OB Exam 4

A postpartum patient calls for the nurse because she is having a very heavy lochia flow containing large clots. What should be the nurse's first action? A) Assess blood pressure B) Palpate fundus C) Have the patient turn onto the left side D) Assess the perineum

Ans: B Feedback: Palpating the fundus will cause it to contract and reduce bleeding. The nurse can measure blood pressure, position the patient, and assess the perineum after the fundus is palpated.

A patient who delivered three hours ago has a temperature of 102.4ºF. What should the nurse do? A) Notify the provider B) Administer an antipyretic C) Assist the client in ambulation D) Continue to monitor for another hour

Ans: A Feedback: A temperature elevated above 100.4ºF is a sign of possible infection. The provider needs to be contacted. Administering an antipyretic can only be done at the physician's order. Assisting in ambulation and continuing to monitor the patient for another hour are not indicated for this patient.

The vital signs of a postpartum patient on day 1 after delivery are: Temp 99ºF, RR 18, HR 78, BP 140/90. What is the appropriate intervention by the nurse? A) Report the slight elevation in BP B) Nothing, the vital signs are within normal limits C) Recheck all vital signs in 30 minutes D) Recheck only the BP in 30 minutes

Ans: A Feedback: An elevated BP may be a sign the patient is developing preeclampsia after delivery. This finding should be reported. The BP is not within normal limits. The nurse may recheck the BP in 30 minutes; however, the elevation should be reported. It would not be necessary to recheck all of the vital signs in 30 minutes.

How should the nurse define bonding to a group of pregnant patients attending prenatal classes? A) A process of developing an attachment and becoming acquainted with each other B) The skin-to-skin contact that occurs in the delivery room C) An ongoing process in the year after delivery D) Family growing closer together after the birth of a new baby

Ans: A Feedback: Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship. Bonding goes beyond contact in the delivery room. The process of bonding does not take a year. The family growing closer together after the birth of a new baby is not bonding.

Which postpartum patient should the nurse suspect of having endometritis? A) Patient with diabetes who delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, the patient appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative. B) Patient with a history of infection and smoking who develops a temperature of 101 degrees on the fourth postpartum day. The patient reports severe perineal pain and the edges of the episiotomy have separated. C) Obese patient who has a temperature of 100.4 degrees at 12 hours after delivery. The patient's lochia is moderate; vaginal cultures are negative. D) Patient with PROM before delivery complains of severe burning with urination, malaise, and severe temperature spikes on the seventh postpartum day. WBC is 21,850 cells/mm3; temperature is 101 degrees; and skin is pale and clammy.

Ans: A Feedback: Endometritis is an infection of the endometrium of the uterus. The patient has an elevated temperature greater than 24 hours after delivery and high WBC. The patient would be treated for infection and monitored. The other patients are not demonstrating manifestations of endometritis.

Which lochia pattern should the nurse report immediately to the RN or primary practitioner? A) Moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 B) Moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 C) Lochia progresses from rubra to serosa to alba within 10 days D) Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5

Ans: A Feedback: Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinged. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding; as is lochia progressing from rubra to serosa to alba within 10 days of delivery; and so is moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5.

The nurse is caring for a postpartum patient. Which potential complication during the first hour after delivery is of the most concern to the nurse? A) Infection B) Dehydration C) Hemorrhage D) Bladder distention

Ans: C Feedback: If a woman is going to hemorrhage, she is most likely to do so within the first postpartum hour. The nurse must assess a postpartum patient every 15 minutes for the first hour. Infection, dehydration, and bladder distention are all assessment parameters but do not take precedence over hemorrhage in the first postpartum hour.

The nurse is providing discharge education to a first-time mother and father on their newborn female infant. The father notes the infant has a yellow skin color. How should the nurse explain what the father is noting? A) The tint is yellow from jaundice B) Yellow is the normal color for a newborn C) The infant needs to be in the sunlight to clear the skin D) This might be a sign of a bleeding problem

Ans: A Feedback: Newborns often have a yellow tint to the skin if the newborn develops jaundice. Any newborn developing jaundice needs to be assessed by the health care provider. Yellow is not the normal color for a newborn. Placing the infant in sunlight may help to clear the skin of the yellow color; however, unless instructed by the physician, this is not information provided in discharge teaching. Jaundice is not a sign of a bleeding problem.

When caring for a newborn who is jittery and irritable 30 minutes after birth, what should the nurse do? A) Take blood, using a heel stick, to check for hypoglycemia B) Place the child beneath a radiant warmer C) Rule out hypoglycemia by checking the mother's chart for diabetes or other risk factors D) Assess the baby's temperature with a thermal skin probe

Ans: A Feedback: One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level with a heel stick. The infant does not need to be placed under a radiant warmer or have its temperature assessed with a thermal skin probe. The nurse does not rule out hypoglycemia in an infant by checking the mother's chart to see if she is diabetic or has other risk factors.

A newborn born by a cesarean birth is a risk for complication of which system during transition? A) Respiratory B) Cardiovascular C) Metabolic D) Thermoregulatory

Ans: A Feedback: The infant born from a cesarean birth has not had the opportunity to exit the birth canal and experience the squeezing of fluid from the lungs. The lungs have more amniotic fluid than the lungs of a baby from a vaginal delivery and are at greater risk for respiratory complications. An infant born by cesarean birth is not at increased risk for complications of the cardiovascular, metabolic, nor thermoregulatory systems.

A postpartum patient received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. The incision is red, warm, and very sensitive to touch, and remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care to teach the patient? A) Wound care and hand washing B) Strict adherence to antibiotic therapy C) Proper perineal care D) Use of warm compresses and sitz baths

Ans: A Feedback: The use of systemic corticosteroids prior to delivery increased the patient's risk for development of an infection. The patient has been treated for endometritis and is now at greater risk for infection. Hand washing is the best defense against transmission of any infection. While adherence to antibiotic therapy, proper perineal care, and use of warm compresses and sitz baths may be indicated, they would not be a higher priority than wound care and hand washing.

Infants receive vitamin K within the first hour after delivery. What is the A) Helps in formation of clotting factors, to prevent bleeding B) Is a routine vitamin needed by the infant C) Administered to give the infant better eyesight D) Used to help infant fight infections

Ans: A Feedback: Vitamin K is necessary in the formation of certain clotting factors. The newborn is lacking in vitamin K and the only method for the infant to receive it is to administer the vitamin IM. Vitamin K is manufactured by normal flora in the gut. Since the newborn has not yet eaten, there is no normal flora in the gut so the infant cannot manufacture vitamin K. Vitamin K is not administered to give the infant better eyesight nor is it to help fight infections.

Prior to discharge the nurse is preparing a newborn for sensory perception diagnostic tests. Which tests will the newborn have before going home with the mother? (Select all that apply.) A) Auditory brainstem response B) Otoacoustic emissions C) Ophthalmologic examination D) Olfactory stimulation E) Tactile discrimination

Ans: A, B Feedback: A hearing screen is now encouraged for all newborns before they are discharged home. There are two tests that are used to screen a newborn's hearing—the auditory brainstem response and otoacoustic emissions. A newborn is not given an ophthalmologic examination before discharge. Olfactory stimulation and tactile discrimination are not sensory perception diagnostic tests.

The nurse is planning to evaluate a postpartum patient's lower extremities. What should the nurse do for this assessment? (Select all that apply.) A) Check pulses B) Inspect for edema C) Evaluate capillary refill in the toes D) Ask the patient to dorsiflex the calf E) Assess for coolness of skin temperature

Ans: A, B, C, D Feedback: When assessing the lower extremities the nurse should check pulses, inspect for edema, evaluate capillary refill in the toes, and ask the patient to dorsiflex the calf. The nurse should assess for warmth and not coolness of the skin of the lower extremities.

The nurse is preparing to assess a newborn's first Apgar score. What will the nurse assess to determine this score? (Select all that apply.) A) Heart rate B) Skin color C) Urine output D) Respiratory effort E) Passing of meconium

Ans: A, B, D Feedback: The Apgar score is created by assessing the newborn's heart rate, respiratory effort, muscle tone, irritability, and skin color. Urine output and passing of meconium are not criteria for the Apgar score.

The nurse is providing discharge teaching to a new mother about the baby's feeding schedule. What should the nurse include in these instructions? (Select all that apply.) A) Feed every two hours B) Spitting up is expected C) Vomiting is a daily occurrence D) Frequent vomiting can cause dehydration E) Feeding patterns become regular in about two weeks

Ans: A, B, D, E Feedback: Most newborns eat every two to four hours. Feeding patterns become fairly regular in approximately two weeks. Spitting up is expected. Vomiting should be reported to the pediatrician. Frequent vomiting can quickly lead to dehydration.

The nurse is planning care to assist a patient and spouse through the unexpected death of their newborn. Which interventions should the nurse use to support the couple at this time? (Select all that apply.) A) Provide a lock of hair B) Schedule for counseling C) Provide a photo of the baby D) Encourage to name their baby E) Prepare an identification bracelet

Ans: A, C, D, E Feedback: Several measures can help provide meaning to the family during this difficult time. Encourage the family to name their newborn, provide a lock of hair, a photo, and identification bracelet to help the couple with memories of the newborn. Scheduling for counseling might be premature at this time.

How should the nurse explain to a new mother why a newborn develops physiologic hyperbilirubinemia? (Select all that apply.) A) Newborn liver is immature B) Liver is not functioning upon birth C) Mother has underlying liver disease D) Liver is overwhelmed with a large number of red blood cells E) Lungs begin to function and excess red blood cells are not needed

Ans: A, D, E Feedback: The newborn's liver is immature at birth. The fetus has a high percentage of circulating red blood cells to make use of all available oxygen in a low-oxygen environment. Because of this, the newborn has a hematocrit about 45% to 65%. After birth, the newborn's lungs begin to function, and more oxygen is available immediately. Therefore, the "extra" red blood cells gradually die and circulate to the liver to be broken down. The influx of red blood cells causes hyperbilirubinemia. The newborn's liver is functioning upon birth. Hyperbilirubinemia is not caused by the mother having an underlying liver disease.

A patient delivered her fourth child after protracted and difficult labor during which oxytocin was used to augment contractions. The next day, her vaginal bleeding continues to be moderately heavy with numerous large clots. Palpating the fundus, the nurse find that it is in the midline but boggy and above the level of the umbilicus. Fundal massage is indicated. What should the nurse do first? A) Ensure that her bladder is empty B) Place one hand over the symphysis pubis C) Seek an order to obtain and administer an oxytocic D) Insert uterine packing to control the hemorrhage

Ans: B Feedback: A boggy fundus with active bleedings and clots the day after delivery is indicative of uterus atony. The nurse should prepare to initiate fundal massage. The first step in this procedure is to place one hand over the symphysis pubis. The first step in fundal massage is not to ensure that the patient's bladder is empty, seek an order for an oxytocic, or insert uterine packing.

Which maternal reaction is cause for concern and should prompt a consultation with the RN? A) Hesitation to take newborn when offered and expresses disappointment with the way the baby looks B) Neglects to engage with or provide care for the baby and shows little interest in it C) Tearful for several days and has difficulty eating and sleeping D) Expresses doubt about her ability to care for the baby as well as the nurse can

Ans: B Feedback: A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn, and express disappointment in the way the baby looks, especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with "postpartum blues."

Twelve hours after delivery, the fundus of a patient who has just delivered her fifth child after 14 hours of labor is two fingers above the umbilicus and her uterus feels soft and spongy. What should the nurse do first? A) Put on the call button to summon help B) Gently massage the fundus until it tones up C) Administer oxytocics to prevent uterine atony D) Teach the patient to perform periodic self-fundal massage

Ans: B Feedback: After delivery, the fundus should be firm and at the umbilicus or lower. The first action is to massage the uterus until firm. The scenario described does not indicate any need to summon help. The administration of oxytocics to prevent uterine atony can only be done by order of the health care provider. Teaching the woman to perform self-fundal massage is not appropriate at this time. It would be appropriate after the atony of the uterus is corrected.

The nurse is discharging a new mother and notes she is not rubella-immune and administers the rubella vaccine. The patient will breast-feed her infant and plans to get pregnant again as soon as possible. What is the most important information the nurse should give her about this immunization? A) Advise her that the vaccine is excreted in breast milk B) Warn her not to attempt another pregnancy for at least three months C) Tell her that she may experience rash, sore throat, headache, general malaise, or some combination of these symptoms within two to four weeks of the injection D) Advise her that the immunization will prevent hemolytic disease of the infant in her next pregnancy

Ans: B Feedback: After the immunization, she needs to wait for at least three months so the fetus would not be exposed to the rubella vaccination. The rubella vaccine is a live virus and is considered teratogenic. Inform the breast-feeding woman that the rubella vaccine crosses over into the breast milk. The newborn benefits from short-term immunity but may become flushed, fussy, or develop a slight rash. Suggest that the patient speak to the pediatrician if she has concerns. The nurse should not advise the new mother that the immunization will prevent hemolytic disease of the infant in her next pregnancy because this is incorrect information.

A newborn in the nursery has a temperature of 97.4°F. What may happen first if the infant continues to be cold stressed? A) Seizure B) Respiratory distress C) Cardiovascular distress D) Hypoglycemia

Ans: B Feedback: An infant who has an episode of cold stress is as risk for distress in the respiratory system. The infant needs to be warmed and monitored. If the infant is not warmed hypoglycemia, seizures and cardiovascular distress can occur, but they will not happen before the infant has respiratory distress.

The father of a newborn asks the nurse what medication is in the baby's eyes and why it is needed. Which should the nurse explain to the father? A) Destroy an infectious exudate of the vaginal canal B) Prevent infection of the baby's eyes by bacteria which may have been in the vaginal canal C) Prevent potentially harmful virus from invading the tear ducts D) Prevent the baby's eyelids from sticking together to help see

Ans: B Feedback: Antibiotic ointment is used in the infant's eyes at delivery to prevent ophthalmia neonatorum, an infection which can lead to blindness. The eye medication is not used to destroy infectious exudate from the vaginal canal. Antibiotic ointment is not used for a potentially harmful virus; therefore option C is incorrect. The medication is also not used to prevent the baby's eyelids from sticking together to support vision.

One postpartum patient, delivering two days prior, is asking when she needs to use "protection to not get pregnant again right now." How should the nurse respond? A) You should not have intercourse until you are cleared by the provider B) Ovulation may return as soon as three weeks after delivery C) You will not ovulate until your menstrual cycle returns D) Ovulation does not return for six months after delivery

Ans: B Feedback: Ovulation may start as soon as three weeks after delivery. The patient needs to be aware and use a form of birth control. She needs to be cleared by her provider prior to intercourse if she has a vaginal delivery, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than six months after delivery.

A male baby is born at 5:15 AM on a Wednesday. At 1:15 PM on the same day, the nurse notes yellow staining of the skin on the head and face of this infant. What does this finding likely indicate? A) The infant has physiologic jaundice B) The infant has pathologic jaundice C) The nurse should not expect the yellow staining to occur on the trunk or extremities D) The unconjugated bilirubin levels in the infant are less than 4 mg/dL

Ans: B Feedback: Bilirubin is released as blood cells are broken down in the body of the infant. The liver is immature and not able to break down the bilirubin and the infant demonstrates excessive bilirubin the blood by a yellow-tinged skin. Elevated bilirubin levels in the first 24 hours of life are considered pathologic. Physiologic jaundice is characterized by jaundice that occurs after the first 24 hours of life usually on day 2 or 3 after birth. Jaundice appears first on the head and face; then as bilirubin levels rise, jaundice progresses to the trunk and then to the extremities in a cephalocaudal manner. Hyperbilirubinemia, high levels of unconjugated bilirubin in the bloodstream such as serum levels of 4 to 6 mg/dL and greater, can lead to jaundice.

A patient who delivered her infant three days ago and was discharged home calls her provider's office with a complaint of sweating all night. What is the cause of the increased perspiration? A) Change in pregnancy hormone B) Body secreting the excess fluids from pregnancy C) The patient may be drinking too much fluid D) The body is trying to get rid of the extra blood made during pregnancy

Ans: B Feedback: Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the patient drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.

A newborn male is circumcised. What instructions should the nurse include in the discharge teaching plan for his parents? A) Soak the penis daily in warm water B) Cover the glans generously with Vaseline C) Cleanse the glans daily with alcohol D) Notify her physician if it appears red and sore

Ans: B Feedback: Covering the surgical site with an ointment such as petroleum jelly prevents it from adhering to the diaper and being continually irritated. Normal appearance is red and raw. Soaking the penis daily in warm water is not recommended. Washing the penis with warm water, dribbled gently from a washcloth at each diaper change, is the recommended way of keeping the penis clean. Alcohol should not be applied to the site.

Why should a nurse monitor a newborn after cesarean birth more closely than after a vaginal birth? A) The baby's lifeline to oxygen is cut off when the umbilical cord is clamped, resulting in oxygen levels falling and carbon dioxide rising B) The baby will have more fluid in its lungs, making respiratory adaptation more challenging C) Fetal lungs are uninflated and full of amniotic fluid that must be absorbed D) Much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal

Ans: B Feedback: During a vaginal delivery the infant is squeezed by the uterine contractions. The infant who is born via cesarean section without labor first does not have the mechanical removal of the fluid from the lungs. This places the infant at increased risk for respiratory compromise. The need to more closely assess a newborn after delivery by cesarean section is not caused by the clamping of the umbilical cord. Amniotic fluid in the lungs of all newborns needs to be absorbed by the body. This is not just a need in an infant born by cesarean section.

What could be considered to be the best practice for the nurse to follow in giving a newborn his or her first bath? A) Give the sponge bath in the baby's bed, keeping the baby wrapped and exposing only the body part being washed B) Wash off all traces of blood and allow the vernix to remain on the skin C) Use a soap such as hexachlorophene to minimize transmission of infection from maternal blood-borne pathogens D) Apply ointment or talcum powder to the perineal area and buttocks after washing

Ans: B Feedback: During the bath, all blood and products from the delivery need to be washed off and the vernix should not be removed. The infant's first bath is given under a radiant warmer, not in the infant's bed. If soap is used at all it is a mild soap, not soaps like hexachlorophene. No special ointments are necessary on the perineal area and buttocks after washing. Talcum powder is contraindicated because of the possibility of respiratory distress.

The standard of care and recommendation by the Centers for Disease Control is to administer an immunization to all newborns. Which immunization is recommended to be administered prior to discharge? A) DTaP B) Hep B C) Prevnar D) HiB

Ans: B Feedback: Hepatitis B virus (HBV) vaccination against Hepatitis B is recommended by the CDC. All the other immunizations are recommended to be started at 2 months of age.

By taking a penlight and holding it against the scrotal sac of a male newborn, the nurse can diagnose what disorder? A) Cryptorchidism B) Hydrocele C) Epispadias D) Phimosis

Ans: B Feedback: Hydrocele occurs when there is a buildup of fluid in the scrotal sac and should be noted on assessment. Cryptorchidism results when the testes do not descend into the scrotal sac during fetal life. The urinary meatus should be positioned at the tip of the penis. If the opening is located abnormally on the dorsal or upper surface of the glans penis, the condition is called epispadias. Phimosis, or tightly adherent foreskin, is a normal condition in the term newborn.

The nurse is taking a newborn to the nursery after delivery. The baby has been cleaned in the labor and delivery suite and swaddled in a blanket and the nurse is going to check the baby's pulse. What must the nurse do first? A) Perform a three-minute surgical-type scrub before touching him B) Wear gloves C) Use infection transmission precautions D) Clean his or her hands with a Betadine scrub

Ans: B Feedback: Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after delivery. A three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking the gloves off. Standard precautions are used with every patient.

What is the process by which the reproductive organs return to the nonpregnant size and function? A) Evolution B) Involution C) Decrement D) Progression

Ans: B Feedback: Involution is the term used to describe the process of the return to nonpregnant size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.

The nurse is providing discharge education on newborn care at home. The nurse provides instructions that infants need to be placed on their back to sleep. What is the nurse reducing the risk for with this education? A) Gastroesophageal reflux B) Sudden infant death syndrome C) Apnea episodes D) Waking at night

Ans: B Feedback: The "back to sleep" campaign is a national campaign used to educate the public concerning the fact that the proper position for sleep of infants is on their back to help decrease the risk of SIDS. Placing the infant on their back to sleep does not reduce the risk for gastroesophageal reflux, apnea episodes, or waking at night.

When assessing infant reflexes the nurse documents a startled response and extension of the arms and legs as being which reflex? A) Fencing B) Moro C) Tonic neck D) Rooting

Ans: B Feedback: The Moro reflex is also known as the startle reflex. When the infant is startled they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body reflex. The rooting reflex assesses the infant's ability to "look" for food.

What is the primary function of uterine contractions after delivery of the infant and placenta? A) Return the uterus to normal size B) Seal off the blood vessels at the site of the placenta C) Stop the flow of blood D) Close the cervix

Ans: B Feedback: The contractions of the uterus help to constrict the vessels where the placenta was located. This does decrease the flow of blood, but is secondary in occurrence to the constriction of the blood vessels. Uterine contraction also leads to uterine involution, which normally occurs at a predictable rate. Uterine involution assists in closing the cervix.

A patient has just delivered a baby. Her prelabor vital signs were T - 98.8 B/P-P-R 120/70, 80, 20. Which combination of findings during the early postpartum period should be reported immediately? A) Shaking chills with a fever of 100.3ºF B) B/P-P-R 90/50, 120, 24 C) Bradycardia and excessive, soaking diaphoresis D) Blood loss of 250 mL and WBC 25,000 cells/mL

Ans: B Feedback: The decrease in BP with an increase in HR and RR indicate a potential significant complication, and are out of the range of normal, from delivery and need to be reported immediately. Shaking chills with a temperature of 100.3ºF can occur due to stress on the body and is considered a normal finding. Bradycardia, diaphoresis, blood loss of 250 mL and WBC count of 25,000 cells/mL are considered to be within normal limits after delivering a baby.

The nurse is working in the transition nursery. What is the most critical transition time for a newborn? A) First 24 hours B) First 12 hours C) First four hours D) First two hours

Ans: B Feedback: The first 12 hours after birth are the critical transition hours for a newborn. The newborn may stay with the mother, but under close observation by a nurse.

A mother is concerned because her newborn has lost 8 oz three days after birth. What response by the nurse is appropriate? A) "Your baby needs to be checked for a viral illness." B) "This is a normal and expected finding." C) "Your baby is probably just dehydrated." D) "You need to give your baby formula since she has lost weight during breast-feeding."

Ans: B Feedback: The infant has a 5% to 10% loss of birth weight during the first few days of life as the body loses excess fluid and has limited food intake. The nurse should not tell the new mother that her infant needs to be checked for a viral illness because there is no way of knowing if the newborn has a viral or bacterial illness. Weight loss in a newborn is a normal finding. A new breast-feeding mother should not supplement feedings with formula.

A newborn has secretions in the mouth and nose. What are the first steps the nurse should take to clear the newborn's airways? A) Position on the side and guide his caregivers in suctioning his mouth with a bulb syringe B) Position on the side with his head slightly below the body; use a bulb syringe to clear the mouth C) Position on his side with the head slightly below his body; use a small suction catheter to clear the nose D) Position on his side with the head slightly below his body; use a bulb syringe to clear the nose

Ans: B Feedback: The infant needs to have bulb suction used to remove the secretions. The head should be held slightly lower than the body to facilitate use of gravity. Right after birth is not the time for the parents of the newborn to be instructed in how to suction their infant. A bulb syringe, not a small suction catheter, is used to suction the mouth and nose of a newborn. The nose and mouth need to be cleared of secretions.

The nurse has completed the initial assessment and vital signs for an infant born at 12 noon. The assessment and vital signs were completed at 1:30 PM. What time will the nurse plan to complete the next set of vital signs? A) 1:45 PM B) 2:00 PM C) 2:30 PM D) 3:30 PM

Ans: B Feedback: The nurse needs to complete vital signs every 30 minutes for the first two hours of life.

Infants have a substance in their lungs, surfactant. What is role of surfactant in the respiratory system? A) Expands the lungs with breaths B) Keeps alveoli from collapsing with breaths C) Removes fluid from the lungs D) Allows oxygen to move in the lungs

Ans: B Feedback: The role of surfactant is to act on surface tension and assist to keep the alveoli open in the lungs so the lungs do not collapse with the respiratory effort of the newborn. Surfactant does not expand the lungs, remove fluid from the lungs, nor allow oxygen to move in the lungs.

A woman who delivered her infant one week ago calls the clinic to complain of pain with urination and increased frequency. What response by the nurse is appropriate? A) "This is normal, give it a few days and then call back." B) "After delivery it is easier to develop an infection in the urinary system, we need to see you today." C) "Are you washing and providing good perineal hygiene? If not, this may be the reason for the irritation." D) "It is common for women to have yeast problems, try an over-the-counter cream and let us know if this continues."

Ans: B Feedback: The urinary system is more susceptible to infection during the postpartum period. The woman needs to be checked to rule out a urinary infection. The other responses are incorrect.

If a newborn's skin is wet, the nurse can assume that the infant is in danger of what kind of heat loss? A) Conduction B) Radiation C) Evaporation D) None; wet skin will not cause an infant to lose heat

Ans: C Feedback: Evaporation is one of the four ways a newborn can lose heat. As moisture evaporates from the body surface of the infant, the newborn loses heat. When the newborn's skin is wet, heat is lost as the moisture evaporates. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn.

A newborn is challenged to maintain an adequate body temperature. If a baby is placed too close to a cold air vent, the nurse can assume that the infant will lose heat by which mechanism? A) Conduction B) Convection C) Radiation D) Evaporation

Ans: B Feedback: There are four main ways that a newborn loses heat. Convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture.

A nurse making a general assessment notices the newborn's skin is dark red on one side of the body, while the other side of the body is pale. In the 10 minutes prior to the assessment, what was the newborn most likely doing? A) Breast-feeding B) Crying vigorously C) Sleeping D) Being handled by a nurse wearing gloves

Ans: B Feedback: This is termed Harlequin sign and is related to dilatation of blood vessels often following vigorous crying. The condition will resolve without intervention. This condition does not occur when the infant has been breast-feeding, sleeping, or being handled by a nurse wearing gloves.

What is the most frequent reason for postpartum hemorrhage? A) Endometritis B) Uterine atony C) Perineal lacerations D) Disseminated intravascular coagulation

Ans: B Feedback: When a uterus does not contract well, the denuded placental surface can bleed excessively. Most cases of early postpartum hemorrhage result from uterine atony. Most cases of early postpartum hemorrhage are not from endometritis, perineal lacerations, or disseminated intravascular coagulation.

The nurse is ensuring a newborn is properly identified after birth. What will the nurse do to prevent misidentification of the baby? (Select all that apply.) A) Finger print the infant and mother B) Prepare four identification bands after the birth C) Apply an identification band to the mother's wrist D) Apply identification bands to the newborn's ankle and wrist E) Apply an identification band to another family member's wrist

Ans: B, C, D, E Feedback: Most hospitals use some form of bracelet system. Three to four bracelets with identical numbers on the bands are prepared immediately after delivery and before the newborn is separated from the parents. Information included on the bands is the mother's name, hospital number, and physician, and the newborn's date and time of birth and sex. Two bands are placed on the newborn, one on the arm and one on the leg. A matching band is placed on the mother and another band may be placed on the father or other designated adult. Fingerprinting is not done as a method to identify a newborn.

The nurse is assessing a postpartum patient who had a cesarean section. Which assessments are important for the nurse to perform with this patient? (Select all that apply.) A) Appetite B) Bleeding C) Urine output D) Lung sounds E) Bowel sounds

Ans: B, C, D, E Feedback: When providing care to the patient recovering from a cesarean section the nurse needs to assess for bleeding, urine output, and lung and bowel sounds. Appetite is not typically assessed after a cesarean section.

During the latest behavioral assessment the nurse documents that a newborn is sleeping lightly. What behavior did the nurse observe in the newborn? (Select all that apply.) A) Fussy B) Eyes closed C) Slight activity D) Heavy eyelids E) Sucking on fist

Ans: B, C, E Feedback: In light sleep the newborn's eyes are closed, but more activity is noted. The newborn moves actively and may show sucking behavior. Fussiness and heavy eyelids are observations when the newborn is drowsy.

The nurse is teaching a first-time mother on the danger signs to report to the health care provider. What information should the nurse include in this teaching? (Select all that apply.) A) Extreme thirst B) Shaking chills C) Aching muscles D) Painful urination E) Passage of blood clots

Ans: B, D, E Feedback: The nurse should teach the patient to report shaking chills, painful urination, and passage of blood clots. Extreme thirst and aching muscles are not typically associated with the postpartum period.

During a physical examination an infant's cry is very high pitched and shrill. What does this type of cry indicate to the nurse? A) Normal cry from pain B) Tired and stress from delivery C) Neurologic dysfunction D) Cold stress cry

Ans: C Feedback: A high-pitched cry which is shrill is associated with a neurologic disorder. The infant needs further assessment. A high-pitched, shrill cry in a newborn is not a normal cry from pain. It does not indicate the infant is tired and stressed from delivery, and it is not a cry indicating cold stress.

What is the normal range of blood sugar for an infant during the first 24 hours of life? A) 90 to 100 mg/dL B) 30 to 40 mg/dL C) 50 to 60 mg/dL D) 70 to 80 mg/dL

Ans: C Feedback: Blood levels between 50 and 60 mg/dL during the 24 hours of life are considered normal. Levels less than 50 mg/dL are indicative of hypoglycemia in the newborn. Levels greater than 70 mg/dL would be considered hyperglycemia in the newborn.

What is the primary mechanism for temperature regulation in a newborn infant? A) External with blankets by the nursing staff B) Skin-to-skin contact with mother C) Brown fat store usage D) Shivering and increased metabolic rate

Ans: C Feedback: Brown fat stores are the stores used by the newborn infant to maintain warmth until feeding begins and the infant is able to maintain temperature without assistance. The infant's thermoregulatory system is not fully functional at birth. Infants cannot shiver to warm themselves. The use of external blankets as well as skin-to-skin contact with the mother assists in keeping the baby's temperature within the normal range, but they are not the primary mechanism for temperature regulation in the newborn infant.

The nurse is caring for a postpartum patient who is receiving IV antibiotics and supportive care for endometritis. Which finding should the nurse report immediately? A) Gradually decreasing temperature and pulse rate B) Breast-feeding C) Steadily decreasing volume of urine D) Excessive diaphoresis

Ans: C Feedback: Decreasing amounts of urine indicate hypovolemic complications and need to be further assessed by the health care provider. This is a concern. A gradually decreasing temperature and pulse rate, breast-feeding, or excessive diaphoresis are not indications for further assessment by the health care provider.

Which intervention would a nurse implement to best prevent heat loss in a 1-day-old newborn? A) Keep the newborn under the radiant heater when not with mom B) Cover the newborn with several blankets while under the warmer C) Warm all surfaces and objects that come in contact with the newborn D) Bathe and wash the newborn when temperature is 36.4°C (97.5°F)

Ans: C Feedback: Interventions to prevent heat loss through convection are the best way to prevent heat loss for this newborn. Keeping the newborn under a radiant heater and covering the newborn with several blankets while under the warmer could lead to hyperthermia which can be just as detrimental to the newborn as hypothermia. Infants are bathed when their temperatures are stable.

What is the best thing the nurse can do to manage pain in a neonate? A) Teach the infant's caregivers ways to soothe and comfort the child during any episode of pain B) Adhere carefully to the plan for administration of any analgesics to the child C) Advocate to the physician to use effective treatment methods that cause no pain or less pain D) Provide a soothing environment, swaddling, and holding to the newborn experiencing pain

Ans: C Feedback: It is the ethical responsibility of the nurse to prevent and treat pain. The nurse should advocate to the provider to provide treatments that cause no or minimal pain. All answer options are correct; however, the best answer is to advocate for effective treatment methods that cause no pain, or less pain.

While completing an admission assessment on a newborn the nurse notes poor tone, low temperature, and jitteriness. What is the most appropriate nursing intervention at this time? A) Check infant temperature, again B) Complete an entire set of vital signs C) Assess the infant's blood glucose D) Check oxygen saturation of the blood

Ans: C Feedback: Manifestations of hypoglycemia include poor tone, low temperature, and jitteriness. The infant's blood glucose level needs to be assessed. Appropriate interventions do not include checking the infant's temperature a second time, completing an entire set of vital signs, or checking the oxygen saturation of the blood.

A patient develops mastitis three weeks after delivery. What part of self-care should the nurse instruct as being the most important? A) Take prescribed antibiotic for the full course even if improvement is noted B) Use NSAIDs, warm showers, and warm compresses to relieve discomfort C) Breast-feed or otherwise empty the breasts every one to two hours D) Increase fluid intake to ensure an adequate amount of milk

Ans: C Feedback: Mastitis treatment involves complete removal of the milk from the breast as often as possible but no longer than a three-hour time span and antibiotic therapy. It is most important to have the patient keep the breast empty to prevent further stasis of milk ducts and worsening mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the patient well hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care.

Two weeks after their baby is born, the spouse is concerned that the patient is extremely talkative and energetic, is only sleeping for a few hours each night, and forgets to eat. The patient is also neglecting her appearance and unaware that a baby has needs. What health problem should the nurse suspect the patient is experiencing? A) Postpartum blues B) Postpartum depression C) Postpartum psychosis D) Maladjustment

Ans: C Feedback: Postpartum psychosis can present with a patient in extreme mood changes and odd behavior. Sudden changes in behavior from normal and lack of self-care and care for the infant are signs of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the patient's ability to function but perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum patients. Maladjustment is not associated with postpartum patients.

A newborn has a respiratory rate of 66 breaths per minute, flaring nostrils, and is making a grunting sound during respiration. What health problem should the nurse consider based upon these findings? A) The infant is burning brown fat B) The infant is cold-stressed C) The infant is in respiratory distress D) The infant is experiencing radiation heat loss

Ans: C Feedback: The assessment findings discussed are signs of respiratory distress. An infant with a respiratory rate of greater than 60 breaths per minute with noise requires further assessment. All newborns burn brown fat to produce heat for their bodies. This is not something the nurse can assess. The scenario described does not indicate that the newborn is cold-stressed nor experiencing radiation heat loss.

The nurse is assessing a postpartum patient's uterus. In which position should the nurse place the patient for this assessment? A) Semi-Fowler B) High-Fowler C) Supine D) Left-lateral side lying

Ans: C Feedback: The best position for a complete assessment of the uterus is supine. The other positions will not allow for a true assessment of the location of the uterus in relation to the umbilicus.

A newborn male has been circumcised, has stable temperature, breathing, and heart rate, and is ready to be discharged from the hospital. What should the nurse teach the parents that might indicate the newborn needs medical attention? A) A yellowish crusty substance on the circumcision site B) Crying for two hours or more each day C) Redness at the base of the umbilical cord D) Straining when he is passing stools

Ans: C Feedback: The cord should dry and fall off in the 7 to 10 days after delivery. If the cord base changes color or develops drainage the health care provider needs to be notified as these could be signs of infection. A yellowish crusty substance on the circumcision site indicates normal healing. Crying for two hours or more each day and straining at stools are normal in a newborn.

At birth there are multiple changes in the cardiac and respiratory systems. What is a change that occurs at birth in the cardiovascular system? A) Oxygen is exchanged in the lungs B) Fluid is removed from the alveoli and replaced with air C) Pressure changes occur and result in closure of the ductus arteriosus D) The oxygen in the blood decreases

Ans: C Feedback: The ductus arteriosus is one of the openings through which there was fetal circulation. At birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. The exchange of oxygen in the lungs is a function of the respiratory system. The removal of fluid from the alveoli is not a function of the cardiovascular system. The oxygen content of the blood increases.

The nurse is caring for a patient on postpartum day 1. Before assessing her uterus, where should the nurse anticipate she will locate the fundus? A) At level of umbilicus B) 1 cm above the umbilicus C) 1 cm below the umbilicus D) At the symphysis pubis

Ans: C Feedback: The fundus of the uterus should be at the umbilicus after delivery. Every day after delivery it should decrease 1 cm until it is descended below the pubic bone.

At what time after delivery is an initial full physical examination of an infant to be performed? A) 30 minutes B) One hour C) Two hours D) Four hours

Ans: C Feedback: The infant and mother need time for bonding after delivery, while the nurse is monitoring and may take vital signs, the initial full examination must be completed within two hours of birth.

During a postpartum examination on the day of delivery, a patient complains that she is still so sore that she can't sit comfortably. The nurse examines her perineum and finds the edges of the episiotomy approximated without signs of a hematoma. Which intervention will be most beneficial at this point? A) Notify the health care provider B) Apply a warm washcloth C) Place an ice pack D) Put on a witch hazel pad

Ans: C Feedback: The labia and perineum may be edematous after delivery and bruised, the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the physician. Notifying the health care provider is not necessary at this time as this is considered a normal finding.

When assessing a two-day postpartum patient the nurses finds the fundus is boggy, at the level of the umbilicus, and slightly to the right. What is the most likely cause of this assessment finding? A) Uterine atony B) Full bowel C) Bladder distention D) Poor bladder tone

Ans: C Feedback: The most often cause of a displaced uterus is a distended bladder. Ask the patient to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.

A new mother has taken her baby girl home from the hospital. The mother calls the clinic concerned her baby girl "is having her period." How should the nurse respond to this mother? A) "The baby may have a problem, let's schedule an appointment." B) "This can be related to cleaning her perineal area; be more careful." C) "This can be from the sudden withdrawal of your hormones. It is not a cause of alarm." D) "If this continues, call us back for now just watch her."

Ans: C Feedback: The mother is describing pseudomenstruation and is usually the result of the infant no longer having the mother hormones in the body. This is not a cause for alarm, it is always appropriate to offer to schedule an appointment if the mother continues to be upset. The baby does not have a problem. The bleeding is not caused by incorrect cleansing of the perineal area. The nurse needs to provide an explanation to the mother and not just tell her to watch the infant.

To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate for six seconds. What should the count minimally be? A) 9 B) 10 C) 11 D) 12

Ans: C Feedback: The normal infant heart rate should be greater than 100 bpm. Values of 9 or 10 in six seconds would not be an acceptable rate. The value of 12 is an acceptable heart rate in an infant but is not the minimal accepted heart rate.

Initial measures to stop a postpartum patient's bleeding are not successful and she is being transferred to the ICU. Her family is frightened by the IV lines and the nasal cannula and the patient's brother suddenly says to her partner, "This is all your fault!" What is the best response by the nurse? A) Leave the room quietly; this is a family matter B) Draw the brother aside and tell him that if he can't control himself, he'll have to leave C) Explain the patient's care, focusing on any signs of improvement, while acknowledging that this is a difficult time for them D) Tell them that the physician will explain the patient's treatment to them

Ans: C Feedback: The nurse's first responsibility is to the patient. The nurse needs to be aware of the interaction and focus the family on the patient, explaining the cares and acknowledging the difficult time for all involved. Leaving the room is not an appropriate action. The nurse would only ask the patient's brother to leave if he could not be redirected and continued to cause a disruption. The nurse would not have the physician explain the patient's treatment unless the nurse could not explain it adequately to the family's satisfaction.

The nurse is assessing a patient who is breast-feeding 72 hours after delivery. When assessing the breasts, the patient complains of bilateral breast pain around the entire breast. What is the most likely cause of the pain? A) Mastitis B) Blocked milk duct C) Engorgement D) Interductal yeast infection

Ans: C Feedback: The patient is only 72 hours post delivery and is complaining of bilateral breast tenderness. Milk typically comes in at 72 hours after delivery, and with the production of the milk comes engorgement. The other problems do not typically develop until breast-feeding is established.

For several hours after delivery, a patient who experienced a much more difficult labor this time than any time previously wants to talk about why the birthing process was so hard for her this time. She is focusing on this aspect to the point that she seems relatively indifferent to her newborn. How should the nurse handle this situation? A) Redirect her attention to the baby by reminding her of the details of newborn care B) Ask her to describe how she plans to integrate the newcomer into her existing family, including any actions she has taken to prepare the siblings C) Encourage her to discuss her experience of the birth and answer any questions or concerns she may have D) Point out positive features of her baby and encourage her to hold and cuddle the baby

Ans: C Feedback: The patient needs to explore her birth experience and clarify her questions. The nurse should allow her to ask questions, be supportive and encourage her to express her feelings. Redirecting her attention to the baby, asking her to describe how she plans to integrate the new baby into the family, or pointing out positive features of the new baby do not meet the needs of the patient at this time.

If a nurse assesses a newborn as having erythema toxicum, what should be done? A) Immediately call the doctor B) Change and bathe the infant C) Check all of the baby's vital signs before calling the doctor D) Do nothing

Ans: D Feedback: Erythema toxicum is otherwise known as normal newborn rash. The rash will resolve without intervention. The nurse does not need to call the doctor, change and bathe the infant, or assess the newborn's vital signs.

A very healthy patient delivered a newborn with an immediate Apgar score of 10. The baby has been with the parents for 45 minutes and her parents feel ready to get cleaned up and let the baby be taken care of by the health care personnel for a little while. What eye care action will the nurse now take? A) Instill 0.5% silver nitrate eye drops B) Instill 1% erythromycin eye drops C) Instill antibiotic 0.5% erythromycin or 1% tetracycline eye drops, if they are available, or 1% silver nitrate if necessary D) Wait to see if the eyes show signs of irritation before any eye care treatment is completed

Ans: C Feedback: The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin or 1% tetracycline eye drops and use of 1% silver nitrate only if necessary. 0.5% silver nitrate drops and 1% erythromycin eye drops are the wrong concentrations of these medications and should not be instilled into the eyes of the newborn. The nurse would not wait to see if the eyes show signs of irritation before completing eye care treatment on the newborn.

The nurse is documenting assessment of infant reflexes. She strokes the side of the infants face and the baby turns toward the stroke. What reflex has the nurse elicited? A) Moro B) Tonic neck C) Rooting D) Sucking

Ans: C Feedback: This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle) reflex are total body reflexes and assess neurologic function in the newborn.

The nurse is concerned with the interactions between a mother and her 2-day-old infant. The nurse observes signs of impaired bonding and attachment. What should the nurse document as a cause for concern? A) Making eye contact with the baby B) Breast-feeding the infant on demand C) Turning away from the baby D) Asking for assistance changing a diaper

Ans: C Feedback: Turning away from the baby is cause for concern. Making eye contact with the baby and breast-feeding the baby on demand does not indicate an issue with bonding. Many new parents will need assistance with diaper changes. This is not a concern.

How should the nurse document the white thick coating on the infant at delivery? A) Lanugo B) Milia C) Vernix D) Amniotic fluid

Ans: C Feedback: Vernix is the coating on the infant which was covering fetal skin to prevent the skin from the drying effects of amniotic fluid. Lanugo is fine, downy hair that is present in abundance on the preterm infant but is found in thinning patches on the shoulders, arms, and back of the term newborn. Milia are frequently found on the infant's face. These tiny white papules resemble pimples in appearance. Normal amniotic fluid is not thick and white; it should be clear and give the baby a wet appearance.

Why are newborns born to mothers with diabetes prone to hypoglycemia? A) Excess subcutaneous fat reduces blood flow to the tissues B) Increased metabolic stress due to the stress on mother's body C) Elevated insulin production metabolizes glucose faster D) Liver is immature and cannot convert glycogen to glucose

Ans: C Feedback: When the mother has diabetes she has levels of insulin and blood glucose that differ from normal. The infant/fetus develops elevated levels of insulin to combat the elevated sugars. The infant is then at risk of low blood glucose upon birth. Infants born to mothers with diabetes do not have excess subcutaneous fat that reduces blood flow to the tissues. They do not have increased metabolic stress because of stress on the mother's body. Their immature liver is not the reason the newborn is prone to hypoglycemia.

The nurse is providing postpartum care to a woman who has delivered by cesarean section. According to her records, simethicone, diphenhydramine, and naloxone have been prescribed. Which manifestation should the nurse report immediately? A) Intense itching manifested by scratching B) Abdominal distention and pain C) Difficulty coughing and turning D) Slow respiration's, less than 12 a minute

Ans: D

A postpartum patient is developing a thrombophlebitis in her right leg. Which assessment should the nurse make to detect this? A) Bend the knee and palpate the calf for pain B) Ask to raise the foot and draw a circle C) Blanch a toe and count the seconds it takes to color again D) Dorsiflex the right foot and ask if pain is in the calf

Ans: D Feedback: A Homans sign (pain in the calf on dorsiflexion of the foot) is a common assessment for thrombophlebitis in conjunction with assessing for edema and calf redness. Having her raise her foot and draw a circle would not be an assessment for thrombophlebitis in her leg, nor would assessing capillary refill in a toe.

A postpartum patient is diagnosed as having endometritis. Which position should the nurse place the patient? A) Flat in bed B) On her left side C) Trendelenburg D) Semi-Fowler

Ans: D Feedback: A semi-Fowler position encourages lochia to drain so it will not become stagnant and cause further infection. Placing the woman flat in bed, on her left side, or in the Trendelenburg position would be contraindicated.

Which assessment findings for a one-hour-old infant should the nurse report? A) Temperature of 97.6°F B) Heart rate 158 C) Respiratory rate 42 D) Blood sugar 42 mg/dL

Ans: D Feedback: Any blood sugar lower than 50 mg/dL is considered hypoglycemic and should be reported for further assessment. The infant's temperature, heart rate, and respiratory rate are all considered within normal limits.

The nurse receives report from labor and delivery on an infant and mother couplet. Which reported Apgar score would indicate a need for close observation for the entire transition period by the nurse? A) 8 at one minute; 9 at five minutes B) 7 at one minute; 8 at five minutes C) 6 at one minute; 7 at five minutes D) 5 at one minute; 6 at five minutes

Ans: D Feedback: Apgar scores between 4 and 6 at five minutes of life indicate a newborn is having difficulty in adjusting to life outside the womb and needs close observation. They would transition in the nursery under close observation. The other scores indicate that the newborn is transitioning with minimal difficulty and does not need close monitoring for the entire transition period.

Which clinical manifestation in a patient with DVT should the nurse report immediately? A) Homans sign B) Pyrexia C) Edema D) Dyspnea

Ans: D Feedback: Dyspnea in any patient with a DVT may be an indicator the clot has moved from the original site to the lungs. This is an emergency. A patient who has a DVT would be expected to have a positive Homans sign, pyrexia, and edema.

A postpartum patient develops cystitis and does not want to drink more fluids because it burns when she voids. What should the nurse respond to this patient's issue? A) Advise that acetaminophen or another OTC pain reliever can be used to ease symptoms B) Agree to order a urinary analgesic for the patient C) Instruct use a sitz bath while voiding D) Teach that voiding large volumes of fluids that acidify the urine can actually reduce the burning and irritation

Ans: D Feedback: Hydration and good perineal hygiene are important following delivery for prevention of all infections. All responses can be correct, depending on whether the mother is breast-feeding or not. However, teaching the mother about voiding large volumes of fluids is the best answer.

An infant's temperature is 97.2°F axillary an hour after birth. Which intervention is appropriate for the nurse? A) Take the infant to the mother for bonding B) Place a second stockinette on the baby's head C) Administer a warm bath with temperature slightly higher than usual D) Place the infant under a radiant warmer or in a heated isolette

Ans: D Feedback: If the infant has a low temperature of 97.2°F, the nurse should place the infant in a radiant warmer or in an isolette. Once the infant has a core temperature of greater than 97.7°F, the nurse will double bundle and recheck the temperature in 30 minutes. If an infant has a temperature that is considered low you would not take the infant to its mother for bonding nor administer a warm bath. You would initiate interventions to stabilize the infant's temperature within normal range.

When caring for a normal newborn several hours after birth, which finding is an expected respiratory rate? A) 12 to 16 breaths/min B) 16 to 20 breaths/min C) 20 to 30 breaths/min D) 30 to 60 breaths/min

Ans: D Feedback: Newborns typically breathe more rapidly than adults or older children, at a rate of 30 to 60 breaths/min. 12 to 16 breaths/min is a normal respiratory rate for an adult; 16 to 20 breaths/min is normal for older children; and 20 to 30 breaths/min is normal for preschoolers.

The nurse is assisting with an assessment of Ortolani maneuver on the infant. The sign is positive. What is the procedure assessing? A) Spinal column movement B) Shoulder movement C) Clavicles for dislocation D) Hip for dislocation

Ans: D Feedback: Ortolani maneuver is used to assess the possibility of a dislocated hip in an infant. Ortolani maneuver does not assess for spinal column movement, shoulder movement, nor does it assess the clavicles for dislocation.

Which patients should the nurse be most concerned about on postpartum day 1? A) Temp: 99.4ºF, HR 90, RR 18, BP 112/67 B) Temp: 97ºF, HR 80, RR 20, BP 120/72 C) Temp: 100.4ºF, HR 65, RR 22, BP 130/78 D) Temp: 98.6ºF, HR 74, RR 16, BP 150/85

Ans: D Feedback: Postpartum patients may have an elevated temperature to 100.4ºF for 24 hours after delivery; they may also have decreased pulse a few weeks after delivery. The elevated BP is a concern, as a postpartum patient is still at risk of developing preeclampsia even after delivery.

What is the most important thing the nurse can teach the family of a newborn to prevent abduction while the baby is in the hospital? A) Learn to recognize the baby's cry B) Check the name on the baby's identification bracelet C) Check the number on the baby's identification bracelet D) Check the identification badge of any health care worker before he or she takes the baby from the room

Ans: D Feedback: Since infant abduction is a concern, all personal should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. Learning to recognize the baby's cry would be ineffective in the prevention of an infant abduction from the hospital, the baby may not be crying as it is carried out of the unit. Checking the name and number on the baby's identification bracelet would tell the family it is their baby, not if it is being abducted by someone who is not employed by the hospital.

A father is asking questions about the circumcision of his son and wants to know if there are any disadvantages to the procedure. How should the nurse respond? A) Lower rate of urinary tract infections B) Reduced risk of penile cancer C) Fewer complications than if done later in life D) Pain administration may not be effective during the procedure

Ans: D Feedback: The anesthetic block is not always effective. Not all providers use anesthetics prior to the procedure and the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications are advantages to the procedure.

Within 24 hours of delivery, the postpartum patient complains of pain in the pelvic region. Comfort measures and medication fail to eliminate the pain. Her pulse is rapid, and blood pressure, hematocrit, and hemoglobin are low. The fundus is firm and lochia is dark red and flowing in only moderate amounts without pooling. What should the nurse suspect is occurring with the patient? A) Retained placental fragments B) Deep vein thrombosis (DVT) C) Lacerations in the uterus D) Deep pelvic hematoma

Ans: D Feedback: The assessment data indicates a blood loss in the body, and the lack of active bleeding leads one to believe it may be a hematoma. Retained placental fragments are characterized by late postpartum bleeding. Along with an abrupt onset of bleeding, the woman's uterus is not well contracted. The woman with DVT may have no symptoms. If she does exhibit signs, these typically include swelling and calf pain or tenderness in the affected leg. The area may be warm, tender, and red. Homans sign may be positive. Lacerations can occur as small tears or cuts in the perineal tissue, vaginal sidewall, or cervix.

A new mother adapts to her role as a mother through four developmental stages. Which stage is the first stage of adaptation? A) Maternal identity B) Physical restoration and learning to care for infant C) Shift in normal life to "new normal" D) Beginning attachment and preparation for family

Ans: D Feedback: The first stage is the beginning attachment to the fetus and idea of a family. This occurs during pregnancy. Maternal identity is the last stage. Physical restoration and caring for the infant is the second stage. A shift to a new normal is the third stage.

While educating a class of postpartum patients before discharging home after delivery, one woman asks "when will I stop bleeding?" How should the nurse respond? A) The bleeding may continue for six weeks B) Bleeding may occur on and off for the next two to three weeks C) You should stop bleeding and have no discharge in the next one to two weeks D) The bleeding may slowly decrease over the next one to three weeks, changing color to a white discharge, which may continue for up to six weeks

Ans: D Feedback: The lochia changes color in the first few weeks postpartum; the active bleeding stops in the first week but a white discharge may continue for up to six weeks after delivery. The nurse needs to explain more than bleeding will continue for six weeks. Bleeding does not occur "off and on." The bleeding may stop during the first week but a discharge continues to occur.

When educating patients in a maternal-newborn unit about prevention of infant abduction, what should the nurse teach to prevent abduction? A) Policy posted about security B) Use of monitor attached to babies C) Staff awareness of infant abduction profiles D) Cooperation by the parents with the hospital policies

Ans: D Feedback: The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Posting security policies, placing monitors on the babies, and educating the staff about infant abduction profiles are not the most essential elements of an effective abduction prevention plan.

A patient has just delivered her second child and will breast-feed. The patient does not want to become pregnant again until her second child is at least 2 years old. When should the nurse counsel the patient to begin birth control? A) As soon as she stops breast-feeding B) Within 18 months C) Within six weeks D) As soon as she resumes sexual activity

Ans: D Feedback: The patient can ovulate even though she is not having a normal menstrual cycle and needs to take precautions. Beginning to use birth control within six weeks, or within 18 months, or as soon as breast-feeding ends is not affording her protection from getting pregnant. The patient should use mechanical means of birth control as soon as she resumes sexual activity.

The nurse explains Dr. T. Berry Brazelton's Neonatal Behavioral Scale, which identifies six states of reactivity in newborns. The newborn's body is relatively still and his eyes are open. The parents ask which state the baby is in right now, and how should they react to this state? What is the best answer the nurse could give? A) Active alert; rock the baby to sleep B) Active alert; play with the baby C) Quiet alert; rock the baby to sleep D) Quiet alert; play with the baby

Ans: D Feedback: The quiet alert state is when the baby is still with the eyes open and attentive to people. There is movement, but limited. This is a good time for the parents to interact with the infant. Other states of reactivity include active alert - eyes are open and active body movements are present, newborn responds to stimuli with activity; deep sleep - quiet, nonrestless sleep state, newborn is hard to awaken; light sleep - eyes are closed but more activity is noted, newborn moves actively and may show sucking behavior; drowsy - eyes open and close and the eyelids look heavy, body activity is present with intermittent periods of fussiness; and crying - eyes may be tightly closed, thrashing movements are made in conjunction with active crying.

Before delivery a pregnant patient's hemoglobin was 14 g/dL and hematocrit of 42%. Which postpartum measurements should the nurse report? A) Hemoglobin 13 g/dL and hematocrit 40% in a woman who has given birth vaginally B) Hemoglobin 12 g/dL and hematocrit 38% in a woman who has given birth vaginally C) Hemoglobin 11 g/dL and hematocrit 34% in a woman who has given birth by cesarean D) Hemoglobin 9 g/dL and hematocrit 32% in a woman who has given birth by cesarean

Ans: D Feedback: There was a significant change from the prepartum H&H to the postpartum H&H. These values need to be reported and the patient needs a complete assessment for any bleeding. The other choices are considered to be within normal limits for a postpartum H&H, given the prepartum values.