OB Exam 4

The nurse is reviewing the medical record of a newborn born 2 hours ago. The nurse notes that the newborn was born at 35 weeks' gestation. How would the nurse classify this newborn? 1- preterm 2- late preterm 3- full term 4- postterm

2

A postpartum client is prescribed medication therapy as part of the treatment plan for postpartum hemorrhage. Which medication would the nurse least expect to administer in this situation? 1 oxytocin 2 methylergonovine 3 carboprost 4 nifedipine

4

A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries and attempts to suck on her hand. After a few minutes, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family? A. the newborn would benefit from skin-to-skin contact in a quiet environment B. the newborn's blanket should be removed so her movements will not be restricted C. the newborn's hat should be removed to avoid overheating D. the newborn should be discouraged from sucking on her hand since this habit can interfere with feeding

A

A nurse is providing teaching about newborn baths to a pt who is 2 days postpartum. Which of the following pieces of information should the nurse INCLUDE? A. wash the newborn's face w/ pain warm water B. wash the newborn's hair before the rest of the body C. bathe the newborn once each day D. bathe the newborn immediately after a feeding

A

A nurse is reviewing the lab findings of a 24 hr old. Which of the following should the nurse report to the provider? A. hemoglobin 12 g/dL B. platelet count 200,000/mm^3 C. total bilirubin 4 mg/dL D. glucose 50 mg/dL

A

One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lower leg, temperature elevation of 37 ° C (99.8° F), rust-colored lochia, and sore breasts. From these symptoms, the nurse suspects? A. phlebitis B. puerperal infections C. late postpartum hemorrhage D. mastitis

A

A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication? 1- atelectasis 2- infection 3- intracranial hemorrhage 4- hypoglycemia

1

On a follow-up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition? 1 delusional beliefs 2 feelings of anxiety 3 sadness 4 insomnia

1

The client brings her infant daughter to the pediatrician's office for her first visit since hospital discharge. At birth, the newborn was at the 8th percentile with a weight of 2,350 g. She was born at 36 weeks' gestation. Which documentation is most accurate? 1- The infant was a preterm, low birth weight and small for gestational age neonate. 2- The infant was born at term but at a low birth weight and small for gestational age. 3- The infant was born at term but a very low birth weight and small for gestational age. 4- The infant was a preterm, very low birth weight and small for gestational age.

1

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 a SGA infant? 1- placental factors 2- blood group incompatabilty 3- grand multiparity 4- age of 30 years

1

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? 1- polycythemia 2- hyperglycemia 3- hypercalcemia 4- hyponatremia

1

The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated? 1- 20th 2- 9th 3- 5th 4- 95th

1

The priority for the nurse caring of a newborn with esophageal atresia is to observe for which finding? 1- Aspiration 2- Bleeding 3- Constipation 4- Vomiting

1

When an infant is jaundiced, what is the nurse's main role in treatment? 1- Educate the caregiver 2- Comfort the infant 3- Feed the infant 4- Draw blood for analysis

1

Which assessment finding by the nurse would indicate that a neonate is being comforted? 1- increased oxygen saturation 2- decreased oxygen saturation 3- increased heart rate 4- decreased heart rate

1

A new mother is concerned because she fears that her infant's head is larger than normal. What would be the nurse's best response? 1- A large head at birth suggests hydrocephalus. 2- A large head at birth in itself is not indicative of hydrocephalus, but we will keep a check on it. 3- It will become even larger as the baby grows. 4- If we do not drain the excessive fluid building up the child will have a problem raising the head when older.

2

A maculopopular rash w/ a red base & small white papule in the center is a. milia b. mongolian spots c. erythema toxicum d. cafe-au-lait-spots

C

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 approximately when? 1 within 3 months of giving birth 2 within 4 months of giving birth 3 within 2 months of giving birth 4 within 5 months of giving birth

1

A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification? 1- term, small for gestational age, and low-birth-weight infant 2- term, small for gestational age, and very-low-birth-weight infant 3- late preterm and appropriate for gestational age 4- late preterm, large for gestational age, and low-birth-weight infant

1

A nurse is aware that the newborn's neuromuscular maturity is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity? 1 Moro reflex 2 square window 3 popliteal angle 4 scarf sign

1

A nurse places a newborn under a radiant heat warmer. At which location should the temperature probe be placed? 1- Abdomen, between the umbilicus and the xiphoid process 2- Gluteus maximus 3- Abdomen, over the liver 4- Back, over the rib cage

1

A postpartal patient is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the patient about breast-feeding during this time? 1 Breast-feeding can continue. 2 The baby will need weekly blood work. 3 The effect of anticoagulants is counteracted by infant gastric juices. 4 All anticoagulants pass in breast milk so breastfeeding will have to stop

1

The nurse notes a newborn has a temperature of 97.4oF (36.3oC) on assessment. The nurse takes action to prevent which complication first? 1- Seizure 2- Respiratory distress 3- Cardiovascular distress 4- Hypoglycemia

2

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? 1- a sleepy, lethargic neonate 2- lanugo covering the neonate's body 3- peeling and wrinkling of the neonate's epidermis 4- vernix caseosa covering the neonate's body

3

A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which measure would the nurse include as the most cost-effective method for prevention? 1 prophylactic heparin administration 2 compression stockings 3 early ambulation 4 warm compresses

3

When examining a newborn's eyes, the nurse would expect which assessment? 1 follows your finger a full 180 degrees 2 has a white rather than a red reflex 3 follows a light to the midline 4 produces tears when he cries

3

A nurse assesses a premature newborn and suspects hypothermia based on which of the following? 1- Regular respirations 2- Oxygen saturation of 95% 3- Pink skin 4- Nasal flaring

4

A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving? 1- Reticulocyte count is 6%. 2- Hematocrit is 38. 3- Skin looks less jaundiced. 4- Bilirubin level went from 15 to 11.

4

Five days after a spontaneous vaginal delivery, a woman comes to the ED b/c she has a fever & persistent cramping. What does the nurse recognize as the possible cause of these Sxs? A. dehydration B. hypovolemic shock C. endometritis D. cystitis

C

A 4-week postpartum pt w/ mastitis asks the nurse if she can continue to breastfeed. What is the nurses most helpful response? A. stop breastfeeding until the infection clears B. pump the breasts to continue milk production, but don't give breast milk to the infant C. begin all feeding w/ the affected breast until the mastitis is resolved D. breastfeeding can continue unless there is abscess formation

D

A newborn who is AGA is ___ percentile for Wt a, below the 90th b. less than the 10th c. greater than the 90th d. between the 10th and 90th

D

A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. d. This condition is also known as "breast milk jaundice."

C

A meconium stool can be differentiated from a transitional stool in the newborn b/c the meconium stool is a. seen at age 3 days b. the residue of a milk curd c. passed in the 1st 12hrs of life d. lighter in color & looser in consistency

C

A newborn who is large for gestational age (LGA) is ___ percentile for Wt a, below the 90th b. less than the 10th c. greater than the 90th d. between the 10th and 90th

C

A nurse is reinforcing teaching about nutritional requirements during lactation for a client who is planning to breastfeed. Which of the following nutrients should the client increase during lactation? A. calcium B. iron C. vitamin D D. vitamin C

D

Which assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn? 1 Measure weight once every 2 to 3 days. 2 Assess for increased muscle tone. 3 Assess for decrease in urinary output. 4 Monitor for fall in temperature, indicative of dehydration.

3

Which of the following is not an appropriate technique when administering an intramuscular (IM) injection to a term newborn? 1 Pulling back to check for blood return 2 Stabilizing the needle with your nondominant hand. 3 Inserting the needle at a 45-degree angle 4 Using a quick darting motion

3

Which of the following would lead the nurse to suspect that a postpartum client is experiencing hypovolemic shock? 1 Lightheadedness 2 Severe localized pain 3 Cyanosis and oliguria 4 Increased rectal pressure

3

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia? 1- temperature instability 2- tea-colored urine 3- seizures 4- feeble sucking

2

Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth? 1 white blood cells: 5,000/mm3 2 hemoglobin: 17.5 g/dL 3 platelets: 400,000/uL 4 red blood cells: 3,500,000/uL

2

A postpartal patient is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the patient about breast-feeding during this time? 1 Breast-feeding can continue. 2 The baby will need weekly blood work. 3 The effect of anticoagulants is counteracted by infant gastric juices. 4 All anticoagulants pass in breast milk so breastfeeding will have to stop.

1

A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess? 1- head larger than body 2- round flushed face 3- brown lanugo body hair 4- protuberant abdomen

1

A multipara client develops thrombophlebitis after birth. Which assessment findings would lead the nurse to intervene immediately? 1 dyspnea, diaphoresis, hypotension, and chest pain 2 dyspnea, bradycardia, hypertension, and confusion 3 weakness, anorexia, change in level of consciousness, and coma 4 pallor, tachycardia, seizures, and jaundice

1

A neonate has been administered a prescribed dose of vitamin K. What outcome would most clearly indicate to the nurse that the medication has had the intended effect? 1 The infant remains free of bleeding 2 The infant's jaundice resolves 3 The infant's hemoglobin level increases 4 The infant remains free of infection

1

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism? a. convection b. radiation c. conduction d. evaporation

A

A nurse is caring for a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take? A. saline lock the IV catheter B. provide oxygen via nasal cannula C. elevate the client's legs to a 30 degree angle D. place the client in a semi-Fowler's position

C

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? A. post-term birth B. macrosomia C. respiratory distress syndrome D. maternal gestational diabetes

C

What is a consequence of hypothermia in a newborn? 1- respirations of 46 2- heart rate of 126 3- holds breath 25 seconds 4- skin pink and warm

3

Infants in whom cephalhematomas develop are at increased risk for: a. Infection. b. Jaundice. c. Caput succedaneum. d. Erythema toxicum.

B

A woman is prescribed Coumadin (warfarin) to treat DVT. What will the nurse instruct the pt is the antidote for warfarin overdose? A. Vitamin A B. Vitamin B C. Vitamin E D. Vitamin K

D

A newborn has scheduled heel sticks for bilirubin checks every 4 hours. The mother asks the nurse "what can be done to calm my baby after those heel pricks?" What is the nurse's most appropriate response? 1- "You can give your baby a sucrose solution by bottle for pain relief." 2- "Offer your baby a feeding of sterile water solution by bottle." 3- "The fussiness will go away shortly with tight swaddling." 4- "Your baby is not feeling pain but irritated with all the handling."

1

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition? 1- respiratory distress syndrome 2- Down syndrome 3- hydrocephalus 4- esophageal atresia

1

A newborn is designated as very low birth weight. When weighing this newborn, the nurse would expect to find which weight? 1- less than 1,500 g 2- more than 4,000 g 3- approximately 2,500 g 4- less than 1,000 g

1

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? 1 first 30 to 60 minutes 2 first 3 to 5 days 3 first month 4 first 6 months

1

A nurse is implementing measures to prevent hypothermia in a premature newborn. The nurse determines that the newborn is experiencing an effect of hypothermia based on which assessment finding? 1- No breathing for 15 seconds 2- Respiratory rate of 45 breaths per minute 3- Heart rate of 130 beats per minute 4- Pink skin color

1

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? 1 Venous duplex ultrasound of the right leg 2 Transthoracic echocardiogram 3 Venogram of the right leg 4 Noninvasive arterial studies of the right leg

1

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to: 1- administer oxygen by mask. 2- increase her intravenous fluid infusion rate. 3- put firm pressure on the fundus of her uterus. 4- tell the woman to take short, catchy breaths.

1

A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience? 1 postpartum baby blues 2 postpartum anxiety 3 postpartum reaction 4 postpartum depression

1

An Rh positive client vaginally gives birth to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection? 1 length of labor 2 maternal Rh status 3 method of birth 4 size of the neonate

1

Assessment of a 26-week-old premature newborn reveals that the newborn is having problems with thermoregulation. The nurse would be alert for the development of which of the following? 1- Apnea 2- Tachycardia 3- Sleepiness 4- Crying

1

At birth, a term infant has irregular respirations and a weak cry. What is the sequence of events initiated by the nurse when caring for this infant? 1- Dry the infant, stimulate the infant, and keep the infant warm. 2- Dry the infant, administer blow-by oxygen, and keep the infant warm. 3- Open the airway, initiate respirations, and dry the infant. 4- Open the airway, suction the trachea, and administer oxygen

1

At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate? 1- The infant was a preterm, low birth weight and small for gestational age 2- The infant was born at term but at a low birth weight and small for gestational age 3- The infant was born at term but a very low birth weight and small for gestational age 4- The infant was a preterm, very low birthweight and small for gestational age

1

Eight days after birth the woman notices a return to red lochia. What condition does the nurse anticipate this patient is experiencing? 1 Retained placental fragments 2 Perineal hematoma rupture 3 Genital tract infection 4 Disseminate intravascular coagulopathy

1

In pulse oximetry for a newborn, what is the percentage of oxygen that is considered abnormal? 1- 75% 2- 95% 3- 85% 4- 87%

1

The health care provider is reluctant to provide pain medication to a patient delivering a preterm fetus. What should the nurse explain to the patient as the reason for the preterm fetus being more affected by medication? 1- Affinity of the preterm fetus to fat-soluble drugs 2- Inability of the immature liver to metabolize or inactivate drugs 3- Affinity of the preterm fetus to drugs that are strongly bound to protein 4- Inability of the preterm fetus to use drugs with a molecular weight over 1,000

1

The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production? 1 nonshivering thermogenesis 2 thermoregulation 3 thermoconduction 4 shivering thermogenesis

1

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 voiding per day as a good indicator of adequate fluids? 1 6 to 8 2 4 to 6 3 8 to 10 4 2 to 4

1

Which is the best place to perform a heel stick on a newborn? 1 the fat pads on the lateral aspects of the foot 2 the vascularized flat surface of the foot 3 the front of the heel (the outer arch) 4 the calcaneus

1

Why is thermoregulation a problem for the preterm newborn? 1- A preterm infant is not born with brown fat. 2- A decrease in skin surface to body mass is noted. 3- Water cannot escape easily through the skin. 4- The CNS is overactive, leading to excessive shivering and use of glucose stores.

1

After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement? 1 "If the symptoms last more than a few days, I need to call my doctor." 2 "I might feel like laughing one minute and crying the next." 3 "I'll need to take medication to treat the anxiety and sadness." 4 "I should call this support line only if I hear voices."

2

The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis? 1- jaundice 2- positive Moro reflex 3- jitteriness 4- palmar creases

3

The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2F (38.4C), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation? 1 Dehydration 2 Normal vital signs 3 Infection 4 Shock

3

A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanelle. The client is anxious to know when the posterior fontanelle will close. Which time span is the normal duration for the closure of the posterior fontanelle? 1 4 to 6 weeks 2 8 to 12 weeks 3 12 to 14 weeks 4 14 to 8 weeks

2

A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening? 1 infection 2 hemorrhage 3 fluid volume overload 4 pulmonary emboli

2

A neonate undergoing phototherapy treatment must be monitored for which adverse effect? 1- Hyperglycemia 2- Increased insensible water loss 3- Severe decrease in platelet count 4- Increased GI transit time

2

A newborn is returned to the newborn observational nursery demonstrating signs of cold stress after a prolonged bath. Which action would be a priority for the nurse? 1- Perform a neurological assessment. 2- Assess blood sugar level. 3- Request arterial blood gases. 4- Assess feeding patterns.

2

A newborn male has just returned to the mother's room after being circumcised. Which behaviors will concern the nurse? 1 Appearing very sleepy 2 Being restless and crying 3 Having a bowel movement 4 An apical pulse of 150

2

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? 1- The infant's mother must have had a long labor. 2- The infant's mother probably had diabetes. 3- The infant may have experienced birth trauma. 4- The infant may have been exposed to alcohol during pregnancy.

2

A nurse is conducting a class for expectant parents about newborns. As part of the class, the nurse describes newborns with birth weight variations. The nurse identifies which variation if the newborn weighs 5.2 lb (2,358 g) at any gestational age? 1- small for gestational age 2- low birth weight 3- very low birth weight 4- extremely low birth weight

2

A postpartum client is showing signs and symptoms of a pulmonary embolism. What should the nurse do? 1 Start oxygen at 2 to 3 liters per minute via nasal cannula. 2 Raise the head of the bed to at least 45 degrees. 3 Lay the client flat and start oxygen. 4 Sit the client up 90 degrees and call the RN.

2

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? 1 Mastitis 2 Endometritis 3 Subinvolution 4 Episiotomy infection

2

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder? 1 Breast yeast 2 Mastitis 3 Plugged milk duct 4 Engorgement

2

The nurse is responding to an infant crying and notes it is very high pitched and shrill. The nurse predicts this is most likely related to which situation? 1- Normal cry from pain 2- Tired and stress from delivery 3- Neurologic dysfunction 4- Cold stress cry

3

At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has has occurred when a participant makes which statement? 1- "Appropriate for gestational age means a newborn is born with a weight that falls in the 10th percentile." 2- "Newborns who are appropriate for gestational age at birth have lower chance of complications than others." 3- "Appropriate for gestational age describes a newborn with a weight over the 90th percentile at birth." 4- "Infants who are larger for gestational age at birth have fewer complications than the other groups."

2

The nurse assesses the client who is 1 hour postpartum and discovers a heavy, steady gush of bright red blood from the vagina in the presence of a firm fundus. Which potential cause should the nurse question and report to the RN or primary care provider? 1 Uterine atony 2 Laceration 3 Perineal hematoma 4 Infection of the uterus

2

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 showed her to be morbidly obese. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored? 1 Low temperature and hypertonia 2 Jitteriness and irritability 3 Hypotonia and fever 4 Frequent activity and jitteriness

2

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? 1 Attachment, lochia color, complete blood cell count 2 Blood pressure, pulse, reports of dizziness 3 Degree of responsiveness, respiratory rate, fundus location 4 Height, level of orientation, support systems

2

The nurse is giving a newborn his first bath. What should the nurse prioritize? 1 Give the sponge bath in the baby's bed. 2 Wash off all traces of blood and leave the vernix in place. 3 Use a soap such as hexachlorophene to prevent infection. 4 Apply talcum powder to the buttocks after washing.

2

The nurse is preparing a mother for a planned cesarean birth. The nurse ascertains that the mother has previously had a deep vein thrombosis. Heparin is ordered prophylactically. The nurse determines this medication will be administered: 1- 1 hour after birth. 2- 8 hours after birth. 3- 14 hours after birth. 4- 24 hours after birth.

2

The nurse notes in a newborn's chart that the newborn has been diagnosed with physiologic jaundice. The nurse recognizes that physiologic jaundice is determined by what criteria? 1- The jaundice occurred within the first 24 hours after birth. 2- The bilirubin peaked between days 3 and 5 after birth. 3- The bilirubin level rose 6 mg/dL to 13 mg/dL over the last 24 hours. 4- The conjugated bilirubin is higher than the unconjugated bilirubin.

2

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? 1 Perform vigorous fundal massage for the client. 2 Check for bladder distention, while encouraging the client to void. 3 Use semi-Fowler's position to encourage uterine drainage. 4 Offer analgesics prescribed by health care provider

2

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid? 1- total bilirubin level of 15 2- respiratory rate of 60 to 70 bpm 3- heart rate of 162 bpm 4- hematocrit of 44%

2

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? 1 hemoglobin level of 12 g/dL 2 uterine atony 3 thrombophlebitis 4 moderate amount of lochia rubra

2

Which measurement best describes delayed postpartum hemorrhage? 1. blood loss in excess of 300 ml, occurring 24 hours to 6 weeks after birth 2. blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after birth 3. blood loss in excess of 800 ml, occurring 24 hours to 6 weeks after birth 4. blood loss in excess of 1,000 ml, occurring 24 hours to 6 weeks after birth

2

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature? 1 Bathe the infant immediately after birth. 2 Place the infant on the mother's abdomen after birth. 3 Wrap the infant in a warm, dry blanket. 4 Turn the temperature up in the birth room.

3

The nurse receives a report on a client with type 1 diabetes mellitus whose delivery was complicated by polyhydramnios and macrosomia. The nurse is aware of these complications and knows to monitor the client closely for which of the following? 1 Postpartum mastitis 2 Increased insulin needs 3 Postpartum hemorrhage 4 Gestational hypertension

3

The nurse teaches the parents of a newborn with hyperbilirubinemia about home phototherapy using bilirubin lights. Which statement indicates that the teaching was successful? 1- "We'll place the lights so that they are about 5 inches above our baby at all times." 2- "We will turn him every ½ hour to make sure that his whole body is exposed." 3- "We'll take off the patches on his eyes when we're feeding him so he can look at us." 4- "We should see reddened areas on his skin, which means the treatment is working."

3

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client? 1- increased appetite 2- increase in the body temperature 3- lethargy and hypotonia 4- hyperglycemia

3

A client develops mastitis 3 weeks after giving birth. What part of client self-care is emphasized as most important? 1 Administer antibiotic medication for the full 10 days even if she begins to feel better 2 Use NSAIDs, warm showers, and warm compresses to relieve her discomfort 3 Breastfeed or otherwise empty her breasts every 1 to 2 hours 4 Increase her fluid intake to ensure that she will continue to produce adequate milk

3

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of: 1- normal birth weight. 2- low birth weight. 3- very low birth weight. 4- extremely low birth weight.

3

A newborn is diagnosed with ophthalmia neonatorum. The nurse understands that this newborn was exposed to which infection? 1- syphilis 2- Candida albicans 3- gonorrhea 4- human immunodeficiency virus

3

A nurse is caring for a client who gave birth vaginally 2 hours ago. What postpartum complication can the nurse assess within the first few hours following birth? 1 postpartal infection 2 postpartal blues 3 postpartal hemorrhage 4 postpartum depression

3

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature? 1 Tape electronic thermistor probe to the abdominal skin. 2 Obtain the temperature orally. 3 Place electronic temperature probe in the midaxillary area. 4 Obtain the temperature rectally.

3

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem? 1- shivering 2- hyperglycemia 3- apnea 4- metabolic alkalosi

3

At what day of life does jaundice peak in a newborn? 1- 1 to 2 days 2- 7 to 10 days 3- 3 to 5 days 4- 10 to 12 days

3

In an infant who has hypothermia, what would be an appropriate nursing diagnosis? 1- Ineffective parental attachment 2- Alteration in nutrition 3- Impaired tissue perfusion 4- Impaired skin integrity

3

On an Apgar evaluation, how is reflex irritability tested? 1 tightly flexing the infant's trunk and then releasing it 2 dorsiflexing a foot against pressure resistance 3 flicking the soles of the feet and observing the response 4 raising the infant's head and letting it fall back

3

Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition? 1 retained placental fragments 2 hypertension 3 thrombophlebitis 4 uterine subinvolution

3

The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex? 1 Moro 2 Tonic neck 3 Rooting 4 Sucking

3

A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk? 1 increase in clotting factors 2 vessel damage 3 immobility 4 increase in red blood cell production

4

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? 1 Bend her knee, and palpate her calf for pain. 2 Ask her to raise her foot and draw a circle. 3 Blanch a toe, and count the seconds it takes to color again. 4 Assess for pedal edema.

4

A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom? 1 an inverted nipple on the affected breast 2 no breast milk in the affected breast 3 an ecchymotic area on the affected breast 4 hardening of an area in the affected breast

4

A woman had a vaginal delivery 2 days ago & is preparing for discharge. What will the nurse plan to teach the woman to report to help prevent postpartum complications? A. fever B. change in lochia from red to white C. contractions D. fatigue & irritability

A

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? 1 Suction the mouth and then the nose with a suction catheter. 2 Place the newborn on its stomach with the head down and gently pat its back. 3 Suction the nose first and then the mouth with a bulb syringe. 4 Using a bulb syringe, suction the mouth then the nose.

4

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 1 100 mL 2 250 mL 3 300 mL 4 500 mL

4

The nurse is admitting a term, large-for-gestational-age neonate weighing 4,610 g (10 lb, 2 oz), born vaginally with a mid-forceps assist, to a 15-year-old primipara. What would the nurse anticipate as a result of the birth? 1- fracture of the tibia 2- fracture of the femur 3- fracture of a rib 4- midclavicular fracture

4

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 97.7oF (36.5oC), and blood pressure 78/40 mm Hg. Which action should the nurse prioritize? 1 Report tachypnea. 2 Recheck blood pressure in 15 minutes. 3 Put warming blanket over infant. 4 Document normal findings.

4

The nurse is assessing vital signs on the client and notes a normal blood pressure along with an elevated pulse when the patient moves from a lying to a standing or sitting position. What would this indicate? 1 Delayed labor 2 Overhydration 3 Arrested labor 4 Low fluid volume

4

The nurse is assisting a client who has just undergone an amniocentesis. Blood results indicate the mother has type O blood and the fetus has type AB blood. The nurse should point out the mother and fetus are at an increased risk for which situation related to this procedure? 1- Placental abruption 2- Preterm birth 3- Baby developing hemolytic anemia 4- Baby developing postbirth jaundice

4

The nurse is caring for a client who has been diagnosed with a deep vein thrombosis. Which assessment finding should the nurse prioritize and report immediately? 1 Calf pain 2 Pyrexia 3 Edema 4 Dyspnea

4

The nurse is caring for a client within the first four hours after her cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis? 1 Roll a bath blanket or towel and place it firmly behind the knees. 2 Limit oral intake of fluids for the first 24 hours to prevent nausea. 3 Assist client in performing leg exercises every two hours. 4 Ambulate the client as soon as her vital signs are stable.

4

The nurse is evaluating the neonate for gestational age. Which assessment finding will the nurse note when determining the infant is post-term? 1- A scarf sign shows resistance and the elbow is unable to reach midline 2- Breast buds are 4.5 mm and have a raised areola 3- Flexed positions show good muscle tone 4- Ear cartilage is thick and the pinna is stiff

4

The nurse is teaching a discharge session to a group of postpartum clients. When asked how long to expect the bleeding, which time frame should the nurse point out? 1 For 6 weeks 2 On and off for 2 to 3 weeks 3 Stops in 1 to 2 weeks 4 In approximately 10 days

4

The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn? 1- fewer visible blood vessels through the skin 2- more subcutaneous fat in the neck and abdomen 3- well-developed flexor muscles in the extremities 4- greater surface area in proportion to weight

4

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? 1- decreased muscle mass 2- face is angular and pinched 3- decreased body temperature 4- ability to tolerate early oral feeding

4

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn? 1 Swaddle the infant and place in the bassinet. 2 Complete a full head-to-toe assessment. 3 Assess the newborn's glucose level. 4 Dry the newborn and place it skin-to-skin on mother.

4

Which complication is most likely responsible for a late postpartum hemorrhage? 1 cervical laceration 2 clotting deficiency 3 perineal laceration 4 uterine subinvolution

4

Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate? 1 She should stop breast-feeding until completing the antibiotic. 2 She should supplement feeding with formula until the infection resolves. 3 She should not use analgesics because they are not compatible with breast-feeding. 4 She should continue to breast-feed; mastitis will not infect the neonate.

4

Your patient delivered six hours ago. She calls you to her room complaining of pain "deep inside." You medicate her per orders with no relief attained. You check her vital signs and find they are markedly different then when the CNA charted them 30 minutes ago. What would you suspect? 1 Late postpartum hemorrhage 3 Early postpartum hemorrhage 4 Uterine laceration 4 Pelvic hematoma

4

Although the nurse has massaged the uterus every 15 minutes, it remains flaccid, and the patient continues to pass large clots. What does the nurse recognize these signs indicate? A. uterine atony B. uterine dystocia C. uterine hypoplasia D. uterine dysfunction

A

A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding? A. this will resolve in 3-6 wks without treatment B. this will resolve on its own within 3-4 days C. the provider might drain this area with a syringe D. this appearance is expected at birth, so you don't need to worry

A

A nurse is assessing a newborn 1 hr after birth. Which of the following findings should the nurse report to the provider? A. jaundice of the sclera B. RR 50/min C. acrocyanosis D. blood glucose 60 mg/dL

A

A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider? A. small, pinpoint, reddish-purple spots on the chest B. bluish coloring of the feet C. overlapping suture lines D. white, cheese-like substance covering the skin

A

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following statements should the nurse include? A. Notify your provider if you notice cracking on your nipples B. Notify your provider if you have not had a bowel movement within 5 days C. Notify your provider if your breasts leak when you shower D. Notify your provider if your vaginal discharge is a brownish-red color

A

A nurse is teaching a postpartum client how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? A. I should stop swaddling my baby once she is able to roll over by herself B. my baby's legs should be extended straight out when I swaddle her C. I should be able to slide just 1 finger between my baby's chest and the swaddled blanket D. after swaddling, I should place my baby on her side in her crib/bassinet

A

A postpartum nurse is providing care for a client who is breastfeeding and has a perineal hematoma. The nurse should recommend that the client use which of the following breastfeeding positions? A. side-lying B. clutch hold C. across-the-lap D. cross-cradle

A

During a postpartum assessment, a woman reports her right calf is painful. The nurse observes edema & redness along the saphenous vein in the right lower leg. Based on this finding what does the nurse explain the probable Tx will involve? A. anticoagulants for 6 wks B. application of ice to the affected lef C. gentle massage of the affected leg D. passive leg exercises twice a day

A

Early postpartum hemorrhage is defined as a blood loss greater than a. 500 mL in the first 24 hours after vaginal delivery b. 750 mL in the first 24 hours after vaginal delivery c. 1000 mL in the first 48 hours after c-section d. 1500 mL in the first 48 hours after c-section

A

Nurses can prevent evaporative heat loss in the newborn by: a. Drying the baby after birth and wrapping the baby in a dry blanket. b. Keeping the baby out of drafts and away from air conditioners. c. Placing the baby away from the outside wall and the windows. d. Warming the stethoscope and the nurse's hands before touching the baby.

A

The nurse assesses a boggy uterus with the fundus above the umbilicus & deviated to the side. What should the nurses next assessment be? A. fullness of the bladder B. amt of lochia C. BP D. level of pain

A

The nurse should expect medical intervention for subinvolution to include a. oral methylergonovine maleate (methergine) for 48 hrs b. oxytocin IV infusion for 8 hrs c. oral fluids to 3000 mL/day d. IV fluid & blood replacement

A

The parent of a 3-day-old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborn's labia. Which of the following responses should the nurse make? A. "The blood-tinged mucus is a result of pseudomenstration" B. "The blood-tinged mucus indicates a urinary tract infection" C. "The blood-tinged mucus is due to uric acid crystals" D. "The blood-tinged mucus is a result of the initial genital examination"

A

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by a. subinvolution of the uterus b. defective vascularity of the decidura c. cervical lacerations d. coagulation disorders

A

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Tonic neck c. Stepping d. Plantar grasp

A

Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. place a blanket over the scale before weighing the infant b. maintain room temp at 70F c. undress the infant completely for assessments d. take the rectal temp every hour to detect early changes

A

Which statement indicates to the nurse on a postpartum home visit that the pt understands the signs of late postpartum hemorrhage? A. my discharge would change to red after it has been pink/white B. if I have a postpartum hemorrhage, I will have severe abdominal pain C. I should be alert for an increase in bright red blood D. I would pass a large clot that was retained from the placenta

A

While caring for a postpartum pt who had a vaginal delivery yesterday, the nurse assesses a firm uterine fundus & a trickle of bright blood. How does the nurse most likely feel & react to this finding? A. concerned & reports a probable cervical laceration B. attentive & massages the uterus to expel retained clots C. distressed & reports a possible clotting disorder D. satisfied w/ the normal early postpartum findings

A

While caring for the postterm infant, the nurse recognizes that the fetus may have passed meconium prior to birth as a result of a. hypoxia in utero b. NEC c. placental insufficiency d. rapid use of glycogen stores

A

A community health nurse is planning care for 4 high risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? A. a 1 wk old who needs another PKU screening test B. a 4 day old who has an elevated bilirubin and requires phototherapy C. a 10 day old who is SGA and requires daily weighting D. a 2 wk old who was born at 35 wks gestation & weighed 5 lb at discharge

B

A newborn who is small for gestation age (SGA) is ___ percentile for weight a, below the 90th b. less than the 10th c. greater than the 90th d. between the 10th and 90th

B

A nurse is assessing a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use? A. press down & forward with the hand that is placed on the base of the uterus B. measure the height of the fundus in fingerbreadths in relation to the umbilicus C. place the client in a semi-Fowler's position prior to checking the uterus D. place the client in a supine position prior to checking the uterus

B

A nurse is assessing a newborn and notes an axillary temp of 96.9F (36C). Which of the following actions should the nurse perform? A. obtain a rectal temp B. assess the newborn's blood glucose level C. bathe the newborn with warm water D. position the infant's bassinet in front of a heater vent

B

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? A. overlapping suture lines B. generalized petechiae C. acrocyanosis D. transient atrabismus

B

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. anterior fontanel of 5 cm B. central cyanosis C. edematous scrotum D. capillary refill of under 2 seconds

B

A nurse is caring for a client who had a cesarean birth 36 hours ago & is experiencing pain d/t gas. Which of the following strategies should the nurse recommend? A. sip a carbonated beverage throughout the day B. rock in a rocking chair C. lie flat in bed with the legs extended D. use a straw when drinking fluids

B

A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse perform FIRST? A. perform a detailed physical assessment B. place the newborn directly on the client's chest C. give the newborn IM vitamin K D. administer erythromycin ophthalmic ointment

B

A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development? A. rapidly advance oral feedings B. position the naked newborn on the parent's bare chest C. provide frequent periods of visual & auditory stimulation D. discourage the use of pacifiers

B

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of oxygen therapy? A. atelectasis B. retinopathy C. interstitial emphysema D. necrotizing enterocolitis

B

A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take withing 1hr after birth? A. administer the hepatitis B (HBV) vaccine B. assess the newborn's blood glucose level C. bathe the newborn D. perform a screening for congenital heart disease

B

A nurse is determining an Apgar score for a newborn who was born 1 minute ago. For which of the following findings should the nurse assign a score of 1? A. heart rate 116/min B. weak cry C. flaccid muscles D. no response to ctimuli

B

A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include? A. tachycardia B. hypoglycemia C. flushed skin D. generalized petechiae

B

A nurse is monitoring a newborn for indications of septic shock. Which of the following findings should the nurse expect if the newborn develops this complication? A. slow respirations B. decreased blood pressure C. bradycardia D. flushed skin

B

A nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. This could indicate a possible uterine infection B. The bleeding is minimal until I discontinue your IV medication C. You might have retained some fragments of your placenta D. You will require additional medication to increase your bleeding

B

A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? A. gently retract the foreskin to wash the glans w/ soap & water B. sponge bathe the newborn every other day C. use an antimicrobial soap for bathing D. bathe the newborn with water between 46-49C (115-120F)

B

A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include? A. the bedtime bottle can be placed in the crib after the infant is 6 months of age B. discard opened cans of formula after 48 hr refrigeration C. powdered & concentrated formula can be reconstituted w/ tap water straight from the faucet D. bottles & nipples can be hand-washed in hot, soapy water

B

A nurse is teaching a parent of a newborn how to care for the newborn's umbilical cord stump. Which of the following instructions should the nurse included? A. cover the cord w/ the edge of the diaper B. clean the cord stump w/ tap water C. apply a damp cloth over the cord stump once a day D. you should gently tug on the cord stump in 5 days if it has not yet fallen off

B

A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? A. they can cause increased pain from the cord B. they can cause delayed cord separation C. they can cause swelling of the surrounding tissue D. they can cause skin discoloration

B

After a prolonged labor, a woman vaginally delivered a 10 pound 3 ounce infant boy. What complication should the nurse be alert for in the immediate postpartum period? A. cervical laceration B. hematoma C. endometritis D. retained placental fragments

B

At her 6-week postpartum checkup, a woman mentions to the nurse that she cannot sleep and is not eating. She feels guilty because sometimes she believes her infant is dead. What does the nurse recognize as the cause of this woman's symptoms? A. bipolar disorder B. major depression C. postpartum blues D. postpartum depression

B

The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. What action should the nurse implement based on these symptoms? A. notify the charge nurse of a possible upper respiratory infection B. notify the physician of a possible pulmonary embolism C. document expected postpartum mucous membrane congestion D. medicate w/ antipyretic remedy for elevated temp

B

The goal of treatment of the infant with PKU is to a. cure mental retardation b. prevent CNS damage, which leads to mental retardation c. prevent GI symptoms d. cure the UTI

B

What is the 1st sign of hypovolemic shock from postpartum hemorrhage? A. cold, clammy skin B. tachycardia C. hypotension D. decreased UOP

B

What is the first sign of hypovolemic shock from postpartum hemorrhage? a. cold, clammy skin b. tachycardia c. hypotension d. decrease urinary output

B

What statement by the pt leads the nurse to determine a woman w/ mastitis understands Tx instructions? A. I will apply cold compresses to the painful areas B. I will take a warm shower before nursing the baby C. I will nurse first on the affected side D. I will empty the affected breast every 8 hrs

B

When teaching parents about their newborns transition to extrauterine life, the nurse explains which organs are nonfunctional during fetal life. They are the: A. kidneys & adrenals B. lungs & liver C. eyes & ears D, GI system

B

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn? A. 7 B. 8 C. 9 D. 10

C

A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate? A. heel creases over the entire sole of the foot B. pendulous testes C. extended extremities D. leathery cracked skin

C

A nurse is assessing a newborn. For which of the following findings should the nurse notify the provider? A. heart rate 136/min B. acrocyanosis C. mottling D. respiratory rate 60/min

C

A nurse is assessing a postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and located 1cm below the umbilicus. Which of the following actions should the nurse take? A. massage the fundus B. instruct the client to empty her bladder C. notify the provider D. teach the client to perform a sitz bath

C

A nurse is providing education about continuous heparin therapy for a client who is 18 hours postpartum and has developed a DVT. Which of the following statement should the nurse INCLUDE in the teaching? A. An adverse effect of this medication is drowsiness B. this medication will require frequent monitoring of WBC levels C. use a soft toothbrush to brush your teeth gently D. avoid taking acetaminophen while receiving this medication

C

A nurse is teaching a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn? A. altered carbohydrate metabolism B. hyperbilirubinemia C. intracranial hemorrhage D. hypoglycemia

C

A woman has had persistent lochia rubra for two weeks after her delivery and is experiencing pelvic discomfort. What does the nurse explain is the usual Tx for subinvolution? A. uterine massage B. oxytocin infusion C. dilation & curettage D. hysterectomy

C

Heat loss by convection occurs when a newborn is a. Placed on a cold circumcision board b. Given a bath c. Placed in a drafty area of the room d. Wrapped in cool blankets

C

In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is a. important in the production of RBCs B. necessary in the production of platelets C. not initially synthesized b/c of a sterile bowel at birth D. responsible for the breakdown of bilirubin & prevention of jaundice

C

Massage and putting the infant to the breast of a postpartum patient have been ineffective in controlling a boggy uterus. What will the nurse anticipate might be ordered by the physician? A. ritodrine B. magnesium sulfate C. oxytocin D. bromocriptine

C

The mother-baby nurse must be able to recognize what sign of thrombophlebitis? a. visible varicose veins b. positive Homans sign c. local tenderness, heat & swelling d. pedal edema in the affect leg

C

To provide competent newborn care, the nurse understands that respirations are initiated at birth as a result of a. an increase in the PO2 and a decrease in PCO2 b. the continued functioning of the foramen ovale C. chemical, thermal, sensory, & mechanical factors D. drying off the infant

C

What is a result of hypothermia in the newborn? A. shivering to generate heat B. decreased O2 demands C. increased glucose demands D. decreased metabolic rate

C

What should the nurses first action be when postpartum hemorrhage from uterine atony is suspected? A. teach the pt how to massage the abdomen & then get help B. start IV fluids to prevent hypovolemia & then notify the RN C. begin massaging the fundus while another person notifies the physician D. ask the pt to void & reassess fundal tone & location

C

Which statement is TRUE about LGA infants? a. they weigh more than 3500g b. they are above the 80th percentile c. they are prone to hypoglycemia, polycythemia & birth injuries d. postmaturity syndrome and fractured clavicles are the most common complications

C

While assessing the newborn the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is ____ bpm a. 80-100 b. 100-120 c. 120-160 d. 150-180

C

A nurse at a clinic is preparing to teach the process of involution to a group of antenatal clients. Which of the following information should the nurse provide? A. the fundus is approximately 2m (0.79 in) above the level of the umbilicus at the end of the third stage of labor B. the fundus is approximately 3 cm (1.18 in) above the umbilicus within 12 hours after delivery C. the fundus is located halfway between the umbilicus and mons pubis on the sixth day postpartum D. the fundus is not palpable abdominally at 2 weeks postpartum

D

A nurse is assessing a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect? A. distended abdomen B. increased BP C. generalized petechiae D. barrel-shaped chest

D

A nurse is assessing the Moro response of a newborn. Which of the following findings should the nurse expect? A. abduction & extension of the arms are asymmetric B. the opposite leg flexes while a leg is extended and the sole of the foot is stimulated C. toes hyperextend with dorsiflexion of the great toe D. the legs move in a similar pattern of response to the arms

D

A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first? A. place the client's hands in warm water B. administer an analgesic to the client C. pour water from a squeeze bottle over the client's perineum D. assist the client to the bathroom

D

A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first? A. weight the newborn B. instill erythromycin opthalmic ointment in the eyes C. administer vitamin K to the newborn D. dry the newborn

D

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. extended periods of sleep B. poor muscle tone C. RR 50/min D. exaggerated reflexes

D

A nurse is caring for a newborn who was born to a client with a narcotic use disorder. Which of the following nursing actions is contraindicated in the care of this newborn? A. promoting maternal-newborn bonding B. tight swaddling of the newborn C. small frequent feedings D. frequent stimulation

D

A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take? A. administer vitamin K subcutaneously B. administer erythromycin eye ointment within 12 hours C. administer erythromycin eye ointment from the outer canthus toward the inner canthus D. administer vitamin K in the newborn's thigh

D

A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? A. check the newborn's heart rate B. place a pressure dressing on the cord stump C. administer vitamin K D. check the integrity of the cord clamp

D

A nurse is providing teaching to the parents of a newborn about bottle feeding. Which of the following instructions should the nurse INCLUDE in the teaching? A. dilute ready-to-feed formula if the newborn is gaining weight too quickly B, prop the bottle with a blanket for the last feeding of the day C. discard unused refrigerated formula after 72 hr D. boil water for powdered formula for 1-2 min

D

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching? A. apply the diaper tightly over the circumcision area B. remove the yellow exudate with each diaper change C. use prepackaged commercial wipes to clean the circumcision site D. encourage non-nutritive sucking for pain relieg

D

A nurse is teaching a client who is postpartum and breastfeeding. Which of the following statements should the nurse include? A. You will need to wait 3 months before resuming sexual intercourse B. You don't need to use contraception until you are 4 months postpartum C. As long as you breastfeed, you will experience an overproduction of vaginal lubrication D. A reduction in sexual interest could indicate postpartum depression

D

A nurse is teaching about mastitis to a client who is postpartum and breastfeeding. Which of the following statements by the client indicates and understanding of the teaching? A. I will limit breastfeeding to 5 mins per breast B. I will not breastfeed if I start to have flu-like symptoms C. I will shop for an underwire nursing bra today D. I will avoid any of my family members who are ill

D

An African-American woman noticed some bruises on her newborn's buttocks. She asks the nurse who spanked him. The nurse explains that these marks are called a. lanugo b. vascular nevi c. nevus flammeus d. mongolian spots

D

Compared to the term infant, the preterm infant has a. few blood vessels visible through the skin b. more subcutaneous fat c. well-developing flexor muscles d. greater surface area in proportion to weight

D

If nonsurgical treatment for late postpartum hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a. hysterectomy b. laparoscopy c. laparotomy d. D&C

D

The new mother who had a vaginal delivery yesterday has a WBC count of 30,000 cells/dL. What action should the nurse implement? A. notify the charge nurse of a possible infection B. prepare to put the pt in isolation C. have the infant removed from the room and returned to the nursery D. assess the pt further

D

The nurse assesses a positive Homans sign when the patients leg is flexed & foot sharply dorsiflexed. Where does the pt report that the pain is felt? A. groin B. achilles tendon C. top of the foot D. calf of the leg

D

The nurse is caring for a woman who had a c-section birth yesterday. Varicose veins are visible on both legs. What nursing action is the most appropriate to prevent thrombus formation? A. have the woman sit in a chair for meals B. monitor VSs every 4 hrs & report any changes C. tell the woman to remain in bed with her legs elevated D. assist the woman with ambulation for short periods of time

D

Three weeks after delivering her 1st child, a woman tells the nurse, I waited so long for this baby & now that she is here I can't believe how different my life is from what I expected. What is the best nursing response to the womans statement? A. How is your partner adjusting to the change? B. I hear this from a lot of first-time mothers C. Have you told anyone else about your feelings? D. Tell me how things are different

D

What is the best response to a postpartum woman who tells the nurse she feels tired & sick all the time since I had the baby 3 months ago? A. this is a normal response for the body after pregnancy. try to get more rest B. I'll bet you will snap out of this funk real soon C. why don't you arrange for a babysitter so you & your husband can have a night out? D. lets talk about this further. I am concerned about how you are feeling

D

What nursing action is especially important for the SGA newborn? a. observe for respiratory distress syndrome b. observe for & prevent dehydration c. promote bonding d. prevent hypoglycemia by early & frequent feedings

D

Which statement by a postpartum woman indicates that further teaching is not needed regarding thrombus formation? a. I'll stay in bed for the first 3 days after my baby is born B. I'll keep my legs elevated w/ pillows C. I'll sit in my rocking chair most of the time D. I'll put my support stockings on every morning before rising

D