OB Exam 5

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?

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

A nurse is caring for a child with complex esophageal atresia who will be undergoing surgery for repair. What comment by the parents indicates further teaching is required?

"After this surgery is done tomorrow, my baby will be able to eat and drink"

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

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

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence? a) "He calls me stupid and incompetent, asking himself why he ever married me." b) "He threw me against the wall and started punching my face." c) "He tells me that he is sorry and that he will never hit me again." d) "He yells at me for not having dinner waiting for him when he came home."

"He tells me that he is sorry and that he will never hit me again."

A client who gave birth 2 hours ago expresses concern about her baby developing jaundice. Which response from the nurse would be best?

"I understand your concern because as many as 50% of babies can develop jaundice."

A nurse is presenting a program to a church group about domestic violence. During the presentation, a member of the audience asks the nurse to explain what "intergenerational transmission of violence" means because he has seen that phrase used in the media. Which of the following responses by the nurse would be most appropriate? a) "Domestic violence seems to skip every other generation when it is traced in families." b) "People who grow up in violent home situations tend to be involved in domestic violence situations as an adult." c) "Recent research has identified a gene that is responsible for transmission of a risk for violent behavior that is passed on from generation to generation." d) "People who are violent are that way because of the various neurochemical imbalances in their brains."

"People who grow up in violent home situations tend to be involved in domestic violence situations as an adult."

A client is receiving treatment for injuries sustained during a fight with her partner. The nurse observes that the partner visits her daily in the hospital and appears very solicitous and contrite. When questioned, the client tries to convince the nurse that her partner always apologizes and brings gifts after a fight. Which information should the nurse provide this client? a) "Your partner seems to be genuinely contrite." b) "Although your partner seems sorry, often they will repeat this behavior in the future." c) "Sometimes people do things that cause them to be a victim of physical abuse." d) "You should try not to upset your partner in the future."

"Sometimes people do things that cause them to be a victim of physical abuse."

A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?

"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."

The nurse is caring for a newborn client newly diagnosed with dysplasia of the hip. Which response by the nurse educates the parents on the correct plan of treatment for this diagnosis?

"Treatment will begin immediately."

Which of the following statements might empower abuse victims to take action? a. "You deserve better than this." b. "Your children deserve to grow up in a two-parent family." c. "Try to figure out what you do to trigger his abuse and stop it." d. "Give your partner more time to come to his senses about this."

"You deserve better than this."

A set of newborn twins have been admitted to the neonatal intensive care unit with the diagnosis of fetal growth restriction (FGR). Which maternal factors would predispose the newborn to this diagnosis? Select all that apply.

- A1C levels of 8% - heroin use -blood pressure baseline of -170/90 mm Hg -maternal age 39 -multiple gestation

The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply

- swaddling the newborn closely -offering a pacifier prior to a procedure -encouraging kangaroo care during procedures

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply.

-Avoid coming to work when ill. -Use sterile gloves for an invasive procedure. -Initiate universal precautions when caring for the infant.

The nurse is teaching a prenatal class emphasizing factors that pregnant mothers can implement to ensure a healthy newborn. Which nursing recommendations would be important to discuss? Select all that apply.

-Keep all prenatal checkups. -Have good blood sugar control. -Avoid the use of any types drugs and alcohol. -Visit the dentist regularly.

A nurse is caring for a large-for-gestational-age newborn. Which signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply.

-Lethargy and stupor -Respiratory difficulty -Appearance of central cyanosis

A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply.

-encouraging kangaroo care during procedures -removing tape gently from the skin -using a colorful mobile for distraction

The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply.

-swaddling the newborn closely -offering a pacifier prior to a procedure -encouraging kangaroo care during procedures

Which of the following would be considered child abuse? Select all that apply. a) A caregiver intentionally is demeaning to a child. b) A caregiver neglects a child's physical needs. c) A caregiver lets a child participate in school activities and the child gets injured. d) A caregiver allows siblings to talk inappropriately to each other.

A caregiver intentionally is demeaning to a child. A caregiver neglects a child's physical needs.

The nurse is caring for an infant diagnosed with a ventricular septal defect. Which assessment findings does the nurse anticipate?

A harsh murmur

The nurse is talking to a female client who is a survivor of intimate partner violence. The woman relates that her husband has been told that he has the characteristics of an antisocial personality disorder. The woman also informs the nurse that her husband has an extensive criminal record. The nurse interprets this information and suspects that the woman's husband would most likely demonstrate which behavior? a) A risk for moderate to severe violence with people both within and outside his family b) Intermittent remorse for the violence and abuse that he commits c) Symptoms of depression along with harboring feelings of inadequacy d) Purposefully remain socially isolated from people other than those in his family

A risk for moderate to severe violence with people both within and outside his family

The nurse is reviewing the medical record of the antepartum client with an abnormal alpha-fetoprotein test. The mother is distraught and states, "How bad can it be?" The nurse is correct to describe which?

A type of spina bifida

A newborn is scheduled for casting to correct a talipes disorder. You would advise her parents that the cast will extend

Above the knee

The nursing instructor overhears students discussing their recent lecture topic of abuse and realizes that they need clarification when she hears a student say which of the following? a) Violence against lesbian relationships may go unreported for fear of harassment. b) Abuse occurs only in heterosexual relationships. c) Violence against gay relationships may go unreported for fear of harassment. d) Abuse occurs in both heterosexual and homosexual relationships.

Abuse occurs only in heterosexual relationships.

The nurse is caring for a patient who has gone into labor 6 weeks early and whose amniocentesis has shown a lack of lecithin. Of the following interventions, which would the nurse most likely do first?

Administer a glucocorticosteroid to the mother

A nurse is caring for a rape victim who was just brought to the local emergency care facility. Which interventions should the nurse perform to minimize risk of pregnancy in this client? a) Wait for first signs of pregnancy before taking action b) Administer prescribed double dose of emergency contraceptive pills c) Apply spermicidal cream or gel near the vaginal area upon arrival d) Administer prescribed regular oral contraceptive pills

Administer prescribed double dose of emergency contraceptive pills

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?

Apnea

When teaching a group of students about the cycle of violence, which behavior would the nurse describe as eventually disappearing as the violence becomes accelerated over time? a) Denial of the seriousness of the injuries b) Apologies for the pain and abuse c) Loss of control d) Excessive hostility and friction

Apologies for the pain and abuse

Immediately after birth, the nurse is caring for a newborn with a myelomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage?

Apply a sterile dressing moistened in a warm sterile saline solution.

A nurse suspects that a 6-year-old girl is being sexually maltreated by her father, based on some comments made by the girl. Which of the following methods would be most effective in confirming the nurse's suspicion? a) Assess the girl for unexplained fractured bones b) Check for any sexual perpetrators listed in the area under Megan's law c) Ask the girl's mother what she knows of the father's activities d) Ask the girl to draw a picture of what happened

Ask the girl to draw a picture of what happened

Which assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn?

Assess for decrease in urinary output.

A woman comes to a local community health care facility with her partner. She has a broken arm and bruises on the face that she reports were caused by a fall. The nature of the injuries, however, causes the nurse to be convinced that this is a case of physical abuse. Which intervention should the nurse perform? a) Tell the partner to leave the room immediately b) Ask the partner directly if he was responsible c) Attempt to interview the woman in private d) Question the client about the injury in front of the partner

Attempt to interview the woman in private

Nurses at an urban emergency department seek to develop a plan to help women involved in abusive relationships. Which of the following components is critical to the success of the plan? a) A quality of life assessment tool b) An intimate partner violence (IPV) counselor c) Educational materials d) Avenues for referral

Avenues for referral

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?

Begin early feedings either by the breast or bottle.

A newborn at 33 weeks' gestation has an Apgar score of 5 at 10 minutes of life. Which nursing action is a priority?

Begin resuscitation measures.

During a clinical conference, a group of nursing students are discussing a newborn that is large for gestational age. The instructor determines the students have successfully differentiated the potential cause after choosing which contributing maternal factor?

Being 30 pounds overweight before getting pregnant

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?

Cephalhematoma

The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate?

Dehydration

A nurse is assigned to care for a hospitalized 14 year old with gastroenteritis. The teen tells the nurse that a brother ran away about 2 months ago and hasn't been heard from since, a sister has a substance abuse problem, and both parents are fighting. What type of situation is this family displaying? a) Child neglect b) Child abuse c) Dysfunctional dynamics d) Impaired parenting

Dysfunctional dynamics

Which assessment findings are most prominent in the infant with Tetralogy of Fallot and significant pulmonary stenosis?

Dyspnea on limited exertion, fatigue, cyanosis

Which of the following is FALSE regarding emergency contraception (EC)? a) EC will disrupt an established pregnancy if taken within 72 hours. b) EC simply contains the same hormones that are found in birth control pills. c) EC works by preventing fertilization, ovulation, or implantation. d) EC is most effective if it is taken within 12 hours of rape.

EC will disrupt an established pregnancy if taken within 72 hours.

A nurse is assessing a boy who was recently found to have been molested by a neighbor. Which of the following characteristics is most likely in a pedophile? a) Physically abusive b) Violent c) Emotional fixation at a childhood level d) Homosexual

Emotional fixation at a childhood level

After assessing the status of a newborn, the nurse is concerned that this newborn has persistent pulmonary hypertension. When explaining it to the parents, the nurse would integrate knowledge about which event as having most likely occurred?

Foramen ovale has not closed.

The nurse is caring for a pregnant woman who is struggling with controlling her gestational diabetes mellitus. What effect does the nurse predict this situation may have on the fetus?

Grow to an unusually large size

The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition?

Hemolytic disease

The nurse is admitting to the nursery a newborn of a mother who continued to drink alcohol during her pregnancy. Which finding does the nurse predict to encounter on the newborn's assessment?

Hyperactive and irritable

The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which occurrence?

Hypoglycemia

The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority?

Initiate early oral feedings.

Which nursing measure is most effective in reducing newborn infections?

Maintain medical asepsis while providing care.

In the infant born with a cleft lip and a cleft palate, the highest priority of the nurse is related to which intervention?

Maintaining the nutritional needs if the infant

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

Meconium aspiration in utero or at birth

The nursing instructor is discussing violence and abuse that is seen in women with a student. She realizes that the student needs further instruction when the student states which of the following? a) Nurses will come in contact with violence no matter what health care setting they work. b) Violence against women is on the rise in the United States. c) Nurses will come in contact with sexual abuse no matter what health care setting they work. d) Nurses only come in contact with violence in the ER.

Nurses only come in contact with violence in the ER.

When planning preoperative care for a newborn with a cleft lip and palate, a major need for which the nurse would plan interventions is:

Nutrition

In caring for a child who has been admitted after being sexually abused, which of the following interventions would be included in the child's plan of care? a) Encourage frequent family visits b) Weigh on the same scale each day c) Observe for signs of anxiety d) Test the urine for glucose upon admission

Observe for signs of anxiety

A patient who has been seen in the clinic multiple times for counseling recently admitted to being abused by her husband over a period of five years. Today she states, "He has been so sweet to me the last six days that I think this time he has really changed. He even brought me flowers yesterday and said he loves me." How should the nurse respond to this? a) Over a period of time the honeymoon phase ends and abuse becomes accelerated and thus more dangerous. b) That was a very sweet gesture. c) It seems as if he really loves you. d) I certainly would not be sucked into that.

Over a period of time the honeymoon phase ends and abuse becomes accelerated and thus more dangerous.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration?

Retinopathy of prematurity

Women recovering from abusive relationships need to learn ways to improve their: a. Educational level by getting a college degree b. Earning power so they can move to a better neighborhood c. Self-esteem and communication skills to increase assertiveness d. Relationship skills so they will be better prepared to deal with their partners

Self-esteem and communication skills to increase assertiveness

A patient who is abused fails to report the abuse MAINLY because of which of the following reasons? a) She feels lucky to be alive. b) She feels responsible for causing the incident. c) She does not want anyone to know. d) She thinks it will not happen again.

She feels responsible for causing the incident.

A nursing student is caring for a newborn with a defect in the neural arch where the posterior laminae of the vertebrae have failed to close. The nurse knows that this infant is suffering from which disorder?

Spina bifida

The nurse is assisting with a physical exam on a child who has been admitted with a diagnosis of possible child abuse. Which of the following findings might alert the nurse to this possibility that the child may have been abused? a) The child has a fractured bone. b) The child has a burn that has not been treated. c) The child has bruises on the knees and elbows. d) The child is hyperactive and angry.

The child has a burn that has not been treated.

A young mother brings her 6-month-old in for an examination, appearing listless and inattentive of her child. She sets the child in the floor and reads and sends text messages on her phone. The child appears underweight and lethargic. Which finding would confirm the nurse's suspicion that this child is experiencing failure to thrive? a) The child rests her head on the nurse's shoulder and cuddles with her after the examination b) The child is below the fifth percentile for weight and height c) The child resists when the nurse takes her vital signs d) The child cries when the nurse picks her up

The child is below the fifth percentile for weight and height

A nurse is providing information for a pregnant woman who has just discovered that the fetus she's carrying is likely to have Down syndrome. Which statement by the nurse is most accurate regarding the possible concerns for a child with Down syndrome?

They have a higher risk of developing leukemia than those in the general population.

Homicide from intimate partner violence is the number-one cause of death in pregnant women. a) False b) True

True

A nurse is caring for a client who was raped at gunpoint. The client does not want any photos taken of her injuries. The client also does not want the police to be informed about the incident even though state laws require reporting life-threatening injuries. Which intervention should the nurse perform to document and report the findings of the case? a) Document only descriptions of medical interventions taken b) Use direct quotes and specific language c) Respect the client's opinion and avoid informing the police d) Obtain photos to substantiate the client's case in a court of law

Use direct quotes and specific language

Following birth, the newborn's independent circulatory system is established. If there is an abnormal opening between the chambers in the heart, which cardiac defect may occur?

Ventricular septal defect

Which of the following is FALSE regarding screening for intimate partner violence in women? a) Screening should be routinely done at every visit. b) Although women who are abused may exhibit certain behavior patterns, all women should be screened for intimate partner violence. c) Women tend to fit a profile of abuse, and victims tend to share similar physical characteristics. d) An elderly female may be a victim of intimate partner violence.

Women tend to fit a profile of abuse, and victims tend to share similar physical characteristics.

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?

a sudden drop in hemoglobin

When providing care to a newborn with necrotizing enterocolitis (NEC), the nurse would need to report which finding immediately?

abdomen appearing red and shiny

When examining a newborn for developmental hip dysplasia, which motion would the newborn's hip be unable to accomplish?

abduction

When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts?

above 90th percentile

A 16-year-old girl is seen in an emergency room following a rape. The management of a rape victim should be directed primarily toward a) teaching the child how to prevent further attacks. b) decreasing guilt and increasing self-esteem. c) assessing for sources of infection resulting from the rape. d) relieving physical discomfort and pain.

decreasing guilt and increasing self-esteem.

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply.

diabetes mellitus postdates gestation prepregnancy obesity

The nurse assesses an infant. Which finding may indicate heart failure?

diminished peripheral pulses

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:

ductus arteriosus remains open.

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

newborn who is type A, mother who is type O

A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?

newly born preterm infant

A nurse is interviewing a rape victim who was assaulted 6 month ago. Which questions should the nurse ask the client to know the extent of physical symptoms of PTSD? Select all that apply. a) "Are you having trouble sleeping?" b) "Do you have heart palpitations or sweating?" c) "Do you ever feel as you are reliving the event?" d) "Do you feel numb emotionally?" e) "Have you felt irritable or experienced outbursts of anger?"

• "Are you having trouble sleeping?" • "Have you felt irritable or experienced outbursts of anger?" • "Do you have heart palpitations or sweating?" • "Do you ever feel as you are reliving the event?"

If the following data was collected on a group of children, which of the following would most likely be evaluated as possibly related to child abuse? Select all that apply. a) A child who has a spiral fracture in the femur. b) A child who has chronic nausea and diarrhea. c) A child whose blood work shows evidence of anemia. d) A child whose X-ray shows bone fractures in various stages of healing. e) A child whose CT scan shows a cerebral hemorrhage.

• A child who has a spiral fracture in the femur. • A child whose X-ray shows bone fractures in various stages of healing. • A child whose CT scan shows a cerebral hemorrhage.

A nurse is caring for a pregnant client and discovers signs of bruises near her neck. On questioning, the nurse learns that the bruises were caused by her husband. The client tells the nurse that her husband had stopped abusing her some time ago, but this was the first time during the pregnancy that she was assaulted. She blames herself because she admits to not paying enough attention to her husband. Which facts about abuse during pregnancy should the nurse tell the client to convince her that the abuse was not her fault? Select all that apply. a) Most men exhibit violent reactions during pregnancy as a way of coping with the stress. b) Abuse is a result of insecurity and jealousy of the pregnancy and the responsibilities it brings. c) Abuse is a result of the perception of the partner that the baby will be a competitor after he or she is born. d) Abuse is a result of concern for the unborn child when the mother doesn't fulfill her responsibilities toward the newborn. e) Abuse is a result of resentment toward the interference of the growing fetus and change in the woman's shape.

• Abuse is a result of insecurity and jealousy of the pregnancy and the responsibilities it brings. • Abuse is a result of resentment toward the interference of the growing fetus and change in the woman's shape. • Abuse is a result of the perception of the partner that the baby will be a competitor after he or she is born.

Which of the following would the nurse identify as indicating emotional abuse? Select all that apply. a) Calling the victim names b) Throwing things at a victim c) Not allowing the victim to seek care for an injury d) Threatening to hit the victim e) Controlling how the family's money is spent f) Forcing the victim to perform a degrading act

• Calling the victim names • Threatening to hit the victim • Forcing the victim to perform a degrading act

A nurse is working in a local community health care facility where she frequently encounters victims of abuse. For which signs should the nurse assess to find out if a client is a victim of abuse? Select all that apply. a) Reported history of the injury is inconsistent with the presenting problem b) Injuries on the face, head, and neck c) Partner of the suspected victim seems relaxed and not overly worried d) Affected by STIs frequently e) Mental health problems such as depression, anxiety, or substance abuse

• Injuries on the face, head, and neck • Mental health problems such as depression, anxiety, or substance abuse • Reported history of the injury is inconsistent with the presenting problem

Which of the following are forms of emotional abuse? Select all that apply. a) Humiliating b) Incest c) Destroying another's property d) Insulting e) Rape

• Insulting • Humiliating • Destroying another's property

When caring for an abused woman, the nurse uses the ABCDES framework to provide interventions. Which of the following are components of this framework? Select all that apply. a) Plan of action and resources for safety for when the woman decides to leave b) Clear documentation of the nurse's perception of the abuse c) Expression of the belief that there may be a reason for the violence d) Education about the cycle of violence and its escalation e) Maintenance of confidentiality of the information reported f) Reassurance that the woman is not alone in this situation

• Plan of action and resources for safety for when the woman decides to leave • Maintenance of confidentiality of the information reported • Reassurance that the woman is not alone in this situation • Education about the cycle of violence and its escalation

A group of nursing students is preparing a talk on violence against women and how to prevent it. They want to list characteristics of intimate partner violence and should include which of the following? (Check all that apply.) a) use and abuse of substances such as alcohol b) history of childhood abuse c) history of antisocial behavior d) negative affect (hostility and depression) e) current unemployment f) easy-going personality

• history of childhood abuse • use and abuse of substances such as alcohol • history of antisocial behavior • current unemployment • negative affect (hostility and depression)

The nurse working in the obstetrics clinic has been trained to pick up on warning signs of abuse during pregnancy. These include which of the following?(Select all that apply.) a) more weight gain than recommended b) unrealistic fears c) difficulty with physical exams d) weight fluctuations e) noncompliance with treatment f) poor attendance at prenatal visits

• poor attendance at prenatal visits • unrealistic fears • weight fluctuations • difficulty with physical exams • noncompliance with treatment

The nurse is teaching the caregivers of an infant diagnosed with hypospadias how to properly care for the infant. The nurse determines the session is successful when the caregivers make which statement?

"Being able to most likely correct this in one stage rather than several is reassuring."

A woman has just confided in the nurse that her partner slapped and kicked her that morning. What is the best response by the nurse? a) "Oh my goodness, I cannot believe that happened to you. You poor thing, I feel terrible for you." b) "It's very brave of you to tell me all this. Help is available if you choose it." c) "Maybe he didn't mean to do it. Have you talked with him about it?" d) "Is this the first and only time he has done anything?"

"It's very brave of you to tell me all this. Help is available if you choose it."

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?

"Newborns who are appropriate for gestational age at birth have lower chance of complications than others."

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?

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

A nurse is explaining to the parents the preoperative care for their infant born with bladder exstrophy. The parents ask, "What will happen to the bladder while waiting for the surgery?" What is the nurse's best response?

"The bladder will covered in a sterile plastic bag to keep it moist."

A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching?

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

The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's suspicion?

30 mg/dL

The nurse is talking to a female client who is a survivor of intimate partner violence. The woman relates that her husband has been told that he has the characteristics of an antisocial personality disorder. The woman also informs the nurse that her husband has an extensive criminal record. The nurse interprets this information and suspects that the woman's husband would most likely demonstrate which behavior? a) A risk for moderate to severe violence with people both within and outside his family b) Symptoms of depression along with harboring feelings of inadequacy c) Purposefully remain socially isolated from people other than those in his family d) Intermittent remorse for the violence and abuse that he commits

A risk for moderate to severe violence with people both within and outside his family

A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction after making which statement?

All congenital disorders can be diagnosed at birth.

When providing care to a victim of abuse, which of the following would the nurse do? a) Provide an overview of the procedures to be done. b) Make the decisions for the woman. c) Take the lead in providing the interventions quickly. d) Allow the woman to participate in her care.

Allow the woman to participate in her care.

At an amniocentesis just prior to birth, a fetus's lecithin/sphingomyelin ratio was determined to be 1:1. Based on this, she is prone to which type of respiratory problem following birth?

Alveolar collapse on expiration

The results of an amniocentesis conducted just prior to birth showed a fetus's lecithin/sphingomyelin ratio as being 1:1. From this information, for which respiratory problem should the nurse anticipate providing care once the baby is delivered?

Alveolar collapse on expiration

Which clinical manifestation is seen in the child with hydrocephalus?

An extremely large and rapidly growing head

A pregnant client and her husband are at their first prenatal visit. While performing the admission history, the nurse notes several new and old bruises on the woman's neck and body. She is silent and withdrawn. The husband answers all the questions. Based on these observations, the nurse suspects intimate partner violence. Which of the following is the most appropriate nursing intervention at this time? a) Ask the woman if she would like her husband to wait outside in the lobby. b) Ask the husband to wait in the lobby while the client is being examined. c) Ask the couple if they would like to see a social worker. d) Ask the husband if he feels the client has been depressed throughout the pregnancy.

Ask the husband to wait in the lobby while the client is being examined.

The primary goal of intervention in working with abused women is to: a. Set up an appointment with a mental health counselor for the victim b. Convince them to set up a safety plan to use when they leave c. Help them to develop courage and financial support to leave the abuser d. Empower them and improve their self-esteem to regain control of their lives

Empower them and improve their self-esteem to regain control of their lives

A nursing student studying sexual violence makes the following statement in class, "A man who has sex with his wife even though she did not want it cannot be charged with sexual abuse." Is this statement true or false? a) False b) True

False

A nursing student has read that cleft lip is diagnosed at birth based on inspection of physical appearance and that cleft palate is diagnosed in which way?

Feeling the palate with a gloved finger or using a tongue blade

Which of the following are biologic indicators of posttraumatic stress disorder (PTSD)? a) Auditory hallucinations b) A feeling of unreality about oneself c) Memory difficulties d) Flashbacks

Flashbacks

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant?

Focus on decreasing blood viscosity by increasing fluid volume.

The nurse caring for a newborn notes a distended abdomen approximately 24 hours after birth. Which action should the nurse prioritize after review of the medical record reveals an apparent healthy newborn at birth but no documentation of a bowel movement

Inform the RN and/or primary care provider immediately

An infant that is diagnosed with meconium aspiration displays which symptom?

Intercostal and substernal retractions

What is the leading cause of death in pregnant women? a) Amniotic fluid embolism b) Undiagnosed cardiac condition c) Pulmonary embolism d) Intimate partner violence

Intimate partner violence

A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanelle, cyanosis, and increased head circumference. These signs indicate the newborn has which complication?

Intraventricular hemorrhage (IVH)

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?

Intubation and suctioning of the trachea

The nurse is assessing the newborn male of a teen mother who was afraid to seek appropriate prenatal care. Which assessment finding should lead the nurse to question if this infant is preterm?

Lanugo on the back and shoulders

A newborn is identifies as extremely low birth weight placing the newborn's weight at which level?

Less than 1,000 g.

A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration?

Position the child on the side

A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning?

Positive end-expiratory pressure to increase oxygenation

The neonatal intensive care nurse admits an infant of a diabetic mother to the unit with symptoms of respiratory distress. The infant is jaundiced with a ruddy skin color. Which action would be a priority?

Prepare for repeat hematocit levels q12h.

A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn?

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

The nurse manager at a family clinic is identifying ways to address the 2020 National Health Goals for the prevention of birth defects. Which action should the manager encourage all staff to perform when caring for pregnant patients?

Stress the importance of taking prenatal folic acid as prescribed.

A female client has been admitted to the inpatient psychiatric facility with a diagnosis of posttraumatic stress disorder after a history of violence by her boyfriend. During the initial assessment interview, which assessment would be the priority? a) Hydration status b) Suicide risk c) Sleep patterns d) Nutritional status

Suicide risk

The nurse is developing a plan of care for a neonate experiencing symptoms of drug withdrawal. What should be included in this plan?

Swaddle the infant between feedings.

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?

The infant was a preterm, low birth weight and small for gestational age neonate.

A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant?

The neonate is small for its gestational age.

The nurse is checking a newborn for the presence of Ortolani and Barlow signs. For which health problem are these assessments used?

The nurse is checking a newborn for the presence of Ortolani and Barlow signs. For which health problem are these assessments used?

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

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

A 13-year-old immigrant from Asia is admitted to the health care facility with vaginal bleeding. A genital examination reveals unhealed circumcision wounds. The client can understand limited English but cannot speak the language fluently. The service of an interpreter is employed. What are the points the nurse should keep in mind when interacting with this client? a) Allow the interpreter to question the client directly to assist with data gathering b) Use pictures and diagrams to supplement the questions and answers of the client's understanding c) Condemn the cultural practice and explain why it is wrong to the client d) She is still a child so convey important information in precise medical terms to ease understanding

Use pictures and diagrams to supplement the questions and answers of the client's understanding

The generation-to-generation continuum of violence refers to the fact that a) Children who grow up in abusive homes almost always become abusers themselves unless they have professional intervention b) Children who grow up in an abusive home are less likely to be abusers themselves because they see first hand the devastation that violence can cause c) Violence is an innate behavior, and children become abusers because of external factors in their environment more often than in their family d) Violence is a learned behavior, and children who witness abuse are more likely to become abusers themselves

Violence is a learned behavior, and children who witness abuse are more likely to become abusers themselves

A postterm newborn develops perinatal asphyxia. The nurse understands that this condition is most likely the result of:

aging placenta.

The parents are upset their newborn has a cleft lip. When describing the treatment, the nurse should mention that surgical repair can be done:

between the age of 6 to 12 weeks.

The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis?

bloody stools

A preterm newborn is being monitored for potential necrotizing enterocolitis. The nurse recognizes which factors as major pathologic mechanisms that could lead to this complication? Select all that apply.

bowel ischemia perinatal stressors formula feeding

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

conduction

The nurse determines a newborn is small-for-gestational age based on which characteristics?

wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.

• Dress the newborn in ways to preserve warmth. • Take the newborn's temperature often. • Supply oxygen for the newborn, if necessary.

The nurse who works in a woman's health clinic correctly identifies two key objectives for 2020 National Health Goals that addresses violence against women as which of the following? (Check two.) a) reduce the annual rate of rape or attempted rape b) increase the rate of women's depression c) reduce the rate of physical assault by current or former intimate partners d) increase the rate of women's consumed calories

• reduce the rate of physical assault by current or former intimate partners • reduce the annual rate of rape or attempted rape

The nurse is working with an adult female who has PKU and desires to become pregnant. The nurse notes on her assessment her current serum phenylalanine level is 10 mg/dL. Which instruction should the nurse prioritize for this client?

"It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg."

A client comes to a local community health care facility for a routine check-up. While talking to the nurse, the client happens to mention that every time she has a serious fight with her husband, he forces her to have intercourse with him. The client seems to be very disturbed when revealing this to the nurse. Which is an appropriate response by the nurse? a) "Your husband is just trying to reconcile using intimacy." b) "It's okay in cases of fights where you're really at fault." c) "This behavior is considered sexual abuse." d) "Such behavior is considered normal in a married couple."

"This behavior is considered sexual abuse."

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g, and the primary care provider prescribes 0.1 mL/kg. How much would the nurse administer?

0.15 mL

A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. The nurse integrates understanding of this measure, administering the feedings at which rate?

0.5 to 1 mL/kg/h

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

40 mg/100 mL whole blood

When implementing an intervention for a woman in an abusive situation, what is the primary goal? a) For the woman to be able to stand up to her abuser b) For the woman to be removed from her abusive relationship c) For the woman to regain a sense of control in her life d) For the woman to be able to care for herself

For the woman to regain a sense of control in her life

The nurse cares for preterm infants and assesses them for potential complications to provide adequate countermeasures to prevent futher complications. Which complication should the nurse prioritize and initiate proper measures to protect the newborn?

Loss of body heat

The nurse is preparing to assess an infant who is diagnosed with a ventricular septal defect. Which assessment finding should the nurse be prepared to document?

Loud, harsh murmur

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

Peeling and wrinkling of the neonate's epidermis

The nurse is monitoring a new mother changing her newborn's diaper and notices a musty smell to the infant's urine. Which condition should the nurse prioritize in further assessments to rule out?

Phenylketonuria

A nurse is performing a routine physical for a 7-year-old girl who is thin, unwashed, and dressed in rags. Although it is winter time, she has no coat with her. Her teenaged brother in the waiting room, however, is dressed in trendy clothes and looks healthy and well-fed. Which of the following should the nurse most strongly suspect regarding this girl? a) Physical neglect b) Sexual maltreatment c) Psychological maltreatment d) Physical maltreatment

Physical neglect

A nurse is caring for a newborn client after birth who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury?

Place the newborn in a prone or lateral position.

An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHM). What intervention implemented by the nurse would be most beneficial in treating this client?

Provide oxygen by oxygen hood or ventilator.

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?

RDS is caused by a lack of alveolar surfactant.

The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth?

Retinopathy

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

Sternal retraction

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

alcohol

A pregnant woman gives birth to a small for gestational age neonate who is admitted to the neonatal intensive care unit with seizure activity. The neonate appears to have abnormally small eyes and a thin upper lip. The infant is noted to be microcephalic. Based on these findings, which substance would the nurse suspect the women of using during pregnancy?

alcohol

Assessment reveals that a young mother has several risk factors for giving birth to an infant with a neural tube defect. Which laboratory test would the nurse expect to be used to monitor the fetus for this birth defect?

alpha-fetoprotein levels

The nurse is caring for an infant born to a mother who abused cocaine during her pregnancy. The nurse would likely notice that this infant:

cries when touched.

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition?

expiratory grunting

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds

A nurse is providing preoperative care to a female newborn client with the congenital abnormality myelomeningocele. Which intervention is the priority?

preventing infection

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?

undescended testes

The nurse is visiting the parents of a newborn diagnosed with periventricular leukomalacia. Which statement indicates that the parents understand the newborn's health problem?

"We will need to plan for special care to help with learning disabilities.".

The nursing student is studying violence and abuse against the older woman. While researching it, she learns that laws require health care professionals to report elder or vulnerable person abuse. How many states currently have these laws? a) 40 b) 52 c) 50 d) 32

50

The nurse is caring for a group of children on the pediatric unit. The nurse should collect further data and explore the possibility of child abuse in which of the following situations? a) A 6-year-old with a greenstick fracture of the wrist, which the caregiver reports was caused when the child fell while ice-skating b) A 7-year-old with a spiral fracture of the humerus, which the caregiver reports was caused when the child was hit with a bat swung by a Little League teammate c) A 10-year-old with a simple fracture of the femur, which the caregiver reports was caused when the child fell down a set of stairs d) A 9-year-old with a compound fracture of the tibia, which the caregiver reports was caused when the child attempted a flip on a skateboard

A 7-year-old with a spiral fracture of the humerus, which the caregiver reports was caused when the child was hit with a bat swung by a Little League teammate

A nurse observes telltale signs of injuries from physical abuse on the face and neck of a female client. When questioned, the client tells the nurse that the injuries are the result of a physical attack by her partner and that she has developed palpitations thereafter. Which action should the nurse take to gain the trust of the client and enhance the nurse-client relationship? a) Tell the client to forget about the incident to avoid the trauma b) Inform the client that there is no connection between the violence and palpitations c) Offer referrals so the client can get help that will allow her to heal d) Confirm with the partner whether the client's story is true

Offer referrals so the client can get help that will allow her to heal

In which position should the nurse place a newborn to administer oxygen by bag and mask?

On the back with the head slightly extended

Which of the following is TRUE regarding intimate partner violence? a) Even though women seldom blame themselves for the abuse, they often cannot leave the relationship. b) One in four women will be a victim of violence. c) Abusers often have outward signs that they are abusers or have a mental illness. d) Women who are in an abusive relationship experience less abuse while they are pregnant.

One in four women will be a victim of violence.

A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy?

Oxygen saturation levels are at 98%.

The nurse is preparing a nursing care plan for an infant who was born with spina bifida with myelomeningocele. Which nursing goal should the nurse prioritize for this child?

Preventing infection

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?

Provide a mobile the child can see no matter how the child is turned.

The first phase of the abuse cycle is characterized by: a. The woman provoking the abuser to bring about battering b. Tension building and verbal or minor battery c. A honeymoon period that lulls the victim into forgetting d. An acute episode of physical battering

Tension building and verbal or minor battery

Question: Place the three phases of intimate partner violence in the order in which they occur. 1. Acute violence phase 2.Tension-building phase 3.Honeymoon phase

Tension-building phase, Acute violence phase, Honeymoon phase

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?

Term, small for gestational age, and low-birth-weight infant

The nurses at a local free clinic are concerned there may be an increase in small-for-gestational age infants in the community. When collecting data to research the situation, the nurses will exclude infants above which category?

The 10th percentile for gestational age

Nurses sometimes have difficulty assessing women for violence. Which of the following refers to the screen protocol to use to be the most thorough? a) The RACE model b) The FACE model c) The SBAR model d) The SAVE model

The SAVE model

The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding?

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

The nursing instructor is leading a discussion with a group of nursing students who are analyzing the preterm infant's physiologic immaturity and the associated difficulties the newborn and familty must deal with. The instructor determines the session is successful when the students correctly choose which body system that presents with the most critical concerns related to this immaturity?

The respiratory system

Walter is an 11-year-old boy who was raised in a home where his father beat his mother on a regular basis. Which of the following statements is true regarding children being raised in a home where they have witnessed intimate partner violence? a) They have higher rates of schizophrenia b) They are at increase risk for being abused c) It has little impact on child functioning d) Female children are more likely to experience depression

They are at increase risk for being abused

A nurse is conducting an awareness session on sexual abuse, and she is explaining the psychological profile of an average abuser. Which trait is often displayed by abusers? a) They belong to the low-income group. b) They are usually physically imposing. c) They have parents who are divorced. d) They exhibit antisocial behaviors.

They exhibit antisocial behaviors.

A nurse is conducting an awareness session on sexual abuse, and she is explaining the psychological profile of an average abuser. Which trait is often displayed by abusers? a) They have parents who are divorced. b) They are usually physically imposing. c) They exhibit antisocial behaviors. d) They belong to the low-income group.

They exhibit antisocial behaviors.

A newborn with high serum bilirubin is receiving phototherapy. Which nursing intervention is the most appropriate for this client?

application of eye dressings to the infant

A preterm newborn is noted to be cyanotic. Which laboratory test will the nurse prepare the infant for to determine if the cyanosis is due to respiratory or circulatory problems?

arterial blood gases

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?

asymmetrical movement

A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the:

chest rises with each bag compression.

The nurse is teaching the parents of a newborn who was born with a high type of imperforate anus the care the newborn will need at home after surgery. The parents need to be aware that the newborn will require which measure temporarily?

colostomy

A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings?

esophageal atresia

A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is:

expiratory grunting.

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

face

The nurse has learned that the number one factor that will motivate a woman to escape an abusive relationship is which of the following? a) fear of harm to herself b) fear of death c) fear of harm to other family members d) fear of harm to her unborn child

fear of harm to her unborn child

The newborn nursery nurse suspects a newborn of having neonatal abstinence syndrome. What assessment findings would most correlate with the diagnosis?

frequent yawning and sneezing

Prevention and early identification of newborns at risk are necessary nursing functions. A nurse anticipates the need for newborn resuscitation secondary to birth asphyxia based on which prenatal risk factors? Select all that apply.

gestational hypertension maternal infection congenital heart disease

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

hydrocephalus

When evaluating a newborn with congenital clubfoot, the nurse recognizes this condition usually involves:

internal rotation of leg.

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?

meconium stained fluids followed by tachypnea

To administer oxygen by bag and mask to a newborn, you would position the baby

on the back with the head slightly extended.

It would be best to place an infant with a myelomeningocele in which position prior to surgery?

on the stomach (prone)

A woman who has a history of cocaine abuse gives birth to a newborn. Which findings would the nurse expect to assess in the newborn? Select all that apply.

piercing cry poor sucking inconsolable

When a pregnant patient is abused during her pregnancy what complication is likely to occur after delivery due to the abuse? a) post-partum depression b) schizophrenia c) low birth weight d) edema

post-partum depression

A 30 weeks' gestation neonate born with low Apgar scores is in the neonatal intensive care unit with respiratory distress syndrome and underwent an exchange transfusion for anemia. Which factors place the neonate at risk for necrotizing enterocolitis? Select all that apply

preterm birth respiratory distress syndrome low Apgar scores exchange transfusion

A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as:

respiratory distress.

A neonate is admitted to the newborn observation nursery with the possible diagnosis of polycythemia. The nurse would be observing for which findings? Select all that apply.

ruddy skin color respiratory distress cyanosis jitteriness

The nurse who counsels women who suffer from abuse understands that abuse can come in different forms that include which of the following? (Check all that apply.) a) sexual abuse b) spiritual abuse c) physical abuse d) financial abuse e) emotional abuse

sexual abuse physical abuse financial abuse emotional abuse

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?

tea-colored urine

Which newborn would the nurse suspect to be most at risk for cognitive challenge due to the mother's actions during pregnancy?

the child of a client who admits to drinking a liter of alcohol daily during the pregnancy

A nurse working in the newborn observational unit is assigned four newborns closely being monitored. Which newborn is at greatest risk of developing respiratory distress syndrome?

the male preterm infant born by cesarean birth with cold stress

A 5-year-old girl is being admitted with a possible diagnosis of child abuse. The child has bruises in various places on her body that the caregiver attributes to the child recently beginning to play soccer. Bruises associated with child abuse would likely be found in which of the following areas of the body? a) elbows b) forehead c) knees d) thighs

thighs

A nurse is assessing a newborn. The nurse suspects that the newborn was exposed to drugs while in utero based on which findings? Select all that apply.

tremors nasal flaring frequent yawning

The nursing instructor is teaching a session on techniques which the nursing students can use to properly address concerns of parents with children who are born with a congenital disorder. The instructor determines the session is successful when the students correctly choose which nursing intervention as being the most effective in these situations?

use reflective listening and offer nonjudgmental support.