respiratory adaptation more challenging.

A nurse is teaching a new mother about her neonate and the changes that are occurring as the neonate adapts to life outside the client's uterus. The nurse would incorporate understanding of which change when describing the neonate's current status? Select all that apply. The respiratory system is now fluid filled and under high pressure. The neonate's body temperature is maintained by the extrauterine environment. Right atrial pressure is greater than the left leading to closure of the foramen ovale. Lungs are now responsible for the exchange of oxygen and carbon dioxide. The liver begins functioning as the ductus venosus closes.

Lungs are now responsible for the exchange of oxygen and carbon dioxide. The liver begins functioning as the ductus venosus closes.

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see? Creases appear on the interior two-thirds of the sole. The skin is pale, and no vessels show through it. The neonate has 7 to 10 mm of breast tissue. The pinna of the ear is soft and flat and stays folded.

The pinna of the ear is soft and flat and stays folded.

The nurse inspects the client's perineum and finds it is red, swollen, and tender. The nurse explains to the client that she needs to be monitored for blood loss, especially because of bleeding into the tissue of the perineum because of the third degree laceration sustained while giving birth. What parameters will the nurse assess to detect signs of additional blood loss? Select all that apply. Blood pressure Pulse rate Amount of lochia Urine output Uterine fundus

Urine output Blood pressure Pulse rate

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. Suction equipment Glucose water Identification bands Ophthalmoscope Warmer bed

Warmer bed Suction equipment Identification bands

A postpartum mother appears very pale and states she is bleeding heavily. The nurse should first: a. call the client's health provider b. set up IV infusion of magnesium sulfate c. assess the fundus and ask her about her voiding status d. reassure the mother that this is a normal finding after childbirth

c. assess the fundus and ask her about her voiding status

A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article? higher oxygen content of the circulating blood drop in pressure in the neonate's chest higher oxygen levels at the respiratory centers of the brain precipitous drop in blood pressure

higher oxygen content of the circulating blood

What is a consequence of hypothermia in a newborn? respirations of 46 skin pink and warm heart rate of 126 holds breath 25 seconds

holds breath 25 seconds

A nurse is assigned to care for a high-risk newborn with a periventricular-intraventricular hemorrhage (PVH-IVH) in the home environment after discharge. For which condition should the nurse monitor the infant? hydrocephalus spina bifida urinary tract infection formula intolerance

hydrocephalus

An infant who is diagnosed with meconium aspiration displays which symptom? respirations of 45 intercostal and substernal retractions no heart murmur pink skin

intercostal and substernal retractions

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn? continual kicking continual crying constriction of blood vessels lack of subcutaneous fat

lack of subcutaneous fat

Which factors could increase the risk of overheating in a newborn? Select all that apply. limited sugar stores isolette that is too warm limited ability of diaphoresis underdeveloped lungs lack of brown fat

limited ability of diaphoresis isolette that is too warm

The nurse reviews the antenatal chart of a mother with a newborn diagnosed with necrotizing enterocolitis. What would the nurse expect to find in the chart because it correlates with the diagnosis? gestational diabetes preeclampsia oligohydramnios hypertension

preeclampsia

Which complication is most likely responsible for a late postpartum hemorrhage? perineal laceration cervical laceration uterine subinvolution clotting deficiency

uterine subinvolution

At what point should the nurse expect a healthy newborn to pass meconium? within 1 to 2 hours of birth by 12 to 18 hours of life before birth within 24 hours after birth

within 24 hours after birth

What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia? Check the client's blood sugar by a venous blood draw. Feed the newborn some formula immediately. Perform a heel stick to obtain a blood sample for testing for glucose level. Start an IV to provide intravenous glucose.

Perform a heel stick to obtain a blood sample for testing for glucose level.

The nurse is caring for a preterm neonate on an apnea monitor. When the monitor alarms, what action does the nurse take? Select all that apply. Begins bag and mask ventilation Silences the alarm Counts the respiratory rate for a full minute Administers a dose of caffeine Performs a focused assessment of the neonate

Performs a focused assessment of the neonate Silences the alarm Counts the respiratory rate for a full minute

A neonate has an injury to the brachial plexus. Which of the following conditions is a result of a brachial plexus injury? Bulbar palsy Cerebral palsy Bell palsy Erb palsy

Erb palsy

A nursing student will pick which value as a correct laboratory value for a newborn? platelet count 75,000/µL (75 ×109/L) hemoglobin (Hbg) 17 g/dL (170 g/L) white blood cell (WBC) count 40,000/mm³ (40 ×109/L) hematocrit (Hct) 40% (0.4)

hemoglobin (Hbg) 17 g/dL (170 g/L)

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement? "The late preterm infant is more mature and able to cope as well as a full-term infant." "Late preterm newborns have fewer clinical problems leading to shorter hospital stays." "A late preterm newborn may have more clinical problems compared with full-term newborns." "Late preterm infant complications are considered minor compared to the preterm newborn."

"A late preterm newborn may have more clinical problems compared with full-term newborns."

To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern? 108 beats/minute 122 beats/minute 132 beats/minute 140 beats/minute

108 beats/minute

A nurse is assessing a newborn and obtains the newborn's head circumference. The head circumference is 35 cm. The nurse then measures the newborn's chest circumference. Which chest circumference measurement would the nurse document as expected and within normal parameters? 37 cm 28 cm 30 cm 33 cm

33 cm

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life? 15% to 18% of their birth weight 5% to 10% of their birth weight 20% of their birth weight 10% to 15% of their birth weight

5% to 10% of their birth weight

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: 7 to 10. 5 to 9. 1 to 2. 12 to 15.

7 to 10.

The nurse has admitted a small-for-gestational-age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan? Monitor intake and output. Closely monitor temperature. Assess for hyperglycemia. Observe feeding tolerance.

Closely monitor temperature.

The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant? Ensure the caregivers bring blankets and toys from home. Follow the nap and feeding schedule used at home. Be consistently attentive to the infant's basic needs. Allow the infant opportunities to self-soothe.

Be consistently attentive to the infant's basic needs.

The obstetrics nurse has admitted a large-for-gestational-age infant, 1-hour old, for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action? Recheck the newborn's blood glucose in 4 hours. Return the newborn to its parents for bonding. Transfer the newborn to the neonatal intensive care unit. Begin supervised feedings for the newborn.

Begin supervised feedings for the newborn.

A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction? Drink plenty of fluids to decrease a bladder infection. Finish all antibiotics to decrease a genital tract infection. Change the perineal pad every 3 to 4 hours to decrease the uterine infection. Apply ice to the perineum to decrease pain of a perineal infection.

Finish all antibiotics to decrease a genital tract infection.

In completing the newborn assessment checklist, the nurse documents a meconium stool. This documentation rules out which condition? Imperforate anus Spina bifida occulta Epispadias Hiatal hernia

Imperforate anus

The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history reveals gestational hypertension. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored? Jitteriness and irritability Hypotonia and fever Frequent activity and jitteriness Low temperature and hypertonia

Jitteriness and irritability

A nurse is caring for a postpartum client whose most recent assessment reveals a large, purplish area of edema on the left side of the perineum. What action will the nurse take? Report the finding promptly to the primary health care provider. Apply an ice pack and reassess in 30 minutes. Provide a hot pack and administer analgesia as prescribed. Document the expected finding and reassess frequently.

Report the finding promptly to the primary health care provider.

Which condition would be missed if a newborn were screened before he had tolerated protein feedings for at least 48 hours? a. hypothyroidism b. cystic fibrosis c. phenylketonuria d. sickle cell disease

c. phenylketonuria

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider? Elevated blood pressure Warm and flushed skin Decreased respiratory rate Weak and rapid pulse

Weak and rapid pulse

Which of the following is the strongest risk factor for breast cancer? a. advancing age and being female b. high number of children c. BRCA1 and BRCA2 genes d. Family history of colon cancer

a. advancing age and being female

After birth, the nurse would expect which fetal structure to close as a result of increases in the pressure gradients on the left side of the heart? a. foramen ovale b. ductus arteriosus c. ductus venosus d. umbilical vein

a. foramen ovale

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? asymmetrical movement seizures temperature instability feeble sucking

asymmetrical movement

A nurse is conducting a refresher program for a group of nurses returning to work in the newborn clinic. The nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional education is needed when the group identifies which parameter as being included in the assessment? pain pulse temperature blood pressure respirations

blood pressure

A nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal? body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) enlarged labia with pseudomenstruation positive Ortolani sign heart rate of 90 to 100 beats/min

body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)

A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply. covering the newborn loosely with a blanket increasing the volume on device alarms using cool blankets to soothe the newborn encouraging kangaroo care during procedures removing tape gently from the skin

encouraging kangaroo care during procedures removing tape gently from the skin

On an Apgar evaluation, how is reflex irritability tested? flicking the soles of the feet and observing the response dorsiflexing a foot against pressure resistance raising the infant's head and letting it fall back tightly flexing the infant's trunk and then releasing it

flicking the soles of the feet and observing the response

A new mother is concerned that the infant is not eating enough and will not have enough energy. The nurse explains that storage of which substance will provide energy for the first 24 hours after birth? brown fat glucose protein carbohydrate

glucose

The nurse is administering methylergonovine 0.2 mg to a postpartum client with uterine subinvolution. Which assessment will the nurse need to make prior to administering the medication? if hematocrit level is higher than 45% if the client can walk without experiencing dizziness if urine output is higher than 50 ml/h if blood pressure is lower than 140/90 mm Hg

if blood pressure is lower than 140/90 mm Hg

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days' postmature. Which physical finding does not confirm that this newborn is 12 days' postmature? increased amounts of vernix absence of lanugo hypoglycemia meconium aspiration

increased amounts of vernix

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? 24 hours after admission to the nursery 4 hours after admission to the nursery after the newborn has received the initial feeding on admission to the nursery

on admission to the nursery

When conducting a class for new parents, the nurse explains that newborns demonstrate several predictable responses when interacting with their environment. Which behavioral responses would the nurse integrate into the discussion? Select all that apply. attachment to parents adequate feedings self-quieting ability orientation habituation

orientation habituation self-quieting ability attachment to parents

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and the client frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? postpartum depression postpartum panic disorder postpartum psychosis postpartum blues

postpartum psychosis

Which sign appears early in a neonate with respiratory distress syndrome? pale gray skin color bilateral crackles tachypnea more than 60 breaths/minute poor capillary filling time (3 to 4 seconds)

tachypnea more than 60 breaths/minute

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? Radiation Convection Evaporation Conduction

Convection

The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth? Creases covering one fourth of the foot Creases on two-thirds of the foot Longitudinal but no horizontal creases Heel but no anterior creases

Creases on two-thirds of the foot

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize? Recheck blood pressure in 15 minutes. Put warming blanket over infant. Document normal findings. Report tachypnea.

Document normal findings.

What postpartum client should the nurse monitor most closely for signs of a postpartum infection? a client who had a nonelective cesarean birth a primiparous client who had a vaginal birth a client who had an 8-hour labor a client who conceived following fertility treatments

a client who had a nonelective cesarean birth

Which result of a biophysical profile would indicate to the nurse that the fetus might tolerate labor poorly? Select all that apply. a nonreactive nonstress test (NST) a positive stress test poor fundal growth low amniotic fluid volume placental grade III

a nonreactive nonstress test (NST) low amniotic fluid volume placental grade III

SGA and LGA newborns have an excessive number of red blood cells because of: a. Hypoxia b. Hypoglycemia c. Hypocalcemia d. Hypothermia

a. Hypoxia

The nurse is providing care to several newborns with variations in gestational age and birth weight. When developing the plan of care for these newborns, the nurse focuses on energy conservation to promote growth and development. Which measures would the nurse include in the nursing plans of care? Select all that apply. a. keeping the handling of the newborn to a minimum b. maintaining a neutral thermal environment c. decreasing environmental stimuli d. initiating early oral feedings e. using thermal warmers in all cribs

a. keeping the handling of the newborn to a minimum b. maintaining a neutral thermal environment c. decreasing environmental stimuli

A nurse observes a 3-day-old term newborn who is starting to appear mildly jaundiced. What might explain this condition? a. physiologic jaundice secondary to breastfeeding b. hemolytic disease of the newborn due to blood incompatibility c. exposing the newborn to high levels of oxygen d. overfeeding the newborn with too much glucose water

a. physiologic jaundice secondary to breastfeeding

A nurse is caring for a postpartum client with a platelet count of 15,000/ml and has been diagnosed with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first? administration of platelet transfusions as prescribed continual firm massage of the uterus avoiding administration of oxytocics administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs)

administration of platelet transfusions as prescribed

A nurse is reading a journal article about birth defects and finds that some birth defects are preventable. Which risk factor would the nurse expect to find as being cited as the current leading preventable cause of birth defects? smoking obesity recreational drugs alcohol

alcohol

A woman with HPV is likely to present with which nursing assessment finding? a. profuse, pus-filled vaginal discharge b. clusters of genital warts c. single painless ulcer d. multiple vesicles on genitalia

b. clusters of genital warts

Which of the following parameters are measured in determining an APGAR score? Select all that apply a. blood pressure b. oxygen saturation c. skin color d. reflex irritability

b. oxygen saturation c. skin color

The nurse is caring for term neonate who was exposed to cocaine throughout the pregnancy. What effect would this exposure have on the neonates vital signs? a. they would be lower than normal b. they would be higher than normal c. they would not be affected at all d. bp would be lower, pulse would be higher

b. they would be higher than normal

Assessment of a newborn reveals the following findings: Length, 48 cm; weight, 2900 g; apical pulse, 150 beats/min; respirations, 24 breaths/min; head circumference, 31cm; chest circumference, 32 cm; temperature 97.9°F (36.6°C). After reviewing these findings, the nurse would notify the provider about which one(s)? Select all that apply. length respirations head circumference weight chest circumference apical pulse temperature

respirations head circumference

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because, with increased lung tension,: the ductus arteriosus remains open. the pulmonary artery closes. the foramen ovale closes prematurely. there are aortic valve strictures.

the ductus arteriosus remains open.

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? within 30 minutes after birth, in the birthing area prior to the newborn being discharged within the first 2 to 4 hours, when the newborn reaches the nursery 24 hours after the newborn's birth

within the first 2 to 4 hours, when the newborn reaches the nursery

The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days? greenish, tarry, thick black stool thin, yellowish, seedy brown stool yellow-green, pasty, unpleasant-smelling stool sour-smelling, yellowish-gold stool

yellow-green, pasty, unpleasant-smelling stool

The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis? Urine volume excreted Complete blood count Vital signs Pad count

Pad count

When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed? "It is not necessary to give my baby a bath daily." "I will give sponge baths until the umbilical cord falls off." "I can use talc powders to prevent diaper rash." " I will change my baby's diapers frequently."

"I can use talc powders to prevent diaper rash."

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman? "It is an indication that the woman has mistreated her newborn." "It is a sign of a group B streptococcus skin infection. " "It is a self-limiting virus that does not require treatment." "It is a normal skin finding in a newborn."

"It is a normal skin finding in a newborn."

Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents? "Covering the newborn with heavy blankets is the best way to keep your newborn warm." "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." "Newborns weighing below 8 lb (3630 g) lack enough brown fat to produce heat." "Windows can be drafty and placing the newborn by one can result in evaporative heat loss."

"Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss."

The nurse performs a quick assessment of an infant who is now 5 minutes old and determines the heart rate is 110 bpm, has a weak cry, acrocyanosis, extremities are held in partial flexion, and a catheter placed in the nose produces grimacing. What Apgar score does the nurse record and what action should the nurse prioritize? 4; repeat Apgar scoring in 5 minutes 5; repeat Apgar scoring in 5 minutes 6; repeat Apgar scoring in 10 minutes 7; repeat Apgar scoring in 10 minutes

6; repeat Apgar scoring in 10 minutes

A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of: 7. 6. 5. 8.

7.

During a childbirth class, the nurse talks to the parents about how to prevent infant abductions in the hospital by recognizing the profile of an abductor. Which person best fits the profile of a typical infant abductor? A clean cut male between the age of 20 and 40 A middle-age woman who lives in another town A female in her mid-20s who appears pregnant A teenager who is an honor student at school

A female in her mid-20s who appears pregnant

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? Consistency, shape, and location Content, lochia, place Location, shape, and content Consistency, location, and place

Consistency, shape, and location

A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure? Prevent the infant from crying. Evaluate the infant's urinary output. Ensure that the infant is kept warm. Assess the infant's cranial vascular tension.

Ensure that the infant is kept warm.

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? Feeding the infant more formula whenever she begins to fuss Gently patting or stroking the infant's back Swaddling the infant before returning to the crib Rocking and talking to the infant

Feeding the infant more formula whenever she begins to fuss

The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern? Use a swab to explore the nares bilaterally for occlusions. Look for nasal flaring to indicate that the newborn is breathing out of both sides of the nostrils. Pass an NG tube down both sides of the nostrils to assess patency. Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably.

Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably.

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)? Deep inspiration Sternal retraction Inspiratory grunt Expiratory lag

Sternal retraction

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? A breast abscess is a common complication of mastitis. Mastitis usually develops in both breasts of a breastfeeding client. Symptoms include fever, chills, malaise, and localized breast tenderness. The most common pathogen is group A streptococcus (GAS).

Symptoms include fever, chills, malaise, and localized breast tenderness.

The nurse suspects that a mother who delivered her infant 2 weeks ago is experiencing postpartum depression. What is the first line of treatment for this client? telling the client that she has no need to be depressed administrating a selective serotonin reuptake inhibitor talking to the client and reassuring her that she will feel better soon scheduling electroconvulsive therapy

administrating a selective serotonin reuptake inhibitor

While assessing a postpartum multiparous woman, the nurse detects a boggy uterus midline 2 cm above the umbilicus. Which intervention would be the priority? a. assessing vital signs immediately b. measuring her next urinary output c. massaging her fundus d. notifying the womans obstetrician

c. massaging her fundus

AT birth, a newborn's assessment reveals the following: heartrate of 140 bpm, loud crying, some flexion of extremeties, crying when bulb syringe is introduced into the nares, and a pink body with blue extremeties. The nurse would document the newborn's apgar score as: a. 5 points b. 6 points c. 7 points d. 8 points

d. 8 points

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider? less than 96.7° F (35.9° C) or greater than 99.5° F (37.4° C) less than 97.7° F (36.5° C) or greater than 100° F (37.8° C) less than 96° F (35.6° C) or greater than 101° F (38.3° C) less than 97° F (36.1° C) or greater than 100.5° F (38.1° C)

less than 97.7° F (36.5° C) or greater than 100° F (37.8° C)

While caring for a neonate born of a mother with diabetes, the nurse should monitor the neonate for which complication? macrosomia pneumothorax microcephaly atelectasis

macrosomia

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? notifying the primary care provider administering ergonovine massaging the fundus firmly performing bimanual compressions

massaging the fundus firmly

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process? stained umbilical cord and skin meconium stained fluids followed by tachypnea listlessness or lethargy bluish skin discoloration

meconium stained fluids followed by tachypnea

A newborn is passing greenish-black stool of tarry consistency. The nursing student correctly identifies this type of stool as: transitional stool. stool of a formula-fed newborn. meconium stool. stool of a breastfed newborn.

meconium stool.

The nurse assesses a post-term newborn. What finding corresponds with this gestational age diagnosis? Wharton's jelly meconium-stained skin and fingernails few creases on soles abundant vernix caseosa and lanugo

meconium-stained skin and fingernails

A nurse is assisting with the resuscitation of a preterm newborn. Which assessment would help assist the team in determining that the resuscitation efforts have been successful? respiratory rate of 10 breaths per minute pink conjunctiva pulse rate of 110 beats per minute weak cry effort

pulse rate of 110 beats per minute

A nursing student correctly chooses which stage of behavioral adaptation in the infant to reinforce teaching about feeding, positioning for feeding, and diaper-changing techniques? second period of reactivity first period of reactivity There is no preferred time. period of decreased responsiveness

second period of reactivity

A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching? "You need to give your newborn a bath everyday." "Newborns can sleep on a couch to allow constant visual monitoring." "Place the newborn on the back to sleep and stomach to play." "Change the newborn's diaper every four hours while awake."

"Place the newborn on the back to sleep and stomach to play."

A newborn with tracheoesophageal fistula is likely to present with which assessment finding? a. subnormal temperature b. absent moro reflex c. inability to swallow d. drooling from mouth

d. drooling from mouth

The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding? This is a normal lab value, and no intervention is needed. The infant is suffering from polycythemia and needs a partial exchange transfusion to prevent complications. A capillary hematocrit needs to be rechecked in 8 hours to see if it increases or decreases. The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.

The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.

A nurse is assessing a newborn who was born to a woman with diabetes mellitus. The newborn is large-for-gestational age and has a ruddy skin color, short neck, buffalo hump, and distended upper abdomen. Laboratory testing has been completed and the results are as follows: Glucose: 30 mg/dL (1.67 mmol/L) Calcium: 7.2 mg/dL (1.80 mmol/L) Magnesium: 1.5 mg/dL (0.62 mmol/L) Bilirubin: 15 mg/dL (256.56 µmol/L) Hematocrit: 75% (0.75) Which result(s) would the nurse immediately report to the provider? Select all that apply. bilirubin hematocrit glucose calcium magnesium

glucose bilirubin hematocrit

Which finding would lead the nurse to suspect that a newborn is experiencing respiratory distress syndrome? a. abdominal distention b. acrocyanosis c. depressed fontanels d. nasal flaring

d. nasal flaring

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement? "The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." "The ability of my umbilical cord to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." "The ability of my body to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be increased." "The ability of my amniotic fluid to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."

"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."

A nursing instructor is teaching about changes the newborn must make to survive outside of the uterus. The instructor realizes that further teaching is needed when a student makes which statement? "The baby takes the first breath when stimulated by a slight slap." "The baby's lungs begin to function when the umbilical cord is clamped." "The baby takes the first breath when the umbilical cord is clamped." "The baby takes the first breath when ready to leave the uterus."

"The baby takes the first breath when ready to leave the uterus."

Methergine has been ordered for a postpartum woman because of excessive bleeding. The nurse should question this order if which is present? a. mild abdominal cramping b. tender inflamed breasts c. pulse rate of 68 beats per minute d. blood pressure of 158/96

d. blood pressure of 158/96

Characteristics of a newborn with fetal alcohol syndrome would include which of the following? Select all that apply. a. hypocalcium and hypokalemia b. malformed ears and cataracts c. microcephaly and thin upper lip d. congenital cardiac defects and SGA e. prominent cheekbones and LGA f. hyperactive behavior and feeding problems

c. microcephaly and thin upper lip d. congenital cardiac defects and SGA f. hyperactive behavior and feeding problems

Which of the following concepts would the nurse incorporate into the plan of care when assesing pain in a newborn with special needs? a. newborns experience pain primarily with surgical procedures b. preterm newborns in the NICU are at least risk for pain c. pain assessment needs to be comprehensive and frequent d. a newborns facial expression is the primary indicator of pain

c. pain assessment needs to be comprehensive and frequent

A 25-year old woman with an asymptomatic breast mass. Which statement is true concerning her diagnosis and treatment? a. all breast masses should be considered premalignant b. the breast mass should be surgically removed immediately c. ultrasound is typically used to determine the diagnosis d. since it is asymptomatic only reassurance is needed now

c. ultrasound is typically used to determine the diagnosis

A primiparous mother gave birth to an 8 lb 12 oz (3970 g) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice? hepatitis A vaccine cephalohematoma female gender formula feeding Rh positive blood type

cephalohematoma

A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the: infant's neck veins become prominent and palpable. infant's pupils dilate after 3 minutes. abdomen rises while the chest falls with bag compressions. chest rises with each bag compression.

chest rises with each bag compression.

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders? preexisting conditions in the client lack of social support from family or friends drop in estrogen and progesterone levels after birth medications used during labor and birth

drop in estrogen and progesterone levels after birth

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? an allergic reaction to the soap used for the first bath bruising from the birth process concentration of immature blood vessels an immature autoregulation of blood flow

concentration of immature blood vessels

Which newborn could be described as breathing normally? a. Newborn A is breathing deeply with a regular rhythm at a rate of 20 bpm. b. Newborn B is breathing diaphragmatically with sternal retractions at a rate of 70 bpm. c. Newborn C is breathing shallowly with 40-second periods of apnea and cyanosis. d. Newborn D is breathing shallowly at a rate of 36 bpm with short periods of apnea.

d. Newborn D is breathing shallowly at a rate of 36 bpm with short periods of apnea.

When implementing the plan of care for a multigravida postpartum woman who gave birth just a few hours ago, the nurse vigilantly monitors the client for which complication? a. DVT b. postpartum psychosis c. uterine infection d. postpartum hemorrhage

d. postpartum hemorrhage

The nurse is aware that the newborn's circulatory dynamics during transition can be positively affected by which action? delayed umbilical cord clamping giving the infant oxygen as needed clamping the cord immediately clamping the cord at 1 minute

delayed umbilical cord clamping

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply. diabetes alcohol use postdates gestation prepregnancy obesity renal infection

diabetes postdates gestation prepregnancy obesity