OB exam FINAL #2

Peribottle

A plastic squeeze bottle filled with warm tap water that is sprayed over the perineal area after each voiding and before applying a new perineal pad.

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

Less than 1,000 g.

When conducting an assessment, the nurse observes tiny white pinpoint papules on a newborn's nose. These are documented as: a. Milia b. Lanugo c. Harlequin sign d. Vernix caseosa

a. Milia

The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this as which of the following? a. Decrement b. Diastole c. Acme d. Increment

c. Acme

Urinary retention is a major cause of __________, which allows excessive bleeding.

uterine atony

x

100 mm Hg

Frequent voiding of small amounts (less than _____ mL) suggests urinary retention with overflow, and catheterization may be necessary to empty the bladder to restore tone.

150

A baby who is declared AGA (appropriate for gestational age) falls in what weight percentile? a) 95 b) 5 c) 9 d) 20

20

Normal newborn weight range:

2500-4000 grams

Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chest circumference would be:

32

normal head circumference

33-37 cm

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

40 mg/100 mL whole blood

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: A) Greater than after a vaginal delivery B) About the same as after a vaginal delivery C) Less than after a vaginal delivery D) Saturated with clots and mucus

C Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.

Infants of drug-dependent women tend to be large for gestational age. a) True b) False

False

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

aging placenta.

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g and the physician orders 0.1 mL/kg. How much would the nurse administer? a. 0.1 mL b. 0.2 mL c. 0.15 mL d. 0.25 mL

c. 0.15 mL

Milia

unopened sebaceous glands frequently found in newborn

neonatal sepsis is caused by

GROUP B STREP

A client has delivered a small for gestation age (SGA) newborn. Which of the following would the nurse expect to assess? a) Protuberant abdomen b) Brown lanugo body hair c) Round flushed face d) Head larger than body

Head larger than body

diastasis recti

Separation of the longitudinal muscles of the abdomen (rectus abdominis) during pregnancy.

Meconium is the first stool passed in a newborn. What would be the correct documentation of the meconium? a) Formed green b) Soft brown c) Seedy yellow d) Sticky forest green

Sticky forest green

uterine atony

The most common cause of postpartum hemorrhage.

Preterm infant deaths account for 80% to 90% of infant mortality in the first year of life.

True

Hyperbilirubinemia

a total serum bilirubin level above 5 mg/dL resulting from unconjugated bilirubin being deposited in the skin and mucous membranes *jaundice *preterm

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction, documenting this as which of the following? a. Duration b. Peak c. Intensity d. Frequency

a. Duration

As a nurse at the local public health office, you recognize that ______ is a major but often overlooked problem. a. Fetal mortality b. Infant mortality c. Maternal mortality d. Neonatal mortality

a. Fetal mortality

The nurse is performing a newborn assessment. What finding will alert the nurse to the development of polycythemia in the newborn? a. Jaundice b. Restlessness c. Temperature instability d. Wheezing

a. Jaundice

A nurse is caring for a newborn with hypoglycemia. What symptoms of hypoglycemia should the nurse monitor the newborn for? (Select all that apply) a. Lethargy b. Low-pitched cry c. Cyanosis d. Skin rashes e. Jitteriness

a. Lethargy c. Cyanosis e. Jitteriness

Which of the following combination contraceptives has been approved for extended continuous use? a. Seasonale b. Triphasil c. Ortho Evra d. Mirena

a. Seasonale

The nurse is caring for a 5-year-old Hispanic boy and his family. Which action best demonstrates cultural competence? a. Asking about complementary modalities used b. Checking with the father to approve care c. Coordinating care through the mother d. Promoting good medicine over prayers

c. Coordinating care through the mother

During fetal life, a structure allows the pulmonary circulation to be bypassed. Shortly after birth this structure should close. The nurse recognizes which of the following to be this structure? a. Ductus venosus b. Foramen ovale c. Ductus arteriosus d. Umbilical vessels

c. Ductus arteriosus

When educating clients about the dangers of STIs it is important that they understand some STIs can result in damage to other organs if left untreated. The STI that can result in liver damage is: a. HAV b. HCV c. HBV d. HPV

c. HBV

Which of the following designations would the nurse identify as homozygous dominant? a. XX b. Bb c. XY d. BB

d. BB

A client who gave birth 5 days ago complains to the nurse of profuse sweating during the night. What should the nurse recommend to the client in this regard?

"Be sure to change your pajamas to prevent you from chilling."

A newborn has an Apgar score of 6 at 5 minutes. Which of the following is the priority? A) Initiating IV fluid therapy B) Beginning resuscitative measures C) Promoting kangaroo care D) Obtaining a blood culture

Ans: B Feedback: An Apgar score below 7 at 1 or 5 minutes indicates the need for resuscitation. Intravenous fluid therapy and blood cultures may be done once resuscitation is started. Kangaroo care would be appropriate once the newborn is stable.

When performing newborn resuscitation, which action would the nurse do first? A) Intubate with an appropriate-sized endotracheal tube. B) Give chest compressions at a rate of 80 times per minute. C) Administer epinephrine intravenously. D) Suction the mouth and then the nose.

Ans: D Feedback: After placing the newborn's head in a "sniffing" position, the nurse would suction the mouth and then the nose. This is followed by ventilation, circulation (chest compressions), and administration of epinephrine.

A breast-feeding client informs the nurse that she is unable to maintain her milk supply. What instructions should the nurse give to the client to improve milk supply?

Empty the breasts frequently.

A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure?

Ensure that the infant is kept warm.

neutral thermal environment

Environment in which body temperature is maintained without an increase in metabolic rate or oxygen use.

lochia

Lochia is the vaginal discharge that occurs after birth and continues for approximately four to eight weeks.

The nurse considers the contraceptive class at the college dormitory to be effective when the students understand that the effectiveness of oral contraceptives (OCs) can be decreased if they take: a. Antibiotics b. Vitamin supplements c. Antihistamines d. Cold remedies

a. Antibiotics

When describing the pregnant woman's hypercoagulable state, which of the following would the nurse identify as being least likely related? a. Increased number of red blood cells b. Increased levels of fibrin c. Increased clotting factors d. Increased plasma fibrinogen

a. Increased number of red blood cells

After a vaginal examination, the nurse determines that the client's fetus is in an occiput posterior position. The nurse would anticipate that the client will have: a. Intense back pain b. Frequent leg cramps c. Nausea and vomiting d. A precipitous birth

a. Intense back pain

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

Community-based health care has unique challenges for the nurse. It is important that the nurse has excellent _____ skills to handle these challenges. a. Cultural discernment b. Assessment c. Memory d. Documentation

b. Assessment

a nurse is caring for a newborn with asphyxia. What nursing management is involved when treating a newborn with asphyxia? a) Administer surfactant as ordere b) Ensure effective resuscitation measures c) Ensure adequate tissue perfusion d) Administer IV fluids

b. ensure effective resuscitation measures

A nurse is caring for a client who delivered vaginally 2 hours ago. What postpartum complication can the nurse assess within the first few hours following delivery? a. Postpartal infection b. Postpartal blues c. Postpartal hemorrhage d. Postpartum depression

c. Postpartal hemorrhage

Which of the following should the nurse identify as a risk associated with anemia during pregnancy? a. Newborn with heart problems b. Fetal asphyxia c. Preterm birth d. Newborn with enlarged liver

c. Preterm birth

A nurse is caring for a 31-year-old pregnant client who is subjected to abuse by her partner. The client has developed a feeling of hopelessness and does not feel confident in dealing with the situation at home, which makes her feel suicidal. Which of the following nursing interventions should the nurse offer to help the client deal with her situation? a. Counsel the client's partner to refrain from subjecting his partner to abuse b. Help the client understand the legal impact of her situation to protect her c. Provide emotional support to empower the client to help herself d. Introduce the client to a women's rights group

c. Provide emotional support to empower the client to help herself

A nurse is assessing a newborn with the parents. The nurse explains that which of the following is an important indication of neurologic development and function? a. Crying response b. Orientation to surroundings c. Reflex d. Voluntary movements

c. Reflex

The nurse is providing education to a couple regarding the proper procedure for male condom use. The nurse knows that the teaching was effective when the couple states that which of the following procedures should be taken if the man's penis becomes flaccid immediately after ejaculation? a. The woman should douche with white vinegar and water. b. The woman should consider taking a postcoital contraceptive. c. The man should hold the edges of the condom during its removal. d. The man should apply spermicide to the upper edges of the condom.

c. The man should hold the edges of the condom during its removal.

What comment by a woman would indicate that a diaphragm is not the best contraceptive device for her? a. "My husband says it is my job to keep from getting pregnant" b. "I have a hard time remembering to take my vitamins daily" c. "Hormones cause cancer and I don't want to take them" d. "I am not comfortable touching myself down there"

d. "I am not comfortable touching myself down there"

A client is experiencing shoulder dystocia during delivery. Which of the following should the nurse identify as risks to the fetus in such a condition? a. Extensive lacerations b. Bladder injury c. Infection d. Nerve damage

d. Nerve damage

A woman, seen in the emergency department, is diagnosed with pelvic inflammatory disease (PID). Before discharge, the nurse should provide the woman with health teaching regarding which of the following? a. Endometriosis. b. Menopause. c. Ovarian hyperstimulation. d. Sexually transmitted infections.

d. Sexually transmitted infections.

The nurse is teaching a client regarding the treatment for pubic lice. Which of the following should be included in the teaching session? a. The antibiotics should be taken for a full 10 days. b. All clothing should be pretreated with bleach before wearing. c. Shampoo should be applied for at least 2 hours before rinsing. d. The pubic hair should be combed after shampoo is removed.

d. The pubic hair should be combed after shampoo is removed.

Parents often vent their frustration and anger over the loss of their newborn on the nurse. The most appropriate reaction for the nurse is: a. Refer them to the health care provider. b. Ignore their grief and ask them to leave. c. Leave the couple alone as they grieve. d. Validate their feelings and refocus their anger.

d. Validate their feelings and refocus their anger.

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

__________ is considered the first stool passed by newborn

meconium

Analgesics such as acetaminophen and oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or __________ are prescribed to relieve mild postpartum discomfort

naproxen

Which finding is indicative of hypothermia of the preterm infant?

nasal flaring Nasal flaring is a sign of respiratory distress. Infants with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

potential lacerations and bleeding. Forcible rotation of the forceps can cause potential lacerations and bleeding. Cervical ripening increases the risk for uterine rupture in a client attempting vaginal birth after undergoing at least one previous cesarean birth. There is an increased risk for cord entanglement in multiple pregnancies. Damage to the maternal tissues happens if the cup slips off the fetal head and the suction is not released.

nurse cares for a newborn with a congenital cardiac anomaly. What component of nursing care is the priority for the new born?

prevent pain as much as possible

vitamin k and fat-soluble vitamin promotes blood clotting by increasing the synthesis of __________ by the liver

prostaglandins

Labor dystocia is an abnormal progression of labor. It is the most common cause of primary cesarean birth. When is it most common for labor dystocia to occur?

second stage of labor Labor dystocia can occur in any stage of labor, although it occurs most commonly once the woman is in active labor or when she reaches the second stage of labor.

After the nurse provides instructions to a postpartum woman about postpartum blues, which statement would indicate understanding of it? I will a. "Need to take medication daily to treat the anxiety and sadness." b. "Call the OB support line only if I start to hear voices." c. "Contact my doctor if I become dizzy and fell nauseated." d. "Feel like laughing 1 minute and crying the next minute."

"D" because emotional lability is typical of postpartum blues which is usually self-limiting.

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 examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give to the client?

"The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color." Lochia serosa = leukocytes, decidual tissue, RBCs & serous fluid. Only RBCs & leukocytes = blood leukocytes and decidual tissue = lochia alba

Perinatal asphyxia risk factors:

- Trauma - Sepsis - Malformation - Hypovolemic shock - Medication

Gastroschisis

-herniation of the abdominal contents through an abdominal wall defect, at the umbilicus. -Gastroschisis differs from omphalocele in that there is no peritoneal sac protecting the herniated organs, and thus exposure to amniotic fluid makes them thickened, edematous, and inflamed

a nurse in a local health care facility is caring for a new born with periventricular hemorrhage-intraventricular hemorrhage (PVH-IVH), who has recently been discharged from a local NICU. For which likely complications should the nurse assess?

-hydrocephalus -vision or hearing deficit - cerebral palsy

During a neonate resuscitation attempt, the neonatologist has ordered 0.1 mL/kg IV epinephrine (adrenaline) in a 1:10,000 concentration to be given stat. The neonate weighs 3000 grams and is 38 centimeters long. How many millimeters (mL) should the nurse administer? Record your answer using one decimal place.

0.3

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

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

30 mg/dL

Hypoglycemia in a mature infant is defined as a blood glucose level below which of the following? a) 100 mg/100 mL whole blood b) 80 mg/100 mL whole blood c) 40 mg/100 mL whole blood d) 30 mg/100 mL whole blood

40 mg/100 mL whole blood

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:

5. A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.

Women who are unable to return to a healthy weight by ____ months postpartum increase their risk factors for the development of chronic diseases including metabolic syndrome, obesity, and cardiovascular disease

6

A client is Rh-negative and has given birth to a newborn who is Rh-positive. Within how many hours should Rh immunoglobulin be inject

72

Neonatal Abstinence Syndrome. frequently, the first inkling of drug use appears in the newborn when symptoms of withdrawal begin within ____ hours after birth.

72

After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation? A) Dry the newborn thoroughly. B) Put a hat on the newborn's head. C) Check the newborn's temperature. D) Wrap the newborn in a blanket.

A Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.

When describing the neurologic development of a newborn to his parents, the nurse would explain that it occurs in which fashion? A) Head-to-toe B) Lateral-to-medial C) Outward-to-inward D) Distal-caudal

A Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center to outside) pattern.

Perinatal Asphyxia

A newborn who fails to establish adequate, sustained respiration after birth is said to have asphyxia.

Postpartum breast engorgement occurs 48 to 72 hours after giving birth. What physiologic change influences breast engorgement? a. An increase in blood and lymph supply to the breasts b. An increase in estrogen and progesterone levels c. Colostrum production increases dramatically. d. Fluid retention in the breasts due to the intravenous fluids given during labor

A. Engorgement refers to the swelling of the breast tissue as a result of an increase in blood and lymph supply to produce milk for the newborn.

The major purpose of the first postpartum homecare visit is to: A. Identify complications that require interventions B. Obtain a blood specimen for PKU testing C. Complete the official birth certificate D. Support the new parents in their parenting roles

A. Home visits are usually made within the first week of discharge to assess the mother and newborn. This visit is made primarily to provide the nurse with the opportunity to recognize common biomedical and psychosocial problems or complications. Although not the primary reason, this visit also offers an opportunity to provide support and guidance to the parents in making the adjustment to the change in their lives.

flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface

Convection

Which of the following is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight? a) Ability to tolerate early oral feeding b) Decreased body temperature c) Face is angular and pinched d) Decreased muscle mass

Ability to tolerate early oral feeding

sitz bath

After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids.

Anorectal Malformations

An imperforate anus is a gastrointestinal system malformation of the anorectal opening and is identified in the newborn period.

The nurse would expect a postpartum woman to demonstrate lochia in which sequence? A. Rubra, alba, serosa B. Rubra, serosa, alba C. Serosa, alba, rubra D. Alba, rubra, serosa

B. The correct sequence is rubra (red), then serosa (pink/brownish), and then alba (white, creamy).

In the taking-in maternal role phase described by Rubin (1984), the nurse would expect the woman's behavior to be characterized as which of the following? a. Gaining self-confidence b. Adjusting to her new relationships c. Being passive and dependent D. Resuming control over her life

C. According to Reva Rubin, the mother is very passive and is dependent on others to care for her for the first 24 to 48 hours after giving birth.

The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?

Closely monitor temperature.

The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care?

Clustering care and activities

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature? A) Hearing B) Touch C) Taste D) Vision

D Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

In an infant who has hypothermia, what would be an appropriate nursing diagnosis?

Impaired tissue perfusion

A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which of the following should the nurse recommend to the client to improve pelvic floor tone?

Kegel exercises

Which of the following would you expect to assess in an infant with hypoglycemia? a) Prolonged jaundice b) Limpness or jitteriness c) Pain along the sixth cranial nerve d) Excessive hunger

Limpness or jitteriness Correct Explanation: Hypoglycemia (reduced glucose serum level) usually presents with jitteriness.

risk factors for Transient tachypnea of the newborn (TTN)

Lower gestational age, cesarean birth, and male sex

When preparing to resuscitate a preterm newborn, the nurse would perform which action first?

Place the newborn's head in a neutral position.

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?

Prepare the client for a cesarean birth. Cephalopelvic disproportion is associated with postterm pregnancy. This client will not be able to vaginally give birth and should be prepared for a cesarean birth. Lithotomy position, artificial rupture of membranes, and oxytocin are interventions for a vaginal birth.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth.

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

"A nurse is caring for a newborn with hypo- glycemia. What symptoms of hypoglycemia should the nurse monitor the newborn for? Select all that apply. a. Lethargy b. Low-pitched cry c. Cyanosis d. Skin rashes e. Jitteriness"

a, c,e The nurse should monitor the new- born for lethargy, cyanosis, and jitteriness. Low- pitched crying or rashes on the infant's skin are not signs generally associated with hypoglycemia."

A pregnant client arrives at the maternity clinic complaining of constipation. Which of the following factors could be the cause of constipation during pregnancy? (Select all that apply) a. Decreased activity level b. Increase in estrogen level c. Use of iron supplements d. Reduced stomach acidity e. Intestinal displacement

a. Decreased activity level c. Use of iron supplements e. Intestinal displacement

A nurse is assigned to conduct an admission assessment on the phone for a pregnant client. Which of the following information should the nurse obtain from the client? (Select all that apply) a. Estimated due date b. History of drug abuse c. Characteristics of contractions d. Appearance of vaginal blood e. History of drug allergy

a. Estimated due date c. Characteristics of contractions d. Appearance of vaginal blood

A client is in the transitional phase of labor. Which of the following would the nurse most likely find? (Select all that apply.) a. Irritability with restlessness b. Apprehension mixed with excitement c. Strong desire to push d. Cervical dilation of 6 cm e. Contractions occurring every 3 minutes

a. Irritability with restlessness c. Strong desire to push

A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal?a. body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)b. positive Ortolani signc. heart rate of 90 to 100 bpmd. rounded, symmetrical abdomene. enlarged labia with pseudomenstruation

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

After a class discussing the many changes the female body undergoes during pregnancy, you note the class can successfully identify which of the following hormones as being secreted by the placenta? (Select all that apply.) a. hCG b. Relaxin c. Testosterone d. Estrogen e. Cortisol

a. hCG b. Relaxin d. Estrogen

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

administer oxygen by mask. An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

bonding is affected by

affected by a multitude of factors, including the parent's socioeconomic status, family history, role models, support systems, cultural factors, and birth experiences.

As a member of the team caring for clients at the local community center, the nurse can function more effectively as the: a. Case evaluator b. Case manager c. Quality control manager d. Education manager

b. Case manager

kernicterus

bilirubin staining of the basal nuclei of the brain

The shortest but most intense phase of labor is the: a. Latent phase b. Active phase c. Transition phase d. Placental expulsion phase

c. Transition phase

Which of the following sexually transmitted infections is characterized by a foul-smelling, yellow-green discharge that is often accompanied by vaginal pain and dyspareunia? a. Syphilis. b. Herpes simplex. c. Trichomoniasis. d. Condylomata acuminata.

c. Trichomoniasis.

A premature, 38-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply.

clay-colored stools tea-colored urine increased serum bilirubin levels

A feeling expressed by most women upon learning they are pregnant is: a. Acceptance b. Depression c. Jealousy d. Ambivalence

d. Ambivalence

Conduction heat loss

is the loss of heat from the BODY SURFACE to COOLER SURFACES in direct contact

The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails

How does the nurse position the infant experiencing respiratory difficulty?

on the back with the head elevated 15 degrees

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's: A) Finger B) Heel C) Scalp vein D) Umbilical vein

b Heel

Fetal Alcohol Spectrum Disorders (FASDs)

-Microcephaly -Small palpebral (eyelid) fissures -Missing vertical groove in median portion of upper lip -Thin upper lip -Prenatal or postnatal growth ≤10th percentile -Clinically significant brain abnormalities

Because the newborn's red blood cells break down much sooner than those of an adult, what might result? a. Anemia b. Bruising c. Apnea d. Jaundice

D. since newborns produce bilirubin (red blood cell breakdown end product) at twice the rate of adults, their liver is not able to conjugate bilirubin as quickly as needed, this results in jaundice.

While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breast-feeding because it is a major source of which immunoglobulin? a. IgA b. IgG c. IgE d. IgM

a. IgA

Which condition may cause intrauterine asphyxia? Select all that apply.

- cord compression - placenta abruption - intrauterine growth restriction Conditions such as cord compression, placenta abruption, and intrauterine growth restriction alter uteroplacental blood flow and may cause intrauterine asphyxia. Gestational diabetes may cause fetal hyperinsulinemia, and group B strep infection may cause intrauterine infection or PROM/preterm labor.

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

Assess for decrease in urinary output.

After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation? A) Dry the newborn thoroughly. B) Put a hat on the newborn's head. C) Check the newborn's temperature. D) Wrap the newborn in a blanket.

A Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.

A preterm infant born at 32 weeks gestation is being started on formula. When planning care, the nurse anticipates that which formula type is best?

A 24 cal/oz infant formula.

A newborn has been diagnosed with a Group B streptococcal infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which of the following? A) Improper handwashing B) Contaminated formula C) Nonsterile catheter insertion D) Mother's birth canal

Ans: D Feedback: Most often, a newborn develops a Group B streptococcus infection during the birthing process when the newborn comes into contact with an infected birth canal. Improper handwashing, contaminated formula, and nonsterile catheter insertion would most likely lead to a late-onset infection, which typically occurs in the nursery due to horizontal transmission.

signs of Transient tachypnea of the newborn (TTN) improvement

As TTN resolves, the newborn's: * respiratory rate declines to 60 breaths per minute or less * the oxygen requirement decreases *the chest x-ray shows resolution of the perihilar streaking.

BUBBLE-EE

B- breasts U- uterus B- bladder B- bowels L- lochia E- episiotomy/perineum/epidural site E- extremities E- emotional status

A woman is to undergo labor induction. The nurse determines that the woman most likely requires cervical ripening if her Bishop score is: a. 5 b. 6 c. 7 d. 8

a. 5

Three stage role development process

Expectations (they have a plan) Reality Transition to mastery

Infants of drug-dependent women tend to be large for gestational age. a) False b) True

False Infants of drug-dependent women tend to be small for gestational age.

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being delivered. Which of the following interventions should the nurse implement as a result of this finding? a) Gently shaking the infant b) Flicking the sole of the infant's foot c) Administration of oxygen via a bag and mask d) Intubation and suctioning of the trachea

Intubation and suctioning of the trachea

Which action could the nurse initiate to reduce the discomfort of a woman in labor whose fetus is in an occiput posterior position?

Massage her lower back. Counterpressure against the woman's back by a support person can be helpful in reducing this type of pain.

how to prevent hypoglycemia in newborn?

Prevent hypoglycemia by providing early oral feedings with breast milk of formula at frequent intervals (every 2 to 3 hours). *Feedings help to control glucose levels, reduce hematocrit, and promote bilirubin excretion. *neutral thermal environment to avoid cold stress, which may stimulate the metabolic rate, thereby increasing the demand for glucose. Provide rest periods to decrease energy demand and expenditure.

When planning the care for a small for gestational age (SGA) newborn, which action would the nurse determine as a priority?

Preventing hypoglycemia with early feedings

Therapeutic hypothermia

a promising neuroprotective intervention for newborns with moderate to severe perinatal encephalopathy after perinatal asphyxia and has currently been incorporated in many neonatal intensive care units

Kegel exercises

a series of pelvic muscle exercises used to strengthen the muscles of the pelvic floor to control urinary stress incontinence in women

During a counseling session on natural family planning techniques, how should the nurse explain the consistency of cervical mucus at the time of ovulation? a. It becomes thin and elastic. b. It becomes opaque and acidic. c. It contains numerous leukocytes to prevent vaginal infections. d. It decreases in quantity in response to body temperature changes.

a. It becomes thin and elastic.

A nurse would recognize which of the following measures would be most effective in preventing isoimmunization during pregnancy? a. RhoGAM administration to Rh-negative women b. Cerclage c. Amniocentesis d. Blood typing of mothers with type A or B blood

a. RhoGAM administration to Rh-negative women

In preparing for a class to teach new parents basic information on how to care for their new infant, how many diapers should the nurse suggest the parents plan using on a daily basis? a. 12 b. 10 c. 8 d. 6

b. 10

A 19-year-old female client has been diagnosed with pelvic inflammatory disease due to untreated gonorrhea. Which of the following instructions should the nurse offer when caring for the client? Select all that apply. a. Use an intrauterine device (IUD) b. Avoid douching vaginal area c. Complete the antibiotic therapy d. Increase fluid intake e. Limit the number of sex partners

b. Avoid douching vaginal area c. Complete the antibiotic therapy e. Limit the number of sex partners

The nurse is required to assess a client for HELLP syndrome. Which of the following are the signs and symptoms of this condition? (Select all that apply) a. Blood pressure higher than 160/110 b. Epigastric pain c. Oliguria d. Upper right quadrant pain e. Hyperbilirubinemia

b. Epigastric pain d. Upper right quadrant pain e. Hyperbilirubinemia

Hemorrhaging early in the pregnancy is related to several common causes. Which of the following would not be a common cause? a. Ectopic pregnancy b. Spontaneous abortion c. GTD d. Placenta previa

d. Placenta previa

after birth the fundus should be________ and should feel firm.

midline

Immediately after childbirth in the recovery area, the nurse observes the mother's partner's fascination and interest in the new son. This behavior is often termed:

partner's or significant others' developing bond with the newborn—a time of intense absorption, preoccupation, and interest—is called engrossment.

A nursing student is aware that fetal gas exchange takes place in which area?a. placentab. bronchiolesc. uterusd. lungs

a. placenta

The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this patient?

22 calories per ounce

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. Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.

Lochia alba

- final stage - creamy white or light brown and consists of leukocytes

After a class on genes, you note the class was successful when the class recognizes which of the following to not be a source of gene mutation? a. Acquired b. Inherited c. Chemical d. Spontaneous

c. Chemical

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity? a) 100 mm Hg b) 180 mm Hg c) 50 mm Hg d) 40 mm Hg

100 mm Hg

The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?

jitteriness

A nurse is assisting with the resuscitation of a preterm newborn. The nurse is giving ventilations to the newborn at which rate?

40 to 60 breaths per minute

Which of the following would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? a) Temperature instability b) Asymmetrical movement c) Feeble sucking d) Seizures

Asymmetrical movement

When to stop resuscitation

Continue resuscitation until the newborn has a pulse above 100 bpm, a good healthy cry, or good breathing efforts and a pink tongue.

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply. a) Alcohol use b) Renal infection c) Diabetes mellitus d) Postdates gestation e) Prepregnancy obesity

Diabetes mellitus Postdates gestation Prepregnancy obesity

Transient Tachypnea of the Newborn (TTN)

Mild respiratory distress; pulmonary liquid removed slowly or incompletely; resolution by 72 hours of age

engrossment

Paternal analogue of maternal emotional bonding; term used to describe fathers' fascination with their neonates, including their desire to touch, hold, caress, and talk to the newborn baby.

What are the causes of postpartum stress?

Physical stress of pregnancy & birth, the required care-giving tasks assoc. w/the newborn, meeting the demands of other family members, and fatigue.

An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHN). What intervention implemented by the nurse would be appropriate for treating this client?

Provide oxygen by oxygen hood or ventilator.

A client delivers a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of: a) Low birth weight b) Very low birth weight c) Normal birth weight d) Extremely low birth weight

Very low birth weight

A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal?a. 38.0° C (100.4° F)b. 37.0° C (98.6° F)c. 36.0° C (96.8° F)d. 35.0° C (95.0° F)

b. 37.0° C (98.6° F)

When teaching a group of students about the structures of the fetal skull, the nurse describes the anterior fontanelle. Which of the following would the nurse include? a. Closes 8 to 12 weeks after birth b. Located at the back of the fetal head c. Triangular shape d. Approximately 2 to 3 cm in size

d. Approximately 2 to 3 cm in size

The nurse is caring for a pregnant client with severe preeclampsia. Which of the following nursing interventions should a nurse perform to institute and maintain seizure precautions in this client? a. Provide a well-lit room b. Keep head of bed slightly elevated c. Place the client in a supine position d. Keep the suction equipment readily available

d. Keep the suction equipment readily available

A 30-year-old client would like to try using basal body temperature (BBT) as a fertility awareness method. Which of the following instructions should the nurse provide the client? a. Avoid unprotected intercourse until BBT has been elevated for 6 days b. Avoid using other fertility awareness methods along with BBT c. Use the axillary method of taking the temperature d. Take temperature before rising and record it on a chart

d. Take temperature before rising and record it on a chart

A baby who is declared AGA (appropriate for gestational age) falls in what weight percentile? a) 95 b) 20 c) 5 d) 9

20 Explanation: AGA infants are infants that fall between the 10th and 90th percentile for weight.

A nurse is assisting with the resuscitation of a preterm newborn. The nurse is giving ventilations to the newborn at which rate?

40 to 60 breaths per minute When performing newborn resuscitation, the nurse would ventilate at a rate of 40 to 60 breaths per minute.

The nursing instructor is discussing culture with a group of nursing students. Which of the following should be included in the discussion of this topic? Select all that apply. a. Personal space b. Race c. Primary language spoken d. Level of education e. Religious beliefs

a. Personal space c. Primary language spoken e. Religious beliefs

What is a key element when providing family-centered care? a. Communicating specific health information b. Being in control of the way care is given c. Giving only the health information that is absolutely necessary while providing care to the client and his or her family d. Avoid cultural issues by providing care in a standardized fashion

a. Communicating specific health information

A nurse is assessing a client during the postpartum period. Which of the following indicate normal postpartum adjustment?

Active bowel sounds, passing gas, and non-distended abdomen.

The nurse is explaining to a postpartum woman 48 hours after her giving childbirth that the afterpains she is experiencing can be the result of which of the following? a. Abdominal cramping is a sign of endometriosis. b. A small infant weighing less than 8 pounds c. Pregnancies that were too closely spaced d. Contractions of the uterus after birth

D The direct cause of afterpains is uterine contractions

A nurse is caring for an infant born after a prolonged and difficult maternal labor. What nursing intervention should the nurse perform when assessing for trauma and birth injuries in the newborn?

Note any absence of or decrease in deep tendon reflexes.

The second-year nursing student taking an obstetrics course correctly attributes which descriptions to the term dystocia? Select all that apply.

Progress of labor deviates from normal. Labor is slow. Dystocia is said to exist when the progress of labor deviates from normal and is slow.

When developing a teaching plan for a pregnant client with preterm labor who is to be discharged, what would the nurse do first? a. Decide which procedures and medications the client will need at home b. Determine the client's learning needs and styles c. Ask the client if she has ever had preterm labor before d. Tell the client what the goals of the teaching session are

b. Determine the client's learning needs and styles

Congenital heart anomalies affect approximately 8 infants in every 1,000 live births. The nursing assessment should include what important information that might indicate heart failure in the infant? a. Capillary refill time b. Diminished peripheral pulses c. Color of hands and feet d. Blood glucose level

b. Diminished peripheral pulses

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does this indicate? a. Cord compression b. Fetal distress related to hypoxia c. Infection d. CNS involvement

b. Fetal distress related to hypoxia

Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess? A) Respiratory rate 45, irregular B) Costal breathing pattern C) Nasal flaring, rate 65 D) Crackles on auscultation

A Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and crackles suggest a problem.

The nurse is assessing the newborn of a mother who had gestational diabetes. Which of the following would the nurse expect to find? (Select all that apply.) A) Pale skin color B) Buffalo hump C) Distended upper abdomen D) Excessive subcutaneous fat E) Long slender neck

Ans: B, C, D Feedback: Infants of diabetic mothers exhibit full rosy cheeks with a ruddy skin color, short neck, buffalo hump over the nape of the neck, massive shoulders, distended upper abdomen, and excessive subcutaneous fat tissue.

Which of the following is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight? a) Decreased muscle mass b) Face is angular and pinched c) Decreased body temperature d) Ability to tolerate early oral feeding

Ability to tolerate early oral feeding Explanation: Unlike preterm babies with low birth weights, a small for gestational age baby can safely tolerate early oral feeding. It usually has a coordinated sucking and swallowing reflex. Decreased muscle mass, decreased body temperature and an angular and pinched face are features common to both an SGA and a preterm baby.

A nurse is teaching postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching? A) "We can put him in the tub to bathe him once the cord falls off and is healed." B) "The cord stump should change from brown to yellow." C) "Exposing the stump to the air helps it to dry." D) "We need to call the doctor if we notice a funny odor."

B) "The cord stump should change from brown to yellow."

Amount of lochia

Scant: a 1- to 2-in lochia stain on the perineal pad or approximately a 10-mL loss Light or small: an approximately 4-in stain or a 10- to 25-mL loss Moderate: a 4- to 6-in stain with an estimated loss of 25 to 50 mL Large or heavy: a pad is saturated within 1 hour after changing it

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

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

"The mother of a newborn observes a diaper rash on her baby's skin. Which of the fol- lowing should the nurse instruct the parent to prevent diaper rash? a. Expose the newborn's bottom to air several times a day. b. Use plastic pants while bathing the new- born. c. Use products such as powder and items with fragrance. d. Place the newborn's buttocks in warm water often."

a. The nurse should instruct the par- ent to expose the newborn's bottom to air several times per day to prevent diaper rashes. Use of plastic pants and products such as powder and items with fragrance should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night."

A nurse is caring for obstetric clients. The nurse should be aware of which of the following as an indication for labor induction? a. Chorioamnionitis b. Complete placenta previa c. Abruptio placenta d. Transverse fetal lie

a. Chorioamnionitis

A prophylactic agent is instilled in both eyes of all newborns to prevent which of the following conditions? a. Gonorrhea and chlamydia b. Thrush and Enterobacter c. Staphylococcus and syphilis d. Hepatitis B and herpes

a. Gonorrhea and chlamydia

During the discharge planning for new parents, which of the following could the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted? a. Home visits for high-risk families b. Frequent clinic visits for high-risk families c. Ask a family member to monitor their progress d. Provide phone numbers for call centers for questions

a. Home visits for high-risk families

There are various neoplastic disorders that are grouped in the category of gestational trophoblastic disease. Which of the following is a common benign form? a. Hydatidiform mole b. Placenta accreta c. Hydramnios d. Ectopic pregnancy

a. Hydatidiform mole

A nurse is caring for an infant born with a high bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? (Select all that apply) a. Hydration b. Increase water intake c. Early feedings d. Administer vitamin supplements e. Phototherapy

a. Hydration c. Early feedings e. Phototherapy

A woman presents to her first postpartum visit with complaining she does not feel well. Which of the following would lead the nurse to suspect that she has developed metritis? (Select all that apply.) a. Leukocytosis b. Hematuria c. Foul-smelling lochia d. Flank pain e. Pain on both sides of the abdomen

a. Leukocytosis c. Foul-smelling lochia e. Pain on both sides of the abdomen

The initial prenatal visit should be a complete assessment of the client's past and present history. Part of this assessment should include the immunization history. You inform the client to avoid which of the following types of vaccines while she is pregnant? a. Live virus vaccine b. Toxoid vaccine c. Inactivated virus vaccine d. Bacterial vaccine

a. Live virus vaccine

A 26-year-old female, G1,P0, presents to the emergency department with complaints of regular uterine contractions. Since she is in her 36th week of gestation, the nurse recognizes which of the following is potentially occurring? a. Preterm labor b. Dystocia c. Precipitate labor d. Normal labor

a. Preterm labor

A client in her 20th week of gestation expresses concern about her 5-year-old son, who is behaving strangely by not approaching her anymore. He does not seem to be taking the news of a new family member very well. Which of the following strategies can a nurse discuss with the mother to deal with the situation? a. Provide constant reinforcement of love and care to the client b. Avoid talking to the child about the new arrival c. Pay less attention to the child to prepare him for the future d. Consult a child psychologist about the situation

a. Provide constant reinforcement of love and care to the client

A postpartum woman reports hearing voices and says, "The voices are telling me to do bad things to my baby." The clinic nurse interprets these findings as suggesting postpartum: a. Psychosis b. Anxiety disorder c. Depression d. Blues

a. Psychosis

During pregnancy, which of the following should the expectant mother reduce or avoid? a. Raw meat or undercooked shellfish b. Fresh, washed fruits and vegetables c. Whole grains d. Protein and iron from meat sources

a. Raw meat or undercooked shellfish

A nurse is assisting a pregnant client during pregnancy is to monitor uterine contractions. Which of the following factors should the nurse assess to monitor uterine contraction? (Select all that apply) a. Uterine resting tone b. Frequency of contractions c. Change in temperature d. Change in blood pressure e. Intensity of contractions

a. Uterine resting tone b. Frequency of contractions e. Intensity of contractions

The nurse places a newborn experiencing respiratory difficulty under a radiant warmer to prevent which complication?

acidosis A radiant warmer is use to keep the infant warm. When an infant is cold, brown fat metabolism leads to acidosis, which would further complicate respiratory difficulties.

A woman received meperidine during labor to help with pain control. Which of the following would the nurse need to monitor the newborn for after delivery? a. Increased agitation b. Decreased alertness c. Low Apgars d. Increased crying

b. Decreased alertness

Because subcutaneous and brown fat stores were used for survival in utero, the nurse would assess an SGA newborn for which of the following? a. Hyperbilirubinemia b. Hypothermia c. Polycythemia d. Hypoglycemia

b. Hypothermia

The nurse is instructing a client with dysmenorrhea on how to manage her symptoms. Which of the following should the nurse include in the teaching plan? Select all that apply a. Increase intake of salty foods b. Increase water consumption c. Avoid keeping legs elevated while lying down d. Use heating pads or take warm baths e. Increase exercise and physical activity

b. Increase water consumption d. Use heating pads or take warm baths e. Increase exercise and physical activity

Prior to discharge is an appropriate time to evaluate the client's status for preventative measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh negative mother? a. CBC with differential b. Indirect Coombs' test c. Titer screen d. ANA

b. Indirect Coombs' test

The nurse is performing a routine assessment of her client after delivery. Inspection of a woman's perineal pad reveals a 5-inch lochia stain. This amount should be documented as which of the following? a. Heavy b. Moderate c. Light d. Scant

b. Moderate

A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client?a. hypotensionb. fluid overloadc. decreased level of consciousnessd. tachycardia

b. fluid overload

A nurse is caring for a postpartum client. What instruction should the nurse provide to the client as precautionary measures to prevent thromboembolic complications? a. Avoiding performing any deep-breathing exercises b. Try to relax with pillows under knees c. Avoid sitting in one position for long periods of time d. Refrain from elevating legs above heart level

c. Avoid sitting in one position for long periods of time

A nurse, assigned to check the pulse, discerns tachycardia in a postpartum client. Which of the following does it suggest? a. Pulmonary edema b. Atelectasis c. Excessive blood loss d. Pulmonary embolism

c. Excessive blood loss

The nurse teaches the pregnant client how to perform Kegel exercises as a way to accomplish which of the following? a. Prevent perineal lacerations b. Stimulate labor contractions c. Increase pelvic muscle tone d. Lose pregnancy weight quickly

c. Increase pelvic muscle tone

A nurse is caring for a client who has been diagnosed with precipitous labor. For which of the following potential fetal complications should the nurse monitor as a result of precipitous labor? a. Facial nerve injury b. Cephalhematoma c. Intracranial hemorrhage d. Facial lacerations

c. Intracranial hemorrhage

Which of the following biophysical profile findings indicate poor oxygenation of the fetus? a. Two pockets of amniotic fluid b. Well-flexed arms and legs c. Nonreactive fetal heart rate d. Fetal breathing movements noted

c. Nonreactive fetal heart rate

A nurse is newly posted to the obstetric unit of the health care facility. Which of the following are the causes of intrauterine fetal demise in late pregnancy that the nurse should be aware of? (Select all that apply) a. Hydramnios b. Multifetal gestation c. Prolonged pregnancy d. Malpresentation e. Hypertension

c. Prolonged pregnancy e. Hypertension

A woman gives birth to a newborn at 38 weeks' gestation. The nurse classifies this newborn as which of the following? a. Postterm b. Late term c. Term d. Preterm

c. Term

When assessing the umbilical cord of a newborn, which of the following would the nurse expect to find? a. Two arteries and two veins b. Three arteries and no veins c. Two arteries and one vein d. One artery and two veins

c. Two arteries and one vein

Which of the following is a presumptive sign or symptom of pregnancy? a. Restlessness b. Elevated mood c. Urinary frequency d. Low backache

c. Urinary frequency

When assessing a newborn's reflexes, the nurse strokes the newborn's cheek and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive? A) Palmar grasp reflex B) Tonic neck reflex C) Moro reflex D) Rooting reflex

d. Rooting reflex

The nurse is interviewing a client regarding contraceptive choices. Which of the following client statements would most influence the nurse's teaching? a. "I have 2 children." b. "My partner and I have sex twice a week." c. "I am 25 years old." d. "I feel funny touching my private parts."

d. "I feel funny touching my private parts."

During assessment of the mother during the postpartum period, what would alert the nurse that the client is likely experiencing uterine atony? a. Fundus feels firm b. Foul-smelling urine c. Purulent vaginal discharge d. Boggy or relaxed uterus

d. Boggy or relaxed uterus

A client from the Middle East will not make a decision without her husband's approval. The nurse should recognize this is an example of: a. Family preference b. Religious submission c. Old-fashioned values d. Cultural difference

d. Cultural difference

When preparing a presentation for a local woman's group on women's health problems, what would the nurse include as the number-one cause of mortality for women in the United States? a. Breast cancer b. Childbirth complications c. Injury resulting from violence d. Heart disease

d. Heart disease

A pregnant woman has been admitted to the hospital due to severe preeclampsia. Which of the following will be important for the nurse to include in the care plan? a. Institute NPO status. b. Admit the client to the middle of ICU where she can be constantly monitored. c. Plan for immediate induction of labor. d. Institute and maintain seizure precautions.

d. Institute and maintain seizure precautions.

caput succedaneum

diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days

atony

lack of muscle tone

A _________ is an involuntary muscular response to a sensory stimulus

reflex

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." The most common complications for late preterm infants are cold stress, respiratory distress, hypoglycemia, sepsis, cognitive delays, hyperbilirubinemia, and feeding difficulties. These are similar to those facing the preterm newborn and require similar management. Late preterm newborns have more clinical problems, longer lengths of stay, higher costs when compared with full-term newborns, and increased mortalities.

An infant born 10 minutes prior was brought into the nursery for its exam. The nurse notices the infant's lip and palate are malformed. The father comes up to door and asks if the baby seems okay. What is the appropriate response by the nurse?

"Come on over and I will explain your infant's exam and findings." The nurse should include the parents and notify them of any visible anomalies right away. An in-depth discussion can take place later when the diagnosis is more definitive. Although the family may be in shock or denial, the nurse should give a realistic appraisal of the condition of their baby. Keeping communication lines open will lessen the family's feelings of helplessness and support their parental role.

Which statement by the parents is evidence of meeting the desired outcome for a nursing diagnosis of impaired parenting?

"I'm so happy to hold you; I think you like it too."

A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements?

"Transverse lie is the same as when the fetal buttocks present to the birth canal." In most term pregnancies the fetus presents head down. In a breech presentation, the fetal buttocks, feet, or both present to the birth canal. Transverse lie is the same as shoulder presentation.

A newborn has scheduled heel sticks for bilirubin checks every 4 hours. The mother asks the nurse "what can be done to calm my baby after those heel pricks?" What is the nurse's most appropriate response?

"You can give your baby a sucrose solution by bottle for pain relief."

Meconium Aspiration Syndrome

- Intrauterine distress can cause passage into the amniotic fluid. - placental insufficiency - maternal hypertension - preeclampsia - fetal hypoxia - transient umbilical compression - oligohydramnios - maternal drug abuse - especially of tobacco -cocaine.

Normally, the fundus progresses downward at a rate of 1 fingerbreadth (or 1 cm) per day after childbirth and should be nonpalpable by ___ to ____ days postpartum.

10 to 14

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity? a) 180 mm Hg b) 50 mm Hg c) 100 mm Hg d) 40 mm Hg

100 mm Hg Explanation: Retinal capillaries can be damaged by excessive oxygen levels. Keeping the Pa02 level under 100 mm Hg helps prevent this.

The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated?

20th

Hypoglycemia in a mature infant is defined as a blood glucose level below which of the following? a) 30 mg/100 mL whole blood b) 100 mg/100 mL whole blood c) 40 mg/100 mL whole blood d) 80 mg/100 mL whole blood

40 mg/100 mL whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 mL whole blood is considered hypoglycemia

normal newborn length

45-55 cm

Encourage women to lose their pregnancy weight by ___ months postpartum, and refer those who don't to community weight-loss programs.

6

A nurse observes a 3-day-old term newborn that is starting to appear mildly jaundiced. What might explain this condition? a. Physiologic jaundice secondary to breast-feeding b. Hemolytic disease of the newborn due to blood incompatibility c. Exposing the newborn to high levels of oxygen d. Overfeeding the newborn with too much glucose water

A. Physiologic jaundice typically starts after 72 hours of breast-feeding. There is an enzyme in breast milk that inhibits the breakdown of bilirubin, and it is reflected on the newborn skin as jaundice.

A nurse is caring for a newborn with transient tachypnea. Which is the priority nursing intervention? a) Administer IV fluids; gavage feedings b) Perform gentle suctioning c) Monitor for signs of hypotonia d) Maintain adequate hydration

Administer IV fluids; gavage feedings

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

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? a) An infant whose mother craved chocolate during pregnancy b) An infant whose labor began with ruptured membranes c) An infant who has marked acrocyanosis of his hands and feet d) An infant who had difficulty establishing respirations at birth

An infant who had difficulty establishing respirations at birth Explanation: Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.

Which of the following would alert the nurse to suspect that a preterm newborn is in pain? A) Bradycardia B) Oxygen saturation level of 94% C) Decreased muscle tone D) Sudden high-pitched cry

Ans: D Feedback: The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone.

The _____ score is used to evaluate newborns at 1 minute and 5 minutes after birth.

Apgar score

A nursing student is preparing a presentation on minimizing heat loss in the newborn. Which of the following would the student include as a measure to prevent heat loss through convection? A) Placing a cap on a newborn's head B) Working inside an isolette as much as possible. C) Placing the newborn skin-to-skin with the mother D) Using a radiant warmer to transport a newborn

B To prevent heat loss by convection, the nurse would keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment, work inside an isolette as much as possible and minimize opening portholes that allow cold air to flow inside, and warm any oxygen or humidified air that comes in contact with the newborn. Placing a cap on the newborn's head would help minimize heat loss through evaporation. Placing the newborn skin-to-skin with the mother helps to prevent heat loss through conduction. Using a radiant warmer to transport a newborn helps minimize heat loss through radiation.

The neonate's respirations are gasping and irregular with a rate of 24 bpm. Which circulatory alteration will the nurse assess for in this infant?

Blood flows from the aorta to the pulmonary artery.

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes? A) Gastrointestinal and hepatic B) Urinary and hematologic C) Respiratory and cardiovascular D) Neurological and integumentary

C Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

A newborn is receiving bag and mask ventilation and cardiac compression. The resuscitation is paused, and the nurse reassesses the infant. The infant's heart rate is 70 bpm with irregular gasping respirations. What is the appropriate action in this situation?

Continue bag and mask ventilation only.

The nurse is caring for a large-for-gestational-age newborn (also known as macrosomia). What maternal condition is the usual cause of this condition? a) Diabetes b) Celiac disease c) Alcohol use d) Hypertension

Diabetes Correct Explanation: In the condition known as macrosomia, a newborn is born large for gestational age (LGA). These newborns are those with birth weights that exceed the 90th percentile of newborns of the same gestational age. They are born most often to mothers with diabetes.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next?

Educate the client on how to perform Kegel exercises. Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream.

drop in maternal blood volume after birth leads to a similar drop in hematocrit. TRUE or FALSE

FALSE hematocrit level remains relatively stable and may even increase, reflecting predominant loss of plasma

A baby is born with congenital rubella. Which of the following would be an important assessment to be made before hospital discharge?

Hearing assessment

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid? a) Respiratory rate of 60-70 bpm b) Total bilirubin level of 15 c) Heart rate of 162 bpm d) Hematocrit of 44%

Heart rate of 162 bpm

A client asks the nurse what surfactant is. Which explanation would the nurse give as the main role of surfactant in the neonate? a) Helps the lungs remain expanded after the initiation of breathing b) Promotes clearing of mucus from the respiratory tract c) Assists with ciliary body maturation in the upper airways d) Helps maintain a rhythmic breathing pattern

Helps the lungs remain expanded after the initiation of breathing Correct Explanation: Surfactant works by reducing surface tension in the lung, which allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Surfactant hasn't been shown to influence ciliary body maturation, clearing of the respiratory tract, or regulation of the neonate's breathing pattern.

The nurse is caring for a client of Asian descent 1 day after she has given birth. Which foods will the client most likely refuse to eat when her meal tray is delivered? (Select all)

Ice cream; raw carrot & celery; orange slices Many people of Latin American, African, and Asian descent believe that good health involves a balance of heat and cold. The blood loss during childbirth is considered loss of warmth, therefore cold foods are avoided during this time.

The nurse in a newborn nursery is observing for developmentally appropriate care. Which of the following is an example of self-regulation? a) Infant has hand in mouth b) Infant is kicking feet c) Infant is crying d) Infant is quiet

Infant has hand in mouth Correct Explanation: Self-regulation is a form of self-soothing for an infant such as sucking on hands or putting hand to mouth type of movements.

The nurse has been doing bag and mask resuscitation for over 2 minutes. What additional intervention will the nurse initiate?

Insert an orogastric tube.

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? a) Hyperalert state b) Jitteriness c) Loud and forceful crying d) Serum glucose level of 60 mg/dl

Jitteriness

a client delivers a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home?

Keep the newborn wrapped in a blanked with a cap on its head

When reviewing the medical record of a newborn who is large for gestational age (LGA), which of the following factors would the nurse identify as having increased the newborn's risk for being LGA? a) Low weight gain during pregnancy b) Fetal exposure to low estrogen levels c) Low maternal birth weight d) Maternal pregravid obesity

Maternal pregravid obesity

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. Which of the following should the nurse expect when assessing the condition of the newborn? a) Tremors, irritability, and high-pitched cry b) Seizures, respiratory distress, cyanosis, and shrill cry c) Meconium aspiration in utero or at birth d) Yellow appearance of the newborn's skin

Meconium aspiration in utero or at birth

A preterm infant is receiving indomethacin. What is a priority assessment following administration of indomethacin? Select all that apply.

Monitor urine output. Observe for bleeding.

Which intervention should a nurse implement to promote thermal regulation in a preterm newborn?

Observe for clinical signs of cold stress such as weak cry.

Respiratory Distress Syndrome signs:

Observe the infant for expiratory grunting, shallow breathing, nasal flaring, chest wall retractions, seesaw respirations, and generalized cyanosis. Auscultate the heart and lungs, noting tachycardia (rates above 150 to 180), fine inspiratory crackles, and tachypnea (rates above 60 breaths per minute).

The small-for-gestation neonate is at increased risk for which complication during the transitional period? a) Hyperthermia due to decreased glycogen stores b) Polycythemia probably due to chronic fetal hypoxia c) Hyperglycemia due to decreased glycogen stores d) Anemia probably due to chronic fetal hypoxia

Polycythemia probably due to chronic fetal hypoxia The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores

What are the factors that inhibit uterine involution?

Prolonged labor & difficult birth; incomplete expulsion of amniotic membranes & placenta; uterine infection; over-distention of uterine muscles due to: multiple gestation, hydramnios, or large fetus, full bladder which displaces uterus & interferes with contractions, anesthesia, which relaxes uterine muscles, close childbirth spacing, leading to frequent & repeated distention and thus decreasing uterine tone & causing muscular relaxation.

Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor?

Provide ongoing communication about what is happening. Dysfunctional labor at any point is frustrating to women. Maintaining open lines of communication at least keeps the woman well informed about what is happening.

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 loss of body heat to cooler, solid surfaces that are in proximity but not in direct contact with the newborn

Radiation

A nurse from the neonatal intensive care unit is called to the birth room for an infant requiring resuscitation. After placing the newborn in the sniffing position what would the nurse do next?

Suction the mouth then the nose.

A concerned client tells the nurse that her husband, who was very excited about the baby before birth, is apparently happy but seems to be afraid of caring for the baby. What suggestions should the nurse give to the client's husband to resolve the issue?

Suggest that her husband begin by holding the baby frequently.

Which of the following would be signs of dehydration in a newborn? a) Eight wet diapers a day b) 10% weight gain c) Sunken fontanels d) Frequent feedings

Sunken fontanels Correct Explanation: Sunken fontanels in a newborn are a sign of dehydration. Other signs are sunken eyeballs, decreased urine output, lethargy, decreased skin turgor, decreased body weight, and irritability.

Which of the following would be signs of dehydration in a newborn? a) Eight wet diapers a day b) 10% weight gain c) Sunken fontanels d) Frequent feedings

Sunken fontanels Sunken fontanels in a newborn are a sign of dehydration. Other signs are sunken eyeballs, decreased urine output, lethargy, decreased skin turgor, decreased body weight, and irritability.

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching?

The client needs to notify the healthcare provider for blurred vision as this can indicate preeclampsia in the postpartum period. The client should also notify the healthcare provider for a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge.

Prioritize the postpartum mother's needs 4 hours after giving birth by placing a number 1, 2, 3, or 4 in the blank before each need. 1. _________ Learn how to hold and cuddle the infant. 2. _________Watch a baby bath demonstration given by the nurse. 3. _________ Sleep and rest without being disturbed for a few hours. 4. _________ Interaction time (first 30 minutes) with the infant to facilitate bonding

The correct answer would be: 1. Interaction time (first 30 minutes) with the infant to facilitate bonding 2. Sleep and rest without being disturbed for a few hours 3. Learn how to hold and cuddle the infant 4. Watch a baby bath demonstration given by the nurse

how to administer surfactant replacement therapy?

The earlier the surfactant is administered, the better the effect on gas exchange. Following surfactant administration, the newborn must be closely monitored, and preparation for reduced need for oxygen and ventilation should be anticipated

At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate?

The infant was a preterm, low birth weight and small for gestational age Born at 36 weeks gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500g) and small for gestational age at the 8th percentile (under the 10th percentile). The other documentation is not accurate.

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

The infant's mother probably had diabetes.

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.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The testes in the child may be undescended. b) The newborn may have short nails and hair. c) The infant may have excess of lanugo and vernix caseosa. d) The newborn may look wrinkled and old at birth.

The newborn may look wrinkled and old at birth.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth. Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The newborn may have short nails and hair. b) The newborn may look wrinkled and old at birth. c) The testes in the child may be undescended. d) The infant may have excess of lanugo and vernix caseosa.

The newborn may look wrinkled and old at birth. Correct Explanation: Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The newborn may have short nails and hair. b) The infant may have excess of lanugo and vernix caseosa. c) The testes in the child may be undescended. d) The newborn may look wrinkled and old at birth.

The newborn may look wrinkled and old at birth. Correct Explanation: Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants.

A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?

The supply of brown adipose tissue is not developed.

hemolytic disease of the newborn

This disease occurs in the fetus if the fetus is Rh+ while the mother is Rh-.

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which intervention should the nurse implement at this point?

Tip the infant into an upright position. It's important the infant is tipped to an upright position following administration of surfactant and the infant's airway is not suctioned for as long a period as possible after administration of surfactant to help it reach lower lung areas and avoid suctioning the drug away. A blood sample may be taken to rule out a streptococcal infection, which mimics the signs of RDS, but this would have been done before administration of surfactant. The infant should not be placed supine in a radiant heat warmer at this time but should be held in an upright position.

The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant?

To detect rebound hypoglycemia

Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation?

Turn off the pitocin. Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion.

he nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breast-fed newborns?

Yellowish gold color Stringy to pasty consistency

A first time mother is nervous about breast feeding. which intervention would the nurse perform to reduce anxiety about breastfeeding? A. reassure the mother that some newborns latch and catch right away and some take more time to be patient. b. explain that breast feeding comes naturally to all mothers. c. tell her that breast feeding is a mechanical procedure that involves burping once in a while and she should try to finish quickly. d. ensure that the mother breast feeeds the newborn using the cradle method.

a

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? a. "Postpartum depression develops gradually, appearing within the first 6 weeks." b. "Postpartum psychosis usually appears soon after the woman comes home." c. "Postpartum blues usually resolves by the fourth or fifth postpartum day." d. "Postpartum psychosis usually involves psychotropic drugs but not hospitalization."

a. "Postpartum depression develops gradually, appearing within the first 6 weeks."

Which statement by the client indicates that she understands the teaching provided about the intrauterine device (IUD)? a. "The IUD can remain in place for a year or more." b. "I will not menstruate while the IUD is in." c. "Pain during intercourse is a common side effect." d. "The device will reduce my chances of getting infected."

a. "The IUD can remain in place for a year or more."

There is the possibility of a numerical abnormality to occur within the chromosome pairs resulting in various abnormalities. A common form of trisomy most commonly involves all except which of the following? a. 10 b. 13 c. 18 d. 21

a. 10

New parents are upset their newborn has lost weight since birth. The nurse explains that newborns typically lose how much of their birth weight by 3 to 4 days of age? a. 10% b. 12% c. 14% d. 16%

a. 10%

A nurse is caring for a newborn with transient tachypnea in a family maternity center. What is a priority nursing intervention for a newborn with transient tachypnea? a. Administer IV fluids; gavage feedings b. Maintain adequate hydration c. Monitor for signs of hypotonia d. Perform gentle suctioning

a. Administer IV fluids; gavage feedings

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg per dL and the newborn has a weak cry, is irritable, and bradycardic. Which intervention is most appropriate? a. Administer dextrose intravenously b. Monitor the infant's hematocrit levels closely c. Administer IV glucose immediately d. Place the infant on a radiant warmer

a. Administer dextrose intravenously

A nurse recognizes that some birth defects are preventable. Which of the following risk factors is now recognized as the leading preventable cause of birth defects? a. Alcohol b. Recreational drugs c. Obesity d. Smoking

a. Alcohol

There is a concern that your client is not obtaining enough folic acid. Which test can be used to evaluate the fetus for potential neural tube defects? a. Alpha-fetoprotein analysis b. Doppler flow study c. Amniocentesis d. Triple-marker screen

a. Alpha-fetoprotein analysis

Your client, who is 12 hours postdelivery, is now complaining of perineal pain. After the assessment reveals no signs of an infection, which of the following measures could you offer the client? a. An ice pack applied to the perineum b. A sitz bath c. Narcotic pain medication d. A heating pad applied to the perineum

a. An ice pack applied to the perineum

A refugee from a third world country presents to the clinic to find out if she is pregnant. Which of the following signs and/or symptoms indicate she might have an active case of tuberculosis as well? (Select all that apply.) a. Anorexia b. Hemoptysis c. Weight gain d. Night sweats e. Fatigue

a. Anorexia b. Hemoptysis d. Night sweats e. Fatigue

The most common severe adverse pulmonary outcome of preterm birth is bronchopulmonary dysplasia. The nurse recognizes that this can be prevented by including which of the following in the client's care plan? a. Antepartum administration of steroids to the mother b. Administrating tocolytics to the mother before birth c. Immediate intubation after birth d. Start resuscitation with 100% oxygen immediately after birth

a. Antepartum administration of steroids to the mother

The client wants to avoid an episiotomy. What other technique would the nurse suggest for the client to try? a. Apply warm compresses to the perineum. b. Deliver the infant while lying on her back. c. Massage the perineum daily during the last trimester. d. Practice Kegel exercises during pregnancy.

a. Apply warm compresses to the perineum.

A client with preeclampsia is receiving magnesium sulfate to suppress or control seizures. Which of the following nursing interventions should a nurse perform to determine the effectiveness of therapy? a. Assess deep tendon reflexes b. Monitor intake and output c. Assess client's mucous membrane d. Assess client's skin turgor

a. Assess deep tendon reflexes

A client in her third month of pregnancy arrives at the health care facility for a regular follow-up visit. The client complains of discomfort due to increased urinary frequency. Which of the following instructions should the nurse offer the client to reduce the client's discomfort? a. Avoid consumption of caffeinated drinks b. Drink fluids with meals rather than between meals c. Avoid an empty stomach at all times d. Munch on dry crackers and toast in the early morning

a. Avoid consumption of caffeinated drinks

A 19-year-old female presents in advanced labor. Examination reveals the fetus is in frank breech position. You explain to the client this means which of the following? a. Buttocks are presenting first with both legs extended up toward the face. b. Fetus is sitting cross-legged above the cervix. c. One leg is presenting. d. One arm is presenting.

a. Buttocks are presenting first with both legs extended up toward the face.

After conducting a class on possible congenital infections with a group of student nurses, the instructor recognizes the class was successful when the class identifies which of the following as the most common congenital viral infection? a. CMV b. RSV c. HIV d. HPV

a. CMV

The nurse is assessing a pregnant woman's health literacy during a prenatal visit. Which of the following would the nurse identify as impacting the woman's health literacy? (Select all that apply.) a. Complexity of information b. Woman's employment status c. Woman's level of emotional distress d. Lack of familiarity with the information

a. Complexity of information c. Woman's level of emotional distress d. Lack of familiarity with the information

After completing an assessment of a preterm newborn, the nurse is suspicious the infant has a congenital diaphragmatic hernia. Which of the following symptoms are indications of this defect? (Select all that apply.) a. Concave-shaped abdomen b. Hypotension c. Grunting d. Tachycardia e. Poor feeding with vomiting

a. Concave-shaped abdomen c. Grunting d. Tachycardia

You are a member of a postpartum home visiting group. Which of the following would not necessarily be a responsibility of a visit? a. Conducting a well-baby visit to start the child's immunizations b. Link the family to community services, as needed c. Evaluate the emotional well-being of the family d. Identifying potential complications

a. Conducting a well-baby visit to start the child's immunizations

The nurse is planning to speak at a local community center to a group of middle-aged women about osteoporosis. Which of the following would the nurse be sure to include as effective in reducing the risk for osteoporosis? a. Engaging in daily weight-bearing exercise b. Decreasing vitamin D intake c. Limiting intake of cholesterol and saturated fats d. Drinking at least one glass of wine/day

a. Engaging in daily weight-bearing exercise

A woman with a recent incomplete abortion is to receive therapeutic misoprostol. The nurse understands that the rationale for administering this drug is to: a. Ensure passage of all the products of conception b. Suppress the immune response to prevent isoimmunization c. Alleviate strong uterine cramping d. Halt the progression of the abortion

a. Ensure passage of all the products of conception

Which factor would the nurse identify as being least likely to contribute to the rise in community-based care? a. Focus on illness-oriented curative care b. Rise in consumer disposable income c. Technological advances for home care d. Emphasis on primary care and treatment

a. Focus on illness-oriented curative care

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

a. Foramen ovale

The nurse explains that newborns demonstrate several predictable responses when interacting with their environment. Which of the following would the nurse identify as these behavioral responses? (Select all that apply.) a. Habituation b. Self-quieting ability c. Orientation d. Attachment to parents e. Adequate feedings

a. Habituation b. Self-quieting ability c. Orientation

A nurse is caring for a pregnant client during labor. Which of the following methods should the nurse use to provide comfort to the pregnant client? (Select all that apply) a. Hand holding b. Chewing gum c. Massaging d. Acupuncture e. Prescribed pain killers

a. Hand holding c. Massaging d. Acupuncture

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

a. Keeping the handling of the newborn to a minimum b. Maintaining a neutral thermal environment c. Decreasing environmental stimuli

In preparing a talk about STIs for high school students, the nurse should emphasize which of the following as high-risk groups? (Select all that apply.) a. Multiple or new sex partners b. Single women c. Women younger than 25 years old d. Consistent barrier use

a. Multiple or new sex partners b. Single women c. Women younger than 25 years old

A client presents with the possible symptoms of HSV. Which of the following would not be used by the nurse to confirm the diagnosis? a. Pap smear b. Viral culture c. Physical examination d. Clinical signs

a. Pap smear

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

a. Stored glucose

A nurse is caring for a pregnant client with sickle cell anemia. What should the nursing care for the client include? (Select all that apply) a. Teach the client meticulous hand-washing b. Assess serum electrolyte levels of the client at each visit c. Instruct client to consume protein-rich foods d. Assess hydration status of the client at each visit e. Urge the client to drink 8 to 10 glasses of fluid daily

a. Teach the client meticulous hand-washing d. Assess hydration status of the client at each visit e. Urge the client to drink 8 to 10 glasses of fluid daily

The nurse recognizes that a postterm newborn will be less likely to exhibit which of the following characteristics? a. Thick umbilical cord b. Absent lanugo c. Meconium-stained skin d. Creases on entire soles of feet

a. Thick umbilical cord

A nurse is reviewing the maternal history and medical record of an SGA newborn. Which finding would the nurse identify as a placental factor contributing to the newborn's current state?

abnormal cord insertion

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

the immune system's responses may be either natural or

acquired

A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?

administering oxytocin Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used with hypertonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?

amniotomy Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.

Tracheoesophageal fistula

an abnormal communication between the trachea and esophagus.

Third-degree laceration

anal sphincter also

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 A premature infant has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress.

A woman whose fetus in in the occiput-posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain?

applying counter pressure to the back Counter pressure applied to the lower back with a fisted hand sometimes helps the woman cope with "back labor" associated with occiput-posterior positioning. The others are not recommended or used techniques for a woman in labor with back pain.

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 woman with hydramnios has just given birth. The nurse recognizes that the infant must be assessed for which condition? a) ankyloglossia b) esophageal atresia c) torticollis d) talipes

b) esophageal atresia Esophageal atresia must be ruled out in any infant born to a woman with hydramnios (excessive amniotic fluid). Hydramnios occurs because, normally, a fetus swallows amniotic fluid during intrauterine life. A fetus with esophageal atresia cannot effectively swallow, so the amount of amniotic fluid can grow abnormally large. The other conditions listed are not associated with hydramnios.

A newborn is suspected of having fetal alcohol syndrome. Which finding would the nurse expect to assess? a) hydrocephaly b) flattened maxilla c) bradypnea d) hypoactivity

b) flattened maxilla A newborn with fetal alcohol syndrome exhibits characteristic facial features such as microcephaly (not hydrocephaly), small palpebral fissures, and abnormally small eyes, flattened or absent maxilla, epicanthal folds, thin upper lip, and missing vertical groove in the median portion of the upper lip. Bradypnea is not typically associated with fetal alcohol syndrome. Fine and gross motor development is delayed, and the newborn shows poor hand-eye coordination but not hypoactivity

"The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? a. Immediately after birth, in the birthing area b. Within the first 2 to 4 hours, when the newborn is in the nursery c. Before the newborn is discharged d. The day after the newborn's birth"

b. The nurse should complete the sec- ond assessment for the newborn within the first 2 to 4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged."

A client has asked that an opioid be kept on standby in case she needs it for pain control. As a precaution, the nurse will also have which of the following readily available to reverse the effects of that opioid? a. Nalbuphine b. Naloxone c. Hydroxyzine d. Midazolam

b. Naloxone

A nurse is caring for a pregnant client. The nurse learns from the report that the client is diabetic. Which of the following should the nurse identify as the effect of insulin resistance in the client? a. Hypertension b. Postprandial hyperglycemia c. Hypercholesterolemia d. Myocardial infarction

b. Postprandial hyperglycemia

A client has been diagnosed with pubic lice. Which of the following signs/symptoms would the nurse expect to see? a. Macular rash on the labia. b. Pruritus. c. Hyperthermia. d. Foul-smelling discharge.

b. Pruritus

A woman has been diagnosed with syphilis. Which of the following nursing interventions is appropriate? a. Council the woman about how to live with a chronic infection. b. Question the woman regarding symptoms of other sexually transmitted infections. c. Assist the primary health care practitioner with cryotherapy procedures. d. Educate the woman regarding the safe disposal of menstrual pads.

b. Question the woman regarding symptoms of other sexually transmitted infections.

The nurse is preparing to apply a thermistor probe to a newborn to monitor the temperature. Which location would be the optimal location for the nurse to apply the probe? a. Lower back b. Right upper abdominal quadrant c. Upper left arm d. Right great toe

b. Right upper abdominal quadrant

When assessing a newborn, the nurse determines that the newborn is most likely experiencing respiratory distress syndrome (RDS) based on which of the following? a. Respiratory distress occurring by 6 hours of age b. See-saw respirations c. Peripheral cyanosis d. Slightly diminished breath sounds

b. See-saw respirations

Your client presents with complaints of irregular menstrual cycles, bleeding between periods, mood swings, hot flashes and vaginal tenderness. After an examination, you suspect dysfunctional uterine bleeding. Which of the following would be an inappropriate approach to help your client? a. Order CBC and PT blood test b. Tell the client to learn to live with it c. Order a pregnancy test to rule out ectopic pregnancy d. Order ultrasound to check internal pelvic structures

b. Tell the client to learn to live with it

During this initial period, the infant is in a quiet, alert state, looking directly at the holder.

bonding is affected by

Which of the following would the nurse include when teaching the parents of a newborn who have a 2-year-old boy at home? a. "Talk to your 2-year-old about the baby when you're driving him to daycare." b. "Have your 2-year-old stay at home while you're here in the hospital." c. "Ask your 2-year-old to pick out a special toy for his sister." d. "Expect to see your 2-year-old become more independent when the baby gets home."

c. "Ask your 2-year-old to pick out a special toy for his sister."

When discussing the many changes the woman's body undergoes during pregnancy, the nurse may include that the woman's total blood volume will increase by approximately how much by the 30th week gestation? a. 500 mL b. 1,000 mL c. 1,500 mL d. 2,000 mL

c. 1,500 mL

Part of the assessment of the first prenatal visit includes screening for rubella antibodies. The nurse explains which of the following titer results shows evidence of immunity against rubella? a. 1:10 b. 1:6 c. 1:8 d. 1:4

c. 1:8

When assessing the newborn, the nurse notes which of the following would be a normal temperature? a. 35 C b. 36 C c. 37 C d. 38 C

c. 37 C

The nurse documents that a newborn is post-term based on the understanding that he was born after: a. 38 weeks' gestation b. 40 weeks' gestation c. 42 weeks' gestation d. 44 weeks' gestation

c. 42 weeks' gestation

Assessment reveals that a woman's cervix is approximately 1 cm in length. The nurse would document this as: a. 75% effaced b. 100% effaced c. 50% effaced d. 0% effaced

c. 50% effaced

The nurse is educating the family of a 2-day-old Chinese boy with myelomeningocele about the disorder and its treatment. Which of the following actions, involving an interpreter, can jeopardize the family's trust? a. Allowing too little appointment time for the translation b. Using a person who is not a professional interpreter c. Asking the interpreter questions not meant for the family d. Using a relative to communicate with the parents

c. Asking the interpreter questions not meant for the family

A pregnant client has come to a clinic for pelvic examination. What assessments should a nurse perform when examining external genitalia? a. Ensure that the cervix is smooth, long, thick and closed b. Asses for bluish coloration of cervix and vaginal mucosa c. Assess for any infection due to hematomas, varicosities and inflammation d. Assess for hemorrhoids, masses, prolapse and lesions

c. Assess for any infection due to hematomas, varicosities and inflammation

A 40-year-old pregnant client tells her nurse that she would like to give birth in a birthing center because she wants several friends and family members to be there and will have more freedom at the center. What would be the most important factor for the nurse to point out when discussing this option with the client? a. Birthing centers allow the client to give birth in any position b. Birthing centers allow the client to eat and move around during labor c. Birthing centers do not always have pediatricians on staff if the newborn has special needs d. Birthing centers limit the number of friends and family who can attend the birth

c. Birthing centers do not always have pediatricians on staff if the newborn has special needs

After teaching a group of breast-feeding women about nutritional needs, the nurse determines that the teaching was successful when the women state that they need to increase their intake of which nutrients? a. Carbohydrates and fiber b. Fats and vitamins c. Calories and protein d. Iron-rich foods and minerals

c. Calories and protein

Women who drink alcohol during pregnancy: a. Often produce more alcohol dehydrogenase b. Usually become intoxicated faster than before c. Can give birth to an infant with fetal alcohol spectrum disorder d. Gain fewer pounder throughout the gestation

c. Can give birth to an infant with fetal alcohol spectrum disorder

A group of women are attending a community presentation discussing the health concerns of women. Which of the following will be included as the leading cause of death for women? a. Lung cancer b. Cancers of the reproductive system c. Cardiovascular disease d. HIV infection

c. Cardiovascular disease

A nurse is applying ice packs to the perineal area of a client who has had a vaginal delivery. Which of the following interventions should the nurse perform to ensure that the client get the optimum benefits of the procedure? a. Apply ice packs directly to the perineal area b. Apply ice packs for 40 minutes continuously c. Ensure ice pack is changed frequently d. Use ice packs for a week after delivery

c. Ensure ice pack is changed frequently

A pregnant client and her husband have had a session with a genetic specialist. What is the role of the nurse after the client has seen a specialist? a. Identify the best decision to be taken for the client b. Refer the client to another specialist for a second opinion c. Review what has been discussed with the specialist d. Refer the client for further diagnostic and screening tests

c. Review what has been discussed with the specialist

Reva Rubin identified four major tasks that the pregnant woman undertakes to form a mutually gratifying relationship with her infant. What is "binding in"? a. Ensuring safe passage through pregnancy, labor, and birth b. Seeking acceptance of this infant by others c. Seeking acceptance of self as mother to infant d. Learning to give of oneself on behalf of the infant

c. Seeking acceptance of self as mother to infant

In the 1940s, Dr. Arnold Kegel introduced a technique to assist postpartum women with a common issue. What is the purpose of this technique? a. Strengthen the abdominal muscles to lessen the size of stretch marks b. Strengthen the joints and return them to their normal state c. Strengthen the pelvic floor muscles to reduce urinary incontinence d. Strengthen the uterine muscle fibers to return to their prepregnancy condition

c. Strengthen the pelvic floor muscles to reduce urinary incontinence

A man has just had a vasectomy. Which of the following post-procedure teachings should the nurse provide the client? Select all that apply. a. Complete sterility will occur approximately 1 week post-surgery. b. Bed rest should be maintained for a full 24 hours after the vasectomy. c. The surgeon should be contacted immediately if marked enlargement of the scrotal sac is noted after the procedure. d. An athletic supporter should be worn to protect the surgical site. e. Prostate-specific antigen testing (PSA) should be performed every year after a vasectomy.

c. The surgeon should be contacted immediately if marked enlargement of the scrotal sac is noted after the procedure. d. An athletic supporter should be worn to protect the surgical site.

The nurse is caring for a laboring client of Asian descent. The client appears to closely follow traditional cultural behaviors. Which of the following behaviors is most likely to be noted by the nurse? a. The woman is stoic during intense contractions, showing little emotion b. The woman reports a desire to have her extended family present during the labor and delivery c. The woman defers to her husband during interactions d. The woman wishes to labor unclothed

c. The woman defers to her husband during interactions

A couple has chosen fertility awareness as their method of contraception. The nurse explains that the unsafe period for them during the menstrual cycle would be which of the following? a. Midway between the normal menstrual cycle b. Six days before the onset of menstruation c. Three days before and three days after ovulation d. Five days after the first day of the menstrual cycle

c. Three days before and three days after ovulation

A mother has come to the clinic with her 13-year-old daughter to find out why she has not started her menses. After a thorough examination and history, genetic testing is order to rule out which abnormality? a. Cri du Chat syndrome b. Fragile X syndrome c. Turner Syndrome d. Klinefelter's syndrome

c. Turner Syndrome

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.

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. If air is entering the lungs of a newborn, his or her chest muscles are so elastic that the chest can be seen rising and falling with bag compression.

Cephalhematoma

collection of blood between periosteum and skull bone that it covers does not cross suture line results from trauma during birth

A newborn develops physiologic jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate? a. "There is some type of blood incompatibility between you and your baby that's causing the problem." b. "Your baby must have a blocked duct near his liver that's preventing the bilirubin from being excreted." c. "We really don't know why jaundice develops in some babies and not in others. We just know how to treat it." d. "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed."

d. "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed."

The nurse is caring for a client and her partner who are considering a future pregnancy. The client reports her last two pregnancies ended in stillbirth related to an underlying genetic disorder. What response by the nurse is most appropriate? a. "You should contact a geneticist after you become pregnant to closely watch your condition" b. "Your risk of repeated occurrences likely increases with future pregnancies" c. "You are strong to consider such an undertaking" d. "Consultation with a genetic counselor before you become pregnant would likely be beneficial"

d. "Consultation with a genetic counselor before you become pregnant would likely be beneficial"

A young couple desires to use aromatherapy during the labor and delivery of their child. You realize more education is needed after they make the following statement: a. "We are going to make our own custom blend" b. "We will ask our physician for suggestions" c. "We understand some oils should not be used during pregnancy" d. "We will just use whichever smells the best at that moment"

d. "We will just use whichever smells the best at that moment"

A nurse is caring for a 45-year-old pregnant client with a cardiac disorder, who has been instructed by her physician to follow Class I functional activity recommendations. The nurse correctly instructs the client to follow which limitations? a. "You will need to be on bedrest for the remainder of your pregnancy" b. "It is important for you to rest after any physical activity in order to prevent any cardiac complications" c. "It will be beneficial if you plan rest periods throughout your day" d. "You do not need to limit your physical activity unless you experience any problems such as fatigue, chest pain, or shortness of breath"

d. "You do not need to limit your physical activity unless you experience any problems such as fatigue, chest pain, or shortness of breath"

The nurse is counseling a couple, one of whom is affected by an autosomal dominant disorder. They express concerns about the risk of transmitting the disorder. What is the best response by the nurse regarding the risk that their baby may have the disease? a. "You have a one if four (25%) chance" b. "The risk is 12.5% or a one in eight chance" c. "The chance is 100%" d. "Your risk if 50%, or a one in two chance"

d. "Your risk if 50%, or a one in two chance"

To assist the preterm newborn, the nurse may be administering enteral feedings to help prepare the gut. At which rate will these feedings be administered? a. 1.5 to 2 mL/kg/h b. 1 to 1.5 mL/kg/h c. 2 to 2.5 mL/kg/h d. 0.5 to 1 mL/kg/h

d. 0.5 to 1 mL/kg/h

On examination, the nurse determines the fetus is at -1 station. He explains this means the fetus is: a. 1 cm above the pubic bone b. 1 cm below the pubic bone c. 1 cm below the ischial spines d. 1 cm above the ischial spines

d. 1 cm above the ischial spines

A pregnant woman with diabetes is having her glycosylated hemoglobin level evaluated. Which result would require the nurse to revise the client's plan of care? a. 6.5% b. 7.5% c. 5.5% d. 8.5%

d. 8.5%

A potential complication for the mother and fetus is Rh incompatibility; therefore assessment should include blood typing. If the mother is Rh negative, her antibody titer should be evaluated. If treatment with RhoGAM is indicated, when should it be given? a. At 32 weeks b. Only at birth c. At 36 weeks d. At 28 weeks

d. At 28 weeks

A female client is prescribed metronidazole for the treatment of trichomoniasis. Which of the following instructions should the nurse give the client undergoing treatment? a. Avoid extremes of temperature to the genital area b. Use condoms during sex c. Increase fluid intake d. Avoid alcohol

d. Avoid alcohol

When providing prenatal education to a pregnant woman with asthma, which of the following would be important for the nurse to do? a. Explain that she should avoid steroid during her pregnancy b. Demonstrate how to assess her blood glucose levels c. Teach correct administration of subcutaneous bronchodilators d. Ensure she seeks treatment for any acute exacerbation

d. Ensure she seeks treatment for any acute exacerbation

In an effort to decrease complications for the infant right after birth, which of the following would the nurse expect to administer for prophylaxis of potential eye conditions? a. Silver nitrate solution b. Vitamin K c. Gentamicin ophthalmic ointment d. Erythromycin ophthalmic ointment

d. Erythromycin ophthalmic ointment

Lochia rubra

deep-red mixture of mucus first 3 to 4 days

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

fontanels

__________ is the newborn's ability to process and respond to visual and auditory stimuli

habituation

Pelvic floor exercises

help to strengthen the pelvic floor muscles if done properly and regularly

Which assessment finding by the nurse would indicate that a neonate is being comforted?

increased oxygen saturation

A pregnant client is in labor. The nurse reviews a mother's prenatal history and finds that the client has diabetes mellitus. The nurse anticipates that the newborn is at risk for being

large-for-gestational-age.

A newborn is designated as very low birth weight. When weighing this newborn, the nurse would expect to find which weight?

less than 1,500 g

Following resuscitation, a 4-pound infant is admitted to the NICU. The nurse would initiate enteral feedings based on which assessment?

stabilized respiratory effort

Convection heat loss

the flow of heat from the body surface to COOLER AIR

Evaporation heat loss

the loss of heat that occurs when a liquid is converted to a vapor

The nurse is assessing a postterm newborn. Which finding would the nurse be least likely to assess?

thick umbilical cord

a woman has a episiotomy extending from vagina down to through the anal sphincter. What degree of tearing does this describe?

third degree

The nurse encourages a mother to rock, sing, and talk to her premature newborn. What is the purpose of these activities with the infant?

to develop trust in people

A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?

transverse lie A transverse lie, in which the fetus is more horizontal than vertical, occurs in women with pendulous abdomens, with uterine fibroid tumors that obstruct the lower uterine segment, with contraction of the pelvic brim, with congenital abnormalities of the uterus, or with hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelves.

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 Some common physical characteristics of preterm infants include: undescended testes in the male; absent to a few creases in the soles and palms; breast and nipples not clearly delineated; and abundant vernix caseosa.

measures to relieve engorment when breastfeeding

- frequent empying of breast by feeding or manual expression - warm showers

What percentage of neonates require some type of assistance to transition to extrauterine life?

10%

When counseling a mother about the immunologic properties of breast milk, the nurse would emphasize breast milk as a major source of which immunoglobulin? A) IgA B) IgG C) IgM D) IgE

A A major source of IgA is human breast milk. IgG, found in serum and interstitial fluid, crosses the placenta beginning at approximately 20 to 22 weeks' gestation. IgM is found in blood and lymph fluid and levels are generally low at birth unless there is a congenital intrauterine infection. IgE is not found in breast milk and does not play a major role in defense in the newborn.

A group of nursing students are reviewing the different types of congenital heart disease in infants. The students demonstrate a need for additional review when they identify which of the following as an example of increased pulmonary blood flow (left-to-right shunting)? A) Atrial septal defect B) Tetralogy of Fallot C) Ventricular septal defect D) Patent ductus arteriosus

Ans: B Feedback: Tetralogy of Fallot is a congenital heart condition that results from decreased, not increased, pulmonary blood flow. Atrial septal defect, ventricular septal defect, and patent ductus arteriosus are heart conditions that involve increased blood flow from higher pressure (left side of heart) to lower pressure (right side of heart), resulting in left-to-right shunting.

A nurse is developing a teaching plan for a postpartum woman who is breast-feeding about sexuality and contraception. Which of the following would the nurse most likely include? (Select all that apply.) A) Resumption of sexual intercourse about two weeks after delivery B) Possible experience of fluctuations in sexual interest C) Use of a water-based lubricant to ease vaginal discomfort D) Use of combined hormonal contraceptives for the first three weeks E) Possibility of increased breast sensitivity during sexual activity

Ans: B, C, E Typically, sexual intercourse can be resumed once bright-red bleeding has stopped and the perineum is healed from an episiotomy or lacerations. This is usually by the third to the sixth week postpartum. Fluctuations in sexual interest are normal. In addition, breast-feeding women may notice a let-down reflex during orgasm and find that breasts are very sensitive when touched by the partner. Precoital vaginal lubrication may be impaired during the postpartum period, especially in women who are breast-feeding. Use of water-based gel lubricants (KY jelly, Astroglide) can help. The Centers for Disease Control and Prevention recommend that postpartum women not use combined hormonal contraceptives during the first 21 days after childbirth because of the high risk for venous thromboembolism (VTE) during this period.

A newborn is diagnosed with meconium aspiration syndrome. When assessing this newborn, which of the following would the nurse expect to find? (Select all that apply.) A) Pigeon chest B) Prolonged tachypnea C) Intercostal retractions D) High blood pH level E) Coarse crackles on auscultation

Ans: B, C, E Feedback: Assessment findings associated with meconium aspiration syndrome include barrel-shaped chest with an increased anterior-posterior (AP) chest diameter (similar to that found in a client with chronic obstructive pulmonary disease), prolonged tachypnea, progression from mild to severe respiratory distress, intercostal retractions, end-expiratory grunting, and cyanosis. Coarse crackles and rhonchi are noted on lung auscultation.

A nurse is observing a postpartum woman and her partner interact with their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which of the following? (Select all that apply.) A) Frequently ask for the newborn to be taken from the room B) Identify common features between themselves and the newborn C) Refer to the newborn as having a monkey-face D) Make direct eye contact with the newborn E) Refrain from checking out the newborn's features

Ans: B, D Positive behaviors that indicate attachment include identifying common features and making direct eye contact with the newborn. Asking for the newborn to be taken out of the room, referring to the newborn as having a monkey-face and refraining from checking out the newborn's features are negative attachment behaviors.

A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction would be most appropriate to aid in relieving her discomfort? A) "Express some milk from your breasts every so often to relieve the distention." B) "Remove your bra to relieve the pressure on your sensitive nipples and breasts." C) "Apply ice packs to your breasts to reduce the amount of milk being produced." D) "Take several warm showers daily to stimulate the milk let-down reflex."

Ans: C For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the woman who was breast-feeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.

A newborn is suspected of developing persistent pulmonary hypertension. The nurse would expect to prepare the newborn for which of the following to confirm the suspicion? A) Chest x-ray B) Blood cultures C) Echocardiogram D) Stool for occult blood

Ans: C Feedback: An echocardiogram is used to reveal right-to-left shunting of blood to confirm the diagnosis of persistent pulmonary hypertension. Chest x-ray would be most likely used to aid in the diagnosis of RDS or TTN. Blood cultures would be helpful in evaluating for neonatal sepsis. Stool for occult blood may be done to evaluate for NEC.

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: A) Milia B) Mongolian spots C) Stork bites D) Birth trauma

B Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Milia are unopened sebaceous glands frequently found on a newborn's nose. Stork bites are superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling, and possible deformity.

Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: A) Habituation B) Motor maturity C) Orientation D) Social behaviors

B Motor maturity is evidenced by rhythmic, spontaneous movements. Habituation is manifested by the newborn's ability to respond to the environment appropriately. Orientation involves the newborn's response to new stimuli, such as turning the head to a sound. Social behaviors involve cuddling and snuggling into the arms of a parent.

The nurse is assessing a newborn's eyes. Which of the following would the nurse identify as normal? (Select all that apply.) A) Slow blink response B) Able to track object to midline C) Transient deviation of the eyes D) Involuntary repetitive eye movementE) Absent red reflex

B,C,D

The physician orders an ultrasound for a prenatal client prior to an amniocentesis. The nurse explains to the client that the purpose of the ultrasound is to: a)Determine the gestational sac volume. b)Measure the fetus's crown-rump length. c)Locate the placenta. d)Measure the fetus's biparietal diameter.

C During an amniocentesis, the physician scans the uterus using ultrasound to identify the fetal and placental positions and to identify adequate pockets of amniotic fluid. Determination of the gestational sac volume, measuring the crown-rump length, and measuring the biparietal diameter are aspects of assessing fetal well-being (biophysical profile, or BPP), and may or may not be done prior to the amniocentesis, depending on gestational age.

A prenatal client at 35 weeks gestation is scheduled for an amniocentesis to determine fetal lung maturity. The nurse expects the lecithin/sphingomyelin (L/S) ratio to be: a)0.5:1 b)1:1 c)2:1 d)3:1

C Early in pregnancy, the sphingomyelin concentration in amniotic fluid is greater than the concentration of lecithin, and so the L/S ratio is low (lecithin levels are low and sphingomyelin levels are high). At about 32 weeks gestation, sphingomyelin levels begin to fall and the amount of lecithin begins to increase. By 35 weeks gestation, an L/S ratio of 2:1 (also reported as 2.0) is usually achieved in the normal fetus.

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? A) To aid in maturing the newborn's sucking reflex B) To encourage the development of maternal antibodies C) To facilitate maternal-infant bonding D) To enhance the clearing of the newborn's respiratory passages

C Breast-feeding can be initiated immediately after birth. This immediate mother-newborn contact takes advantage of the newborn's natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn's temperature, blood glucose level, and respiratory rate. It is not associated with maturing the sucking reflex, encouraging the development of maternal antibodies, or aiding in clearing of the newborn's respiratory passages.

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: A) Molding B) Microcephaly C) Caput succedaneum D) Cephalhematoma

C Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of the skull.

A nurse is applyng ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? A. apply ice packs directly to the peri area b. apply ice packs for 40 minutes continuously c. ensure ice pack is changed frequently d. use ice packs for a week after birth

C it should be changed frequently to promote normal hygiene

When assessing a postpartum woman, which of the following would lead the nurse to suspect postpartum blues? a. Panic attacks and suicidal thoughts b. Anger toward self and infant c. Periodic crying and insomnia D. Obsessive thoughts and hallucinations

C. Periodic crying and insomnia are characteristics of postpartum blues, in addition to mood changes, irritability, and increased sensitivity.

A nurse is caring for a client in the postpartum period. Which of the following processes should the nurse identify as retrogressive processes involved in involution? (Select all)

Contraction of muscle fibers; catabolism, which reduces individual myometrial cells; regeneration of uterine epithelium.

What is the best intervention a nurse can utilize to promote parent-infant attachment? a)Allow for privacy. b)Contact support families that have been through the same diagnosis with their own child and allow time to discuss the situation. c)Provide an extensive handbook with information related to the preterm newborn. d)Encourage rooming in.

D All will help strengthen the attachment bond, but the best answer would be to encourage rooming in. Rooming in can provide a great opportunity for the stable preterm infant and family to get acquainted; it offers both privacy and readily available help.

A nurse, while examining a newborn, observes salmon patches on the nape and on the eyelids. Which of the following is the most likely cause of the salmon patches?"" a. Concentration of pigmented cells b. Eosinophils reacting to environment c. Immature autoregulation of blood flow d. Concentration of immature blood vessels"

D A concentration of immature blood vessels causes salmon patches. Mongolian spots are caused by a concentration of pigmented cells and usually disappear within the first 4 years of life. Erythema toxicum is caused by the newborn's eosinophils reacting to the environment as the immune system matures, and Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low-birth-weight newborns."

The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following would the nurse include in the teaching plan to facilitate suppression of lactation? A) Encouraging the woman to manually express milk B) Suggesting that she take frequent warm showers to soothe her breasts C) Telling her to limit the amount of fluids that she drinks D)Instructing her to apply ice packs to both breasts every other hour

D If the woman is not breast-feeding, relief measures for engorgement include wearing a tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, and not stimulating her breasts by squeezing or manually expressing milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was breast-feeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum women, regardless of the feeding method chosen

A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds based on the understanding that this most likely is due to which of the following? A) Placing the newborn prone after feeding B) Limited ability of digestive enzymes C) Underdeveloped pyloric sphincter D) Relaxed cardiac sphincter

D The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in their ability to digest complex carbohydrates and fats; this results in fatty stools, not regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric contents.

Which of the following would alert the nurse to suspect that a preterm newborn is in pain? A) Bradycardia B) Oxygen saturation level of 94% C) Decreased muscle tone D) Sudden high-pitched cry

D The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone.

A prenatal client in her second trimester is admitted to the maternity unit with painless, bright red vaginal bleeding. What test might the physician order? a)Alpha-fetoprotein (AFP) b)Contraction stress test (CST) c)Amniocentesis d)Ultrasound

D. An ultrasound for placenta location to rule out placenta previa would be ordered for a client who presents with painless, bright red vaginal bleeding. The ability to see the lower portion of the uterus and cervix with ultrasound is particularly important when vaginal bleeding is noted and placenta previa is the suspected cause. Alpha-fetoprotein (AFP) is a test used to screen for neural tube defects. A contraction stress test is ordered in the third trimester to evaluate the respiratory function of the placenta. Amniocentesis is a procedure used for genetic diagnosis or, in later pregnancy, for lung maturity studies.

Which of the following would lead the nurse to suspect that a postpartum woman was developing a complication? A. Fatigue and irritability B. Perineal discomfort and pink discharge C. Pulse rate of 60 bpm D. Swollen, tender, hot area on breast

D. A swollen, tender area on the breast would indicate mastitis, which would need medical intervention.

At birth, a term infant has irregular respirations and a weak cry. What is the sequence of events initiated by the nurse when caring for this infant?

Dry the infant, stimulate the infant, and keep the infant warm.

If the nurse manages a new infant with low blood sugar, which intervention would be appropriate to prevent hypoglycemia?

Feed the infant. The infant could be fed early either breast milk or formula to prevent low blood sugar. If unable to feed well, the infant can receive intravenous fluids. The other choices do not raise blood sugar.

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

Focus on decreasing blood viscosity by increasing fluid volume

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.

A newborn that has a surfactant deficiency will have which assessment noted on a physical exam: a) Pink skin b) Regular respirations c) Hypertension d) Grunting

Grunting Correct Explanation: Infants that are deficient in lung surfactant will show signs of respiratory distress: grunting, retracting, tachypnea, cyanosis, poor perfusion, hypotension, and skin mottling.

An obese woman with diabetes has just given birth to a term, large for gestational age (LGA) newborn. Which of the following conditions should the nurse most expect to find in this infant? a) Hypotension b) Hypertension c) Hypoglycemia d) Hyperglycemia

Hypoglycemia

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings does not confirm that this newborn is 12 days postmature? a) Increased amounts of vernix. b) Absence of lanugo. c) Meconium aspiration. d) Hypoglycemia.

Increased amounts of vernix. Correct Explanation: Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. A discrepancy between EDC and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress but does not coincide with gestation. The presence of lanugo is greatest at 28 to 30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation.

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? a) Serum glucose level of 60 mg/dl b) Jitteriness c) Hyperalert state d) Loud and forceful crying

Jitteriness Explanation: Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl. A hyperalert state in a neonate is more suggestive of neuralgic irritability and has no correlation to blood glucose levels. Weak crying is found in babies with hypoglycemia. A serum glucose level of 60 mg/dl is a normal level.

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

Less than 1,000 g. An extremely low-birth-weight newborn weighs less than 1,000 g. A very-low-birthweight newborn weighs less than 1,500 g. A large-for-gestational-age newborn typically weighs more than 4,000 g. A small-for-gestational-age newborn or a low-birth-weight newborn typically weighs about 2,500 g.

When preparing to resuscitate a preterm newborn, the nurse would perform which action first?

Place the newborn's head in a neutral position. When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation.

A client's gestational age is 38 weeks and 6 days. If the baby is born today, which of the following terms accurately describes the gestational age of the newborn? a) Term. b) Premature. c) Postterm. d) Preterm.

Term. Correct Explanation: A term infant is born after the beginning of week 38 and before week 42 of pregnancy. Premature or preterm refers to the birth prior to 37 completed weeks. Postterm refers to birth beyond 42 weeks.

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which of the following interventions should the nurse implement at this point? a) Take a blood sample b) Immediately suction the infant's airway c) Place the infant supine in a radiant heat warmer d) Tip the infant into an upright position

Tip the infant into an upright position

The nurse is assisting with the birth of the second child of a healthy young woman. Her pregnancy has been uneventful, and labor has been progressing well. The fetal head begins to emerge, but instead of continuing to emerge, it retracts into the vagina. What should the nurse try first?

Use McRobert's maneuver. This intervention is used with a large baby who may have shoulder dystocia and require assistance. The legs are sharply flexed, by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli's maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is out of the province of the LVN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

A client who has given birth a week ago complains to the nurse of discomfort when defecating and ambulating. The birth involved an episiotomy. Which of the following should the nurse suggest to the client to provide local comfort? (Select all)

Use of warm sitz baths; use of anesthetic sprays; use of witch hazel pads

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which of the following would the nurse do next? A) Document this as pseudomenstruation B) Notify the practitioner immediately C) Obtain a culture of the discharge D) Inspect for engorgement

a Document this as pseudomenstruation

Respiratory Distress Syndrome

a breathing disorder resulting from lung immaturity and lack of alveolar surfactant, which keeps the air sacs in the lungs from collapsing and allows them to inflate easily. *Without surfactant, the alveoli collapse at the end of expiration. *preterm newborns

Esophageal Atresia

a congenitally interrupted esophagus where the proximal and distal ends do not communicate; the upper esophageal segment ends in a blind pouch and the lower segment ends a variable distance above the diaphragm

transient tachypnea of the newborn

a self-limiting condition involving a mild degree of respiratory distress that requires minimal intervention, and resolves over 24 to 72 hours. * It is described as the retention of lung fluid or transient pulmonary edema. * It usually occurs within a few hours of birth and resolves by 72 hours of age.

The nurse is inspecting the external genitalia of a male newborn. Which of the following would alert the nurse to a possible problem? A) Limited rugae B) Large scrotum C) Palpable testes in scrotal sac D) Absence of engorgemen

a. Limited rugae

"As a part of the newborn assessment, the nurse determines the skin turgor. Which of the following nursing interventions is relevant when observing the turgor of the newborn's skin? a. Pinch skin and note return to original position. b. Examine for stork bites or salmon patches. c. Check for unopened sebaceous glands. d. Inspect for blue or purple splotches on buttocks."

a. Skin turgor is checked by pinching the skin over chest or abdomen and noting the return to original position; if the skin remains "tented" after pinching, it denotes dehydration. Stork bites or salmon patches, unopened sebaceous glands, and blue or purple splotches on buttocks are common skin variations not related to skin turgor."

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? a. 500 additional calories per day b. 1,000 additional calories per day c. 750 additional calories per day d. 250 additional calories per day

a. 500 additional calories per day

The nurse is developing a plan of care for clients seeking contraception information. Which of the following issues about the woman must the nurse consider before suggesting contraceptive choices? Select all that apply. a. Age. b. Ethical and moral beliefs. c. Sexual patterns. d. Socioeconomic status. e. Childbearing plans.

a. Age. b. Ethical and moral beliefs. c. Sexual patterns. d. Socioeconomic status. e. Childbearing plans.

It is important that nurses include a discussion about teratogens in their prenatal discussions to help prevent deformities or abnormalities. Teratogens may include which of the following? (Select all that apply.) a. Alcohol b. Multivitamin supplement c. Caustic chemicals d. Certain medications

a. Alcohol c. Caustic chemicals d. Certain medications

During pregnancy, one of progesterone's actions is to allow sodium to be "wasted" or lost in the urine. As the nurse, which hormone would you expect to see increased to help counteract this loss? a. Aldosterone b. Glycogen c. Cortisol d. ADH

a. Aldosterone

BPD is the result of lung injury in the preterm newborn. What can be done to reduce the incidence of BPD in the preterm newborn? a. Antepartal administration of steroids to the mother b. Mechanical ventilation of the newborn with 100% oxygen content c. Steroid injection at birth to all infants at risk for BPD d. Exogenous surfactant given to the mother before the baby's birth

a. Antepartal administration of steroids to the mother

A nurse is required to assess a client complaining of unusual vaginal discharge for bacterial vaginosis. Which of the following is a classic manifestation of this condition that the nurse should assess for? a. Characteristic "stale fish" odor b. Heavy yellow discharge c. Dysfunctional uterine bleeding d. Erythema in the vulvovaginal area

a. Characteristic "stale fish" odor

A client has presented with complaints that suggest a gonorrheal infection. After laboratory test confirm this diagnosis, the nurse understands that the client should also be treated for: a. Chlamydia b. Candidiasis c. Syphilis d. HPV

a. Chlamydia

A relatively common birth defect, hypospadias, occurs when the urethral meatus is found on the underside of the penis instead of at the tip. What frequently accompanies this disorder that can lead to problems urinating? a. Chordee b. Prepuce c. Priapism d. Cholangi

a. Chordee

Certain pharmaceuticals can be used to attain cervical ripening in women who need assistance in cervical ripening. They have also often continued into labor without further agents to stimulate uterine contractions. The nurse is aware that the FDA has approved the use of which of the following as a cervical ripening agent? a. Dinoprostone b. Misoprostol c. Oxytocin d. Magnesium sulfate

a. Dinoprostone

During a prenatal visit, you suspect a client is using CAM without informing the physician. You should: a. Encourage the client to let the doctor know b. Scold the client for jeopardizing herself and baby c. Document your suspicions on the chart d. Ask for her sources of information, to ensure it is accurate

a. Encourage the client to let the doctor know

After a discussion on the HPV vaccine, the nurse recognizes the discussion was successful because the students understand: a. They will need three injections over a 6-month period b. They will need one injection for lifetime protection c. They will need two injections over a 3-month period d. They will need one injection every 5 years

a. They will need three injections over a 6-month period

A woman has gotten pregnant with a Copper T intrauterine device (IUD) in place. The physician has ordered an ultrasound to be done to evaluate the pregnancy. The client asks the nurse why this is so important. The nurse should tell the woman that the ultrasound is done primarily for which of the following reasons? a. To assess for the presence of an ectopic pregnancy. b. To check the baby for serious malformations. c. To assess for pelvic inflammatory disease. d. To check for the possibility of a twin pregnancy.

a. To assess for the presence of an ectopic pregnancy.

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. a) high-pitched, shrill cry b) lethargy and stupor c) appearance of central cyanosis d) respiratory difficulty e) bulging fontanels

b) lethargy and stupor c) appearance of central cyanosis d) respiratory difficulty The features indicating hypoglycemia in LGA infants include lethargy, stupor, fretfulness, respiratory difficulty, and central cyanosis. The other features include poor feeding in a previously well feeding infant and weak, whimpering cry. High-pitched, shrill cry and bulging fontanels are seen in increased intracranial pressure following head trauma in LGA infants

A client has presented to the birthing center after her membranes ruptured. The primary focus of the nurse should be: a. Assessing for infection b. Assessing FHR c. Assessing maternal comfort d. Assessing fetal position

b. Assessing FHR

What are the causes of retinopathy of the preterm newborn? (Select all that apply) a. Insufficient oxygenation in an Isolette b. Assistive ventilation with high oxygen content c. Acidosis d. Alkalosis e. Shock

b. Assistive ventilation with high oxygen content c. Acidosis e. Shock

Within the first hour after birth, the nurse would expect to find the woman's fundus: a. Between the umbilicus and symphysis pubis b. At the level of the umbilicus c. 2 cm above the umbilicus d. One fingerbreadth below the umbilicus

b. At the level of the umbilicus

A couple desires to undergo genetic testing for Huntington disease. As their nurse, you recognize this is which type of genetic disorder? a. X-linked inherited disorder b. Autosomal dominant inherited disorder c. X-linked dominant inherited disorder d. Autosomal recessive inherited disorder

b. Autosomal dominant inherited disorder

The parents are upset their newborn has a cleft lip. When describing the treatment, the nurse should mention that surgical repair can be done: a. Between the age of 8 to 14 weeks b. Between the age of 6 to 12 weeks c. b. Between the age of 12 to 18 weeks d. Between the age of 10 to 16 weeks

b. Between the age of 6 to 12 weeks

The use of real-time ultrasonography allows the health care provider to obtain what type of information about the fetus? a. The effectiveness of neural tube defect treatment b. Biophysical profile c. The size and shape of placenta d. Chromosomal abnormalities

b. Biophysical profile

A nurse is caring for a client who has had an intrauterine fetal death with prolonged retention of the fetus. Which of the following signs and symptoms should the nurse watch for in a client to assess for an increased risk of disseminated intravascular coagulation? (Select all that apply) a. Hypertension b. Bleeding gums c. Tachycardia d. Acute renal failure e. Lochia less than usual

b. Bleeding gums c. Tachycardia d. Acute renal failure

A young mother has tested positive for HIV. When discussing the situation with the client, the nurse should advise the mother that she should avoid which of the following? a. Cesarean delivery b. Breast-feeding c. Future pregnancies d. Handling the infant with open sores

b. Breast-feeding

A female client who has just given birth has been reading health reports and is alarmed at the high rate of infant mortality. She seems anxious about the health of her child and wants to know ways to keep her baby from getting an infection. Which of the following instructions should the nurse offer? a. Place the infant on his or her back to sleep b. Breastfeed the infant c. Feed the infant foods high in starch d. Feed the infant liquids frequently

b. Breastfeed the infant

A fetus is in the LST position. The nurse interprets this as indicating which of the following as the presenting part? a. Chin b. Buttocks c. Fetal head d. Shoulder

b. Buttocks

A young couple are concerned that their fetus may be born with sickle cell anemia. You explain that the recessive traits of sickle-cell anemia can be determined by using which test? a. Blood typing b. Chorionic villus sampling c. Percutaneous umbilical blood sampling d. Amniocentesis

b. Chorionic villus sampling

The public health nurse is teaching a community class on fertility awareness-based methods. He realizes the couples are not understanding, when one decides to use the: a. Symptothermal method b. Coitus interruptus method c. Basal body temperature method d. Cervical mucus ovulation method

b. Coitus interruptus method

A healthy 28-year-old female client who has a sedentary lifestyle and is a chain smoker is seeking information about contraception. The nurse informs this client of the various options available and the benefits and the risks of each. Which of the following should the nurse recognize as contraindicated in the case of this client? a. The Lunelle injection or Depo-Provera b. Combination OCs c. A copper intrauterine device d. Implantable contraceptives

b. Combination OCs

A client reports that she has multiple sex partners and has a lengthy history of various pelvic infections. She would like to know if there is any temporary contraceptive method that would suit her condition. Which of the following should the nurse suggest for this client? a. Intrauterine device b. Condoms c. OCs d. Tubal ligation

b. Condoms

A nurse is educating a client about the various psychological feelings experienced by a woman and her partner during pregnancy. Which of the following is the feeling experienced by the expectant partner during the second trimester of pregnancy? a. Ambivalence along with extremes of emotions b. Confusion when dealing with the partner's mood swings c. Preparation for the new role as a parent and negotiating his or her role during labor d. Sympathetic response to the partner's pregnancy

b. Confusion when dealing with the partner's mood swings

You are preparing to release a client who underwent a percutaneous umbilical blood sampling earlier in the day. You remind the client about the signs to watch for that could indicate an infection and you remind the client for the need to: a. Soak in a tub of warm water if cramping occurs b. Count fetal movements as instructed c. Sleep sitting up for one night d. Remain on bed rest for 48 hours

b. Count fetal movements as instructed

A nurse has started working at a new clinic that treats local refugees. It is important for this nurse to recognize: a. Their ethnic background b. Cultural differences c. Their lack of understanding American ways d. Their language

b. Cultural differences

A nurse is collecting a culture sample to determine if a newborn has an early-onset infection. Which of the following would least likely be the causative agent? a. E.coli b. Cytomegalovirus c. Haemophilus influenzae d. Group B Streptococcus

b. Cytomegalovirus

A pregnant client's last menstrual period was March 10. Using Naegele's rule, the nurse knows that which of the following dates should be the child's estimated date of birth? a. January 7 b. December 17 c. February 21 d. January 30

b. December 17

You are putting together information for a nutrition class for nulliparous women. Some of the guidelines to include in this information are: (Select all that apply.) a. Consume at least one quart of water daily b. Decrease intake of saturated fats, trans fats, and cholesterol c. Increase caloric intake d. No alcohol e. Increase consumption of fruits, vegetables, and whole grains

b. Decrease intake of saturated fats, trans fats, and cholesterol d. No alcohol e. Increase consumption of fruits, vegetables, and whole grains

Which of the following body system changes would the nurse associate with menopause? (Select all that apply.) a. Moist, supple skin b. Decreased bone density c. Hot flashes d. Increased abdominal fat

b. Decreased bone density c. Hot flashes d. Increased abdominal fat

The nurse is aware that the infant's circulatory dynamics during transition can be greatly affected by which of the following actions? a. Giving the infant oxygen as needed b. Delayed clamping of the umbilical cord by 1 to 2 minutes c. Quickly clamping the cord as soon as possible d. Delayed clamping of the umbilical cord by at least 5 minutes

b. Delayed clamping of the umbilical cord by 1 to 2 minutes

A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client? a. Elevated liver enzymes b. Diminished reflexes c. Serum magnesium level of 6.5 mEq/L d. Seizures

b. Diminished reflexes

Some chromosomal abnormalities of number often result because of the failure of the chromosome pair to correctly separate during cell division. One type is referred to as polyploidy. As a nurse, you recognize this type usually results in: a. Edward Syndrome b. Early spontaneous abortion c. Down Syndrome d. Patau syndrome

b. Early spontaneous abortion

Your client is complaining at her prenatal visit that she cannot find any shoes that are comfortable. Assessment of her legs reveals dependent edema. You suggest she attempt to do the following to help reduce the edema: (Select all that apply.) a. When lying down, lie on the right side. b. Elevate feet and legs when sitting or lying. c. Wear knee-high support stockings. d. Drink 6 to 8 glasses of water each day. e. Avoid foods high in sodium, sugar, and fats.

b. Elevate feet and legs when sitting or lying. d. Drink 6 to 8 glasses of water each day. e. Avoid foods high in sodium, sugar, and fats.

The nurse is assessing a couple who have come to the health care facility because they have been unable to conceive a child. When assessing the woman, which factor would the nurse identify as increasing the woman's risk for infertility? a. Age of 25 years b. Endometriosis c. Dysmenorrhea d. Patent fallopian tubes

b. Endometriosis

A nurse in a local family maternity center is caring for a newborn with asphyxia. What nursing management is involved when treating a newborn with asphyxia? a. Ensure adequate tissue perfusion b. Ensure effective resuscitation measures c. Administer IV fluids d. Administer surfactant as ordered

b. Ensure effective resuscitation measures

A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client? a. Switch to breast milk b. Greenish stools with an unpleasant odor are normal c. Increase newborn's fluid intake d. Administer Vitamin K supplements

b. Greenish stools with an unpleasant odor are normal

In preparing for a class in teaching women and their partners, which of the following would be the most important to emphasize as helping to prevent postpartum complications? a. Adequate follow-up with their health care provider b. Handwashing c. Limiting contact with outsiders for the first week d. Ensure proper hydration

b. Handwashing

The nurse is participating in a poisoning prevention program. This activity is an example of which type of community-based nursing intervention? a. Health system referral b. Health education program c. Nutritional counseling d. Health screening

b. Health education program

A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes all except which of the following are potential concerns for the infant? a. Macrosomia b. Hydramnios c. Brachial plexus injuries d. Shoulder dystocia

b. Hydramnios

A nurse is assigned to take care of a high-risk newborn in the home environment after discharge. Which of the following conditions should the nurse monitor for in the infant? a. Anencephaly b. Hydrocephalus c. Fetal distress syndrome d. Spina bifida

b. Hydrocephalus

Which of the following conditions would most likely cause a pregnant woman with type 1 diabetes the greatest difficulty during her pregnancy? a. Placenta previa b. Hyperemesis gravidarum c. Abruptio placentae d. Rh incompatibility

b. Hyperemesis gravidarum

A mother presents to the clinic with her 15-year-old girl daughter complaining of amenorrhea. Which of the following might be a clue to the nurse as the cause? (Select all that apply.) a. Lack of exercise b. Hypothyroidism c. Extreme and rapid weight gain d. Pregnancy

b. Hypothyroidism c. Extreme and rapid weight gain d. Pregnancy

Cytomegalovirus infection can result in different congenital anomalies. It can also be transmitted via different routes. Permanent fetal disability can occur with which type of transmission of CMV? a. With any transmission b. In utero transmission c. During birth transmission d. After birth transmission

b. In utero transmission

When describing the events that occur in a newborn when he or she experiences a cold environment, which of the following would the nurse identify as occurring first? a. Increased cardiac output b. Increased release of norepinephrine c. Breakdown of triglycerides d. Increased blood flow through brown fat

b. Increased release of norepinephrine

A nurse is caring for a pregnant client. The initial interview reveals that the client is accustomed to drinking coffee at regular intervals. What possible effect of maternal coffee consumption during pregnancy should the nurse make the client aware of? a. Increased risk of heart disease b. Increased risk of anemia c. Increased risk of rickets d. Increased risk of scurvy

b. Increased risk of anemia

A nurse is teaching a couple about patterned breathing during their childbirth education. Which of the following techniques should the nurse suggest for slow-paced breathing? a. Inhale and exhale through the mouth at a rate of 4 breaths every 5 seconds b. Inhale slowly through nose and exhale through pursed lips c. Punctuated breathing by a forceful exhalation through pursed lips every few breaths d. Hold breath for 5 seconds after every 3 breaths

b. Inhale slowly through nose and exhale through pursed lips

A pregnant client has been diagnosed with gonorrhea. Which of the following nursing interventions should be performed to prevent gonococcal ophthalmia neonatorum in the baby? a. Administer cephalosporins to mother during pregnancy b. Instill a prophylactic agent in the eyes of the newborn c. Perform a cesarean operation to prevent infection d. Administer an antiretroviral syrup to the newborn

b. Instill a prophylactic agent in the eyes of the newborn

A nurse who is conducting sessions on preventing the spread of STIs in a particular community discovers that there is a very high incidence of hepatitis B in the community. Which of the following measures should she take to ensure the prevention of the disease? a. Ensure that the drinking water is disease free b. Instruct people to get vaccinated for hepatitis B c. Educate about risks of injecting drugs d. Educate teenagers to delay onset of sexual activity

b. Instruct people to get vaccinated for hepatitis B

Which of the following nursing interventions should the nurse perform when assessing fetal well-being through abdominal ultrasonography in a client? a. Inform the client that she may feel hot initially b. Instruct the client to refrain from emptying her bladder c. Instruct the client to report the occurrence of fever d. Obtain and record vital signs of the client

b. Instruct the client to refrain from emptying her bladder

A pregnant woman with sickle cell anemia comes to the emergency department. Which of the following would indicate the client is in crisis? (Select all that apply.) a. Increased skin turgor b. Joint pain c. Fever d. Fatigue e. Pallor

b. Joint pain c. Fever

Working in a reproductive health services clinic, the nurse is aware that the goal of the Human Genome project was to: a. Link specific abnormal genes to specific diseases for better treatment b. Map, sequence, and determine the function of all human genes c. Understand the underlying causes of diseases to transform health care d. Measure the impact of certain chromosomes on disease prevention

b. Map, sequence, and determine the function of all human genes

A postpartum client who has discharged home returns to the primary health care facility within 2 weeks with complaints of fever and pain in the breast. The client is diagnosed with mastitis. What education should the nurse give to the client for managing and preventing mastitis? a. Discontinue breastfeeding to allow time for healing b. Perform hand-washing before and after breastfeeding c. Avoid hot or cold compresses on the breast d. Discourage manual compression of breast for expressing milk

b. Perform hand-washing before and after breastfeeding

A pregnant client arrives at the maternity clinic for a routine check-up. The client has been reading books on pregnancy and wants to know ways to prevent the incidence of neural tube defects (NTDs) in her fetus. Which of the following should the nurse offer the client to prevent the occurrence of NTDs? a. Take vitamin E supplements b. Take folic acid supplements c. Consume legumes frequently d. Consume citrus fruits frequently

b. Take folic acid supplements

When caring for a client with reproductive issues, the nurse is required to clear up misconceptions. This enables new learning to take hold and a better client response to whichever methods are explored and ultimately selected. Which of the following are misconceptions that the nurse needs to clear up? Select all that apply. a. Breastfeeding does not protect against pregnancy b. Taking birth control pills protects against sexually transmitted infections (STIs) c. Douching after sex will prevent pregnancy d. Pregnancy can occur during menses e. Irregular menstruation prevents pregnancy

b. Taking birth control pills protects against sexually transmitted infections (STIs) c. Douching after sex will prevent pregnancy e. Irregular menstruation prevents pregnancy

When completing an assessment of a newborn, the nurse recognizes that the newborn is small-for-gestational-age based on which of the following? a. Weight of 3,000 g b. Weight of 2,400 g c. Weight of 2,800 g d. Weight of 2,600 g

b. Weight of 2,400 g

A 30-year-old client tells the nurse that she would like to use a contraceptive sponge but does not know enough about its use and whether it will protect her against STIs. Which of the following information should the nurse provide the client about using a contraceptive sponge? Select all that apply. a. Keep the sponge for more than 30 hours to prevent STIs b. Wet the sponge with water before inserting it c. Insert the sponge 24 hours before intercourse d. Leave the sponge in place for at least 6 hours following intercourse e. Replace sponge every 2 hours for the method to be effective

b. Wet the sponge with water before inserting it c. Insert the sponge 24 hours before intercourse d. Leave the sponge in place for at least 6 hours following intercourse

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? a. Immediately after birth, in the birthing area b. Within the first 2 to 4 hours, when the newborn is in the nursery c. Before the newborn is discharged d. The day after the newborn's birth

b. Within the first 2 to 4 hours, when the newborn is in the nursery

A woman who is HIV positive and receiving drug therapy comes to the clinic and says, "I have no appetite, and then when I do eat, I get sick to my stomach." Which suggestion would be least effective? a. "Try some high-protein drinks or foods." b. "Eat some dry crackers when you feel nauseated." c. "Drink fluids with anything that you eat." d. "Try eating small meals spaced throughout the day"

c. "Drink fluids with anything that you eat."

The parent of a newborn angrily asks the nurse, "Why would the doctor want to give my baby the vaccination for hepatitis B? It's a sexually transmitted disease, you know!" Which of the following is the best response by the nurse? a. "The hepatitis B vaccine is given to all babies. It is given because many babies get infected from their mothers during pregnancy." b. "It is important for your baby to get the vaccine in the hospital because the shot may not be available when your child gets older." c. "Hepatitis B can be a life-threatening infection that is contracted by contact with contaminated blood as well as sexually." d. "Most parents want to protect their children from as many serious diseases as possible. Hepatitis B is one of those diseases."

c. "Hepatitis B can be a life-threatening infection that is contracted by contact with contaminated blood as well as sexually."

A couple seeking contraception and infection-prevention counseling state, "We know that the best way for us to prevent both pregnancy and infection is to use condoms plus spermicide every time we have sex." Which of the following is the best response by the nurse? a. "That is correct. It is best to use a condom with spermicide during every sexual contact." b. "That is true, except if you have intercourse twice in one evening. Then you do not have to apply more spermicide." c. "That is not true. It has been shown that condoms alone are very effective and that the spermicide might increase the transmission of some viruses." d. "That is not necessarily true. Spermicide has been shown to cause cancer in men and women who use it too frequently."

c. "That is not true. It has been shown that condoms alone are very effective and that the spermicide might increase the transmission of some viruses."

A nurse working in a community health education program is assigned to educate community members about STIs. Which of the following nursing strategies should be adopted to prevent the spread of STIs in the community? a. Promote use of oral contraceptives b. Emphasize the importance of good body hygiene c. Discuss limiting the number of sex partners d. Emphasize not sharing personal items with others

c. Discuss limiting the number of sex partners

A client presents for her routine prenatal visit but on examination, the nurse notices multiple bruises in various stages of healing. Her most appropriate action would be: a. Call the authorities b. Send the client to the women's shelter c. Document findings d. Report her findings to the doctor

c. Document findings

A newly-pregnant 41-year-old woman is requesting genetic testing of her baby. She is concerned that due to her age, her baby has an increased risk of: a. Patau Syndrome b. Cystic fibrosis c. Down Syndrome d. Muscular dystrophy

c. Down Syndrome

A pregnant client with hyperemesis gravidarum needs advice on how to minimize nausea and vomiting. Which of the following instructions should a nurse give this client? a. Lie down or recline for at least 2 hours after eating b. Avoid dry crackers, toast and soda c. Eat small, frequent meals throughout the day d. Decrease intake of carbonated beverages

c. Eat small, frequent meals throughout the day

When providing preconception care to a client, which medication would the nurse identify as being safe to continue during pregnancy? a. Accutane b. Lithium c. Famotidine d. Warfarin

c. Famotidine

An adolescent woman confides to the school nurse that she is sexually active. The young woman asks the nurse to recommend a "very reliable" birth control method, but she refuses to be seen by a gynecologist. Which of the following methods would be best for the nurse to recommend? a. Contraceptive patch. b. Withdrawal method. c. Female condom. d. Contraceptive sponge.

c. Female condom.

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright-red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which of the following would the nurse suspect? a. Uterine inversion b. Uterine atony c. Laceration d. Hematoma

c. Laceration

The nurse teaches a couple that the diaphragm is an excellent method of contraception providing that the woman does which of the following? a. Does not use any cream or jelly with it. b. Douches promptly after its removal. c. Leaves it in place for 6 hours following intercourse. d. Inserts it at least 5 hours prior to having intercourse.

c. Leaves it in place for 6 hours following intercourse.

The health care provider is recommending induction of labor for a 42-week nulliparous client. All except which of the following will be important to assess before induction? a. Fetal dating b. Amniotic fluid studies c. Leopold position d. Bishop scoring

c. Leopold position

A 2-month-old infant is admitted to a local health care facility after experiencing heat loss. Which of the following manifestations should the nurse observe in the infant in order to confirm the occurrence of cold stress? a. Change in color of the urine b. Increase in the body temperature c. Lethargy and hypotonia d. Change in the color of the skin

c. Lethargy and hypotonia

A nurse is explaining the many changes a newborn will go through during his or her first couple of weeks after birth. The nurse may explain how the functions of the placenta are taken over by which organ? a. Intestine b. Cardiovascular system c. Liver d. Kidneys

c. Liver

A pregnant client is admitted to a maternity clinic for childbirth. Which assessment finding indicates that the client's fetus is in the transverse lie position? a. Long axis of fetus is at 60 degrees to that of client b. Long axis of fetus is parallel to that of the client c. Long axis of fetus is perpendicular to that of client d. Long axis of fetus is at 45 degrees to that of client

c. Long axis of fetus is perpendicular to that of client

While assessing a postpartum multiparous woman, the nurse detects a boggy uterus midline 2 cm above the umbilicus. Which intervention would be priority? a. Assessing vital signs immediately b. Measuring her next urinary output c. Massaging her fundus d. Notifying the woman's obstetrician

c. Massaging her fundus

A nurse is caring for a newborn whose chest x-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. The nurse should prepare for the assessment of which of the following dangerous conditions when providing care to this newborn? a. Choanal atresia b. NEC c. Meconium aspiration syndrome d. Hyperbilirubinemia

c. Meconium aspiration syndrome

Which condition would be missed if a newborn were screened before he had tolerated protein feedings for at least 48 hours? a. Hypothyroidism b. Cystic fibrosis c. Phenylketonuria d. Sickle cell disease

c. Phenylketonuria

On a routine hematocrit screen during a prenatal visit, you notice that the client is mildly anemic. When discussing this with the couple, the husband hints that she might be eating unusual things. As a nurse, you recognize which of the following disorders should the client be evaluated for? a. Food allergy b. Vegan diet c. Pica d. Food cravings

c. Pica

A woman who has a history of cocaine abuse gives birth to a newborn. Which of the following would the nurse expect to assess in the newborn? (Select all that apply.) a. Prolonged periods of sleeping b. Flaccid positioning c. Piercing cry d. Inconsolable e. Poor sucking

c. Piercing cry d. Inconsolable e. Poor sucking

A nurse is caring for a newborn with esophageal atresia that had occurred during early fetal development. What should the preoperative nursing care for the newborn focus on? a. Document the amount and color of drainage b. Administer antibiotics and total parenteral nutrition as ordered c. Prevent aspiration by elevating the head of the bed d. Provide colostomy care if required

c. Prevent aspiration by elevating the head of the bed

Providing nursing care to a newborn born with a congenital cardiac anomaly can be a challenging task. What is a priority component of providing nursing care to the newborn with a congenital cardiac anomaly? a. Oversee laboratory procedures b. Accompany the newborn to all radiologic examinations c. Prevent pain as much as possible d. Teach the parents to take pulse and blood pressure measurements

c. Prevent pain as much as possible

The nurse uses a radiant warmer to transport a newborn to reduce heat loss via which mechanism? a. Convection b. Evaporation c. Radiation d. Conduction

c. Radiation

On a routine prenatal visit, the nurse is concerned that the client may have a substance abuse problem. To ensure proper care of her client, the nurse should: a. Report the client to Child Protective Services b. Document the suspicions in the client's record c. Refer the client to available community services d. Refer the client to an inpatient program

c. Refer the client to available community services

What is essential for the nurse to teach a woman who has just had an intrauterine device (IUD) inserted? a. Palpate her lower abdomen each month to check the patency of the device. b. Remain on bed rest for 24 hours after insertion of the device. c. Report any complaints of painful intercourse to the physician. d. Insert spermicidal jelly within 4 hours of every sexual encounter.

c. Report any complaints of painful intercourse to the physician.

The AAP recommends that all newborns be placed on their backs to sleep to reduce the risk of: a. Respiratory distress syndrome b. Bottle mouth syndrome c. Sudden infant death syndrome d. GI regurgitation syndrome

c. Sudden infant death syndrome

When designing a class on the history of childbirth and maternal care, which of the following would the nurse include in describing care during the 18th century? a. Streptococci were identified as the major cause of puerperal fever. b. Heavy doses of narcotics were used during labor. c. The majority of births occurred in the home with female midwives. d. Books on childbirth education became readily available.

c. The majority of births occurred in the home with female midwives.

Which of the following observations would suggest that placental separation is occurring? a. Uterus stops contracting altogether b. Umbilical cord pulsations stop c. Uterine shape changes to globular d. Maternal blood pressure drops

c. Uterine shape changes to globular

A client in her 39th week of gestation complains of swelling in her legs after standing for long periods of time. The nurse recognizes that these factors increase the client's risk for which of the following conditions? a. Hemorrhoids b. Embolism c. Venous thrombosis d. Supine hypotension syndrome

c. Venous thrombosis

A nurse is caring for a female client who has a history of recurring vulvovaginal candidiasis. Which of the following instructions should the nurse include in the teaching session with the client? a. Use superabsorbent tampons b. Douche the affected area regularly c. Wear white, 100% cotton underpants d. Increase intake of carbonated drinks

c. Wear white, 100% cotton underpants

A nurse is obtaining the genetic history of a pregnant client by questioning family members. Which of the following questions is most appropriate for the nurse to ask? a. Were there any instances of premature birth in the family? b. Is there a family history of drinking or drug abuse? c. What was the cause and age of death of deceased family members? d. Were there any instances of depression during pregnancy?

c. What was the cause and age of death of deceased family members?

A client has been discharged from the hospital after a cesarean birth. Which of the following is the most appropriate time for scheduling a follow-up appointment for the client? a. Within 3 weeks of hospital discharge b. Between 4 and 6 weeks after hospital discharge c. Within 2 weeks of hospital discharge d. Within 1 week of hospital discharge

c. Within 2 weeks of hospital discharge

The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which of the following best indicates what the mother would observe after several days? a. Greenish, tarry, thick black stool b. Thin, yellowish, seedy brown stool c. Yellow-green, pasty, unpleasant-smelling stool d. Sour-smelling, yellowish-gold stool

c. Yellow-green, pasty, unpleasant-smelling stool

A nurse is caring for a full-term neonate who's receiving phototherapy for hyperbilirubinemia. Which finding should the nurse report immediately? a) Bronze-colored skin b) Greenish stool c) Maculopapular rash d) Absent Moro reflex

d) Absent Moro reflex An absent Moro reflex, lethargy, and seizures are symptoms of bilirubin encephalopathy, which can be life-threatening. A maculopapular rash, greenish stools, and bronzecolored skin are minor adverse effects of phototherapy that should be monitored but don't require immediate intervention

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? a) A capillary hematocrit needs to be rechecked in 8 hours to see if it increases or decreases. b) This is a normal lab value, and no intervention is needed. c) The infant is suffering from polycythemia and needs a partial exchange transfusion to prevent complications. d) The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.

d) The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is. A hematocrit above 65% is considered elevated and polycythemia is diagnosed. However, to get an accurate venous reading, a central venous hematocrit needs to be drawn to verify the value. Drawing the blood in 8 hours does not address the problem at present, and the infant does not need a partial exchange transfusion immediately. Health care providers will decide if this is needed after monitoring the infant for symptoms and following the central hematocrit levels.

A couple is trying to decide where they want to have their baby: at home, a birthing center, or the hospital. As their nurse, which of the following statements would indicate they need more information to decide: a. "We live just five miles from the hospital, so we would have time to get to the hospital if needed." b. "We understand the situation can change and we need to have a plan B in place." c. "Okay, we understand this is a low-risk birth" d. "My mom had me at home, so I can have this baby at home as well."

d. "My mom had me at home, so I can have this baby at home as well."

Which of the following instructions would the nurse include in the teaching plan for a mother of a substance-exposed newborn? a. "Place your newborn on his side when you feed him." b. "Avoid using a pacifier because it can damage his teeth in the future." c. "Let your newborn sleep in his stomach for naps but not at night." d. "Wrap him snugly in a blanket and gently rock him if he's fussy."

d. "Wrap him snugly in a blanket and gently rock him if he's fussy."

A G3,P2 woman arrives at the birthing center stating that she has been in labor for the past 18 hours. To rule out a potential protracted disorder the nurse is aware that which of the following criteria for cervical dilation is used? a. 1.75 cm per hour b. 1.25 cm per hour c. 1.0 cm per hour d. 1.5 cm per hour

d. 1.5 cm per hour

A nurse is caring for a client with hyperemesis gravidarum. Which of the following should be the first choice for fluid replacement for this client? a. Total parenteral nutrition b. IV fluids and antiemetics c. Percutaneous endoscopic gastrostomy d. 5% dextrose in lactated Ringer solution with vitamins and electrolytes

d. 5% dextrose in lactated Ringer solution with vitamins and electrolytes

A woman with systemic lupus erythematosus is interested in preconception counseling to discuss her desire to get pregnant. As the nurse, you explain it would be best if she is symptom-free or in remission for how long before getting pregnant? a. 3 months b. 9 months c. 12 months d. 6 months

d. 6 months

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

d. 8 points

The client has heard of extended oral contraceptive regimens and desires more information. The nurse explains that these regimens consist of _____ consecutive days of active combination pills, followed by ____ days of placebo pills. a. 42; 4 b. 56; 5 c. 70; 6 d. 84; 7

d. 84; 7

When providing care to a newborn with necrotizing enterocolitis (NEC), which of the following would the nurse need to report immediately? a. Stools negative for blood b. Bowel sounds in all four quadrants c. Decrease in abdominal girth d. Abdomen appearing red and shiny

d. Abdomen appearing red and shiny

A nurse is caring for a client who has been treated for a deep vein thrombosis. Which teaching point should the nurse stress when discharging the client? a. Avoid using compression stockings b. Plan long rest periods throughout the day c. Avoid using products containing aspirin d. Avoid use of oral contraceptives

d. Avoid use of oral contraceptives

A couple is seeking family planning advice. They are newly married and wish to delay childbearing for at least 3 years. The woman, age 26, G0 P0, has no medical problems and does not smoke. She states, however, that she is very embarrassed when she touches her vagina. Which of the following methods would be most appropriate for the nurse to suggest to this couple? a. Diaphragm. b. Cervical cap. c. Intrauterine device (IUD). d. Birth control pills (BCP).

d. Birth control pills (BCP).

A client with a history of substance abuse during her pregnancy has delivered a newborn in a local health care facility. What is the most appropriate nursing intervention when caring for the newborn of this client? a. Encourage early initiation of feedings b. Monitor the newborn's cardiovascular status c. Supplement breast milk with formula d. Check newborn's skin turgor and fontanels

d. Check newborn's skin turgor and fontanels

When assessing the following women, which would the nurse identify as being at the greatest risk for preterm labor? a. Woman who had twins in a previous pregnancy b. Client living in a large city c. Woman working full time as a computer programmer d. Client with a history of a previous preterm birth

d. Client with a history of a previous preterm birth

Which of the following is an example of developmental care in the NICU? a) Giving medications b) Holding the infant c) Giving a bath d) Cluster care and activities

d. Cluster care and activities Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which of the following would be important to collect first? a. STI status b. HIV status c. Urinalysis d. Coagulation studies

d. Coagulation studies

After assessing the processing labor of a client, the nurse suspects the fetus is in a persistent occiput posterior position. Which of the following findings would lead the nurse to suspect that? a. Contractions most forceful in the middle of uterus rather than the fundus b. Lack of cervical dilation past 2 cm c. Fetal buttocks as the presenting part d. Complaints of severe back pain

d. Complaints of severe back pain

A 35-year-old G2, P2 client presents to her postpartum appointment with vague complaints. The nurse suspects postpartum depression after the client expresses all except which of the following? a. Appears detached from infant b. Change in sleep c. Lack of energy and motivation d. Feels like eating all the time

d. Feels like eating all the time

When discussing the various risks to the mother and infant, the nurse should include that which of the following is the leading cause of mental retardation in the United States? a. Genetic anomalies b. Pregnancy Category X medications c. Maternal drug addiction d. Fetal alcohol spectrum disorder

d. Fetal alcohol spectrum disorder

A school nurse notices that a young woman with scars on the knuckles of her right hand runs to the bathroom each day immediately after eating a high-calorie lunch. Which of the following actions by the nurse is appropriate at this time? a. Nothing, because her behavior is normal. b. Question the young woman to see if she is being abused. c. Recommend that the young woman be seen by her doctor. d. Follow the young woman to the bathroom.

d. Follow the young woman to the bathroom.

The nurse recognizes that to assess the fluid status of a newborn, which of the following is the best indicator? a. Fluid intake b. Skin turgor c. Urinary output d. Fontanels

d. Fontanels

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which of the following methods of anesthesia is to be administered to the client? a. Local infiltration b. Epidural block c. Regional anesthesia d. General anesthesia

d. General anesthesia

When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse? a. At the fifth intercostal space at the right midclavicular line b. At the midsternum, just below the suprasternal notch c. At the third intercostal space adjacent to the midclavicular line d. Lateral to the midclavicular line at the fourth intercostal space

d. Lateral to the midclavicular line at the fourth intercostal space

The nurse met four clients in the family planning clinic today. It would be most appropriate for the nurse to recommend the intrauterine device (IUD) to which of the clients? a. Unmarried, 22-year-old, recent college graduate. b. Married, 24-year-old, G0 P0000. c. Unmarried, 25-year-old, history of chlamydia. d. Married, 26-year-old, G3 P2102.

d. Married, 26-year-old, G3 P2102.

A client in her 29th weeks of gestation complains of dizziness and clamminess when assuming a supine position. During the assessment, the nurse observes there is a marked decrease in the client's blood pressure. Which of the following interventions should the nurse implement to help alleviate this client's condition? a. Keep the client's legs slightly elevated b. Place the client in an orthopneic position c. Keep the head of the client's bed slightly elevated d. Place the client in the left lateral position

d. Place the client in the left lateral position

The nurse is teaching a young woman how to use the female condom. Which of the following should be included in the teaching plan? a. Reuse female condoms no more than five times. b. Refrain from using lubricant because the condom may slip out of the vagina. c. Wear both female and male condoms together to maximize effectiveness. d. Remove the condom by twisting the outer ring and pulling gently.

d. Remove the condom by twisting the outer ring and pulling gently.

The nurse in a pediatric clinic is caring for a 9-year-old girl who has been diagnosed with gonorrhea. Which of the following actions is appropriate for the nurse to take? a. Notify the physician so the child can be admitted to the hospital. b. Discuss with the girl the need to stop future sexual encounters. c. Question the mother about her daughter's menstrual history. d. Report the girl's medical findings to child protective services.

d. Report the girl's medical findings to child protective services.

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which of the following marks the importance of the pauses between contractions during labor? a. Effacement and dilation of the cervix b. Shortening of the upper uterine segment c. Reduction in length of the cervical canal d. Restoration of blood flow to uterus and placenta

d. Restoration of blood flow to uterus and placenta

Nurses in community care setting spend more time in management and supervisory roles than their counterparts in the acute care setting. Which of the following activities is part of case management? a. Helping a grandmother to learn a procedure b. Assessing the sanitary conditions of the home c. Establishing eligibility for a Medicaid waiver d. Scheduling speech and respiratory therapy services

d. Scheduling speech and respiratory therapy services

When dealing with a pregnant adolescent, the nurse assists the client to integrate the tasks of pregnancy while at the same time fostering development of which of the following? a. Dependence b. Trust c. Autonomy d. Self-identity

d. Self-identity

Once the infant is born, there are several actions that must be completed. Which of the following would the nurse do first after the birth of a newborn? a. Obtain footprints b. Administer vitamin K c. Apply identification bracelet d. Suction the mouth and nose

d. Suction the mouth and nose

A woman in labor is receiving oxytocin. Which of the following would the nurse need to be alert for potentially occurring? a. Hypertension b. Uterine hypotonicity c. Fetal distress d. Water intoxication

d. Water intoxication

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin, with so little muscle. The nurse responds based on the understanding about which of the following? a. A postterm newborn has begun to break down red blood cells more quickly. b. The newborn was exposed to an infection while in utero. c. The newborn aspirated meconium, causing the wasted appearance. d. With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

d. With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

A nurse has to address a group of women on the issue of women's health during their reproductive years. Which of the following reasons does the nurse provide regarding the need for comprehensive, community-centered care to women during their reproductive years? a. Women have more health problems during their reproductive years b. Women are more susceptible to stress during their reproductive years c. Women's immune system weakens immediately after birth d. Women's health care needs change with their reproductive goals

d. Women's health care needs change with their reproductive goals

Nursing care of the pregnant woman often involves the management of medications. When assessing the client history, the nurse should verify that the client is not taking any prescribed medications of which category? a. B b. C c. D d. X

d. X

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of a breastfed newborn? (Select all that apply). a. Formed in consistency b. Completely odorless c. Firm in shape d. Yellowish gold color e. Stringy to pasty consistency

d. Yellowish gold color e. Stringy to pasty consistency

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? (Select all that apply.) a. Formed in consistency b. Completely odorless c. Firm in shape d. Yellowish gold color e. Stringy to pasty consistency

d. Yellowish gold colore. Stringy to pasty consistency

A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication should she receive? a. Nevirapine b. Maraviroc c. Tenofovir d. Zidovudine

d. Zidovudine

A nurse is transporting a neonate from the nursery to the mother's room. The nurse ensures that the neonate is moved in a warmed isolette to prevent heat loss by which mechanism?a. radiationb. evaporationc. conductiond. convection

d. convection

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

d. lethargy and hypotonia

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

d. lethargy and hypotonia

Infants of diabetic mothers can be large for gestational age (LGA) or small for gestational age (SGA). Why?

depending on the vascular impact of this chronic systemic disease on the mother prior to and during the pregnancy.

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?

diabetes Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position not with shoulder dystocia.

The nurse recognizes that maternal factors can increase the chance of a large-for-gestational-age newborn. When reviewing maternal history, the nurse would interpret which factors as placing a newborn at risk for being LGA? Select all that apply.

diabetes mellitus multiparity history of postdates gestation

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

expiratory grunting. Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).

A common symptom that would alert you that a preterm infant is developing respiratory distress syndrome is a) inspiratory "crowing." b) expiratory grunting. c) inspiratory stridor. d) expiratory wheezing.

expiratory grunting. Correct Explanation: Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).

Second-degree laceration

extends through perineal muscles *episiotomy

The ___________________ is the fetal structure within the heart that allows blood to cross immediately to the left side and bypass the pulmonary circuit. When left side pressure gradients increase at birth, this opening closes, thereby establishing an extrauterine circulation pattern.

foramen ovale

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

intercostal and substernal retractions Meconium aspiration is when the infant passes the first stool in utero and some of stool particles are ingested into the lungs at birth. This can cause the infant to be in distress displayed by mild cyanosis, tachypnea, retractions, hyperinflated chest, and hypercapnia.

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 Although there is some dispute regarding whether all infants with meconium staining need intubation, those with severe staining are usually intubated and meconium is suctioned from their trachea and bronchi. The nurse should not administer oxygen under pressure (bag and mask) until a meconium stained infant has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the infant and flicking the sole of his foot are methods of stimulating breathing in an infant experiencing apnea.

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 Newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. The preterm newborn has an inadequate supply of brown fat. The preterm newborn also has decreased muscle tone and thus cannot assume the flexed fetal position, which reduces the amount of skin exposed to a cooler environment. Preterm newborns have large body surface areas compared to their weight. A term infant with RH factor will not be at any greater risk for heat lost and stabilized with age. A 2-day-old infant postmaturity would not be stabilized and would initially be at risk for heat loss. The diabetic infant is stabilized and heat loss is not a great concern.

The small-for-gestational-age neonate is at increased risk for which complication during the transitional period?

polycythemia, probably due to chronic fetal hypoxia The small-for-gestational-age neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores.

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

postterm

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

postterm These characteristics are consistent with a postterm infant. An SGA infant has some of these same characteristics but does not exhibit long fingernails. A preterm infant has translucent skin, and an LGA infant has excessive subcutaneous fat.

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer?

radiation Radiation heat loss results from the transfer of heat in an environment from warmer to cooler objects that are not in direct contact with each other.

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

respiratory distress syndrome

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

respiratory distress syndrome Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid?

respiratory rate of 60 to 70 bpm

When caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant?

rocking and massaging

Lochia serosa

second stage pinkish brown 3 to 10 days postpartum

A nurse is caring for a baby girl born at 34 weeks' gestation. Which feature should the nurse identify as those of a preterm newborn?

shiny heels and palms A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in postterm newborns and is excessive in premature infants.

newborn normal glucose levels

should remain above 40 mg/dL

First-degree laceration

skin only

Which factors could increase the risk of overheating in a newborn?

• Isolette that is too warm • Limited ability of diaphoresis

A nurse is caring for a large for gestational age newborn. Which of the following signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply. a) Bulging fontanels b) Lethargy and stupor c) Appearance of central cyanosis d) Respiratory difficulty e) High-pitched shrill cry

• Lethargy and stupor • Respiratory difficulty • Appearance of central cyanosis Explanation: The features indicating hypoglycemia in LGA infants include lethargy, stupor and fretfulness, respiratory difficulty and central cyanosis. The other features include poor feeding in a previously well feeding infant and weak whimpering cry. High-pitched shrill cry and bulging fontanels are seen in increased intracranial pressure following head trauma in LGA infants.

Which of the following would the nurse expect to find in a newborn who is considered small for gestational age? Select all that apply. a) Dry or thin umbilical cord b) Poor muscle tone over buttocks c) Sunken abdomen d) Increased subcutaneous fat stores e) Narrow skull sutures

• Sunken abdomen • Poor muscle tone over buttocks • Dry or thin umbilical cord

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."

The mother of a preterm infant tells her nurse that she would like to visit her newborn who is in the neonatal intensive care unit (NICU). Which response by the nurse would be the most appropriate?

"Certainly. You will need to wash your hands and gown before you can hold him, however." The nurse should be certain the parents of a high-risk newborn are kept informed of what is happening with their child. They should be able to visit the special nursing unit to which the newborn is admitted as soon and as often as they choose, and, after washing and gowning, hold and touch their newborn, both actions which help make the child's birth more real to them.

The mother of a preterm infant tells her nurse that she would like to visit her newborn, who is in the neonatal intensive care unit (NICU). Which of the following would be the most appropriate response by the nurse? a) "I'm sorry. You may not visit your son until he has been released from the NICU." b) "Certainly. You may only observe the child from a distance, however, as his immune system is still not developed adequately." c) "Certainly. You will need to wash your hands and gown before you can hold him, however." d) "I'm sorry. You may not visit the NICU, but we can arrange to have your son brought to your room so that you can hold him."

"Certainly. You will need to wash your hands and gown before you can hold him, however." Correct Explanation: Be certain the parents of a high-risk newborn are kept informed of what is happening with their child. They should be able to visit the special nursing unit to which the newborn is admitted as soon and as often as they choose, and, after washing and gowning, hold and touch their newborn, both actions which help make the child's birth more real to them.

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." Birth weight variations include appropriate for gestational age (AGA), which describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age. This describes approximately 80% of all newborns. Infants who are appropriate for gestational age have lower morbidity and mortality than other groups.

A client is 32 weeks pregnant and sent home on modified bedrest for preterm labor. She is on tocolytics and wants to know when she can have intercourse again with her husband. What is the most appropriate response by the nurse?

"That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor." The client needs to be on pelvic rest until the health care provider says otherwise. The intercourse can cause excitability in the uterus and encourage cervical softening and should be avoided unless the provider says it is safe.

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."

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 preterm newborn's immune system is very immature, increasing his or her susceptibility to infections. A deficiency of IgG may occur because transplacental transfer does not occur until after 34 weeks' gestation. This protection is lacking if the baby was born before this time. Preterm newborns have an impaired ability to manufacture antibodies to fight infection if they were exposed to pathogens during the birth process. The preterm newborn's thin skin and fragile blood vessels provide a limited protective barrier, adding to the increased risk for infection. Anticipating and preventing infections is the goal with frequent hand washing while caring for them the gold standard. Breastfeeding will eventually establish some protective mechanisms.

The nurse weighs the new infant and calculates his measurements. The new mom asks, "Did my baby grow well? The doctor said he was LGA: What does that mean?" What is the best explanation? a) "That means your baby is over the 90th percentile for weight." b) "That means your baby is in the 5th percentile for weight." c) "That means that your baby is lazy sometimes." d) "That means your baby is average for gestational age."

"That means your baby is over the 90th percentile for weight." Correct Explanation: LGA stands for large for gestational age. These infants are over the 90th percentile for weight. The other choices are not over the 90th percentile for weight or describe a different characteristic.

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

"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." The ability of the placenta to provide adequate oxygen and nutrients to the fetus after 42 weeks' gestation is thought to be compromised, leading to perinatal mortality and morbidity. After 42 weeks the placenta begins aging. Deposits of fibrin and calcium, along with hemorrhagic infarcts, occur and the placental blood vessels begin to degenerate. All of these changes affect diffusion of oxygen to the fetus. As the placenta loses its ability to nourish the fetus, the fetus uses stored nutrients to stay alive, and wasting occurs.

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."

A client who had a vaginal delivery 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate?

"Within 1 -3 weeks, your diaphragm should return to normal and your breathing will feel like it did before your pregnancy."

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

"Your infant cannot sustain respirations yet due to the lack of assistance from surfactant." Preterm infants lacks surfactant to lower the surface tension in the alveoli and stabilize them to prevent their collapse. Even if preterm newborns can initiate respirations, they have a limited ability to retain air due to insufficient surfactant. Preterm newborns develop atelectasis quickly without alveoli stabilization. Fetal circulation patterns persist.

A client just gave birth to a preterm baby in the 30th week of gestation. Which nursing measures does the nurse acticipate for this newborn? Select all that apply.

- Dress the baby in a stockinette cap. - Place the baby under isolette care. - Estimate the urinary flow by weighing the diaper. The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature on a regular basis. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the newborn. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing.

Women Who Should Not Breast-Feed?

- Drugs such as antithyroid drugs, antineoplastic drugs, alcohol - herpes infection on the breasts - street drugs - HIV positive - newborn with an inborn error of metabolism such as galactosemia or phenylketonuria (PKU) - active tuberculosis, or a mother with - serious mental health disorder that would prevent her from remembering to feed the infant consistently

The nurse assesses an infant's body temperature as 36.2°C during an extended resuscitation at birth. What consequence of a temperature of 36.2°C would the nurse anticipate? Select all that apply.

- Fetal shunts remain open. - Anaerobic glycolysis occurs. - Pulmonary perfusion decreases. - Metabolism increases. When the infant's body temperature is low, the fetal shunts remain open, anaerobic glycolysis occurs, pulmonary perfusion decreases, and metabolism increases. Immune function is not a consequence of body temperature.

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply.

- Increase the infant's hydration. - Offer early feedings. - Initiate phototherapy. Hydration, early feedings, and phototherapy are measures that the nurse should take to reduce bilirubin levels in the newborn. Stopping breastfeeding or administering vitamin supplements will not help reduce bilirubin levels in the infant.

A newborn is being admitted to the intensive care unit with the diagnosis of postterm infant. Which nursing actions would be the priority? Select all that apply.

- Monitor for hematocrit levels. - Assess for jaundice. - Initiate blood glucose monitoring. Postterm infants will need to be monitored closely for alterations in blood glucose levels. The nurse should also closely assess the postterm infant for polycythemia, which contributes to hyperbilirubinemia, so jaundice would be an indicator. Hct levels will be monitored for the risk of polycythemia. RH factor is not a priority. Temperature monitoring is a standard for all newborn care.

The nurse caring for a small for gestational age newborn in the specialcare nursery. What characteristics are commonly documented? Select all that apply.

- Poor skin turgor - Sparse or absent hair - Diminished muscle tissue Characteristics of the small for gestational age newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts.

Recommended exercises for the first few weeks postpartum include:

- abdominal breathing - head lifts - modified sit-ups - double knee roll - and pelvic tilt

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 Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation. Distraction using colorful mobiles or objects also can be effective.

What is a classic sign of neonatal respiratory distress syndrome? Select all that apply.

- expiratory grunting - nasal flaring - retractions - tachypnea The classic signs of respiratory distress are expiratory grunting, nasal flaring, retractions, and tachypnea.

When examining a neonate, which characteristic would indicate to the nurse that the infant is preterm? Select all that apply.

- extended extremities - covered with vernix caseosa - absence of sole creases Characteristics of a preterm infant include extended extremities, presence of vernix caseosa, and the absence of sole creases. A bulging fontanelle is a sign of increased intracranial pressure. An elevated breast bud is consistent with a full-term infant.

An assessment done in the neonatal intensive care unit reveals a small-for-gestational age newborn. Which findings would the nurse connect with this gestational age variation? Select all that apply.

- sunken abdomen - decreased amount of breast tissue - poor muscle tone Nursing assessment of a small for gestational age newborn would include a newborn presenting with decreased amount of breast tissue; scaphoid abdomen (sunken appearance); wide skull sutures; poor muscle tone; and thin umbilical cord. Color would not be ruddy unless polycythemia was present.

nursing management for Periventricular-Intraventricular Hemorrhage

- vitamin K - correct anemia, acidosis and hypotension - administer fluids SLOW - Keep the newborn in a flexed, contained position with the head elevated to prevent or minimize fluctuations in intracranial pressure - measure head circunference daily - reduse stimulation

Omphalocele

-An omphalocele is a defect of the umbilical ring that allows evisceration of the abdominal contents into an external peritoneal sac. - Defects vary in size; they may be limited to bowel loops or may include the entire gastrointestinal tract and liver

postpartum assessment:

-During the first hour: every 15 minutes - During the second hour: every 30 minutes - During the first 24 hours: every 4 hours After 24 hours: every 8 hours

how to reduce bilirubin levels in newborn?

-Encourage early initiation of feedings to prevent hypoglycemia and provide protein to maintain the albumin levels to transport bilirubin to the liver. *every 2- 3 hours *phototherapy

nutrition for newborn with Necrotizing Enterocolitis

-If NEC is suspected, immediately STOP enteral feedings until a diagnosis is made. -Iv fluids -IV antibiotic

phototherapy nursing care

-Nursing responsibilities include ensuring effective irradiance delivery, maximizing skin exposure, providing eye protection and eye care, careful attention to thermoregulation, monitoring the newborn's skin turgor, maintaining adequate hydration, promoting elimination, and supporting parent-infant interaction

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g and the physician orders 0.1 mL/kg. How much would the nurse administer? a) 0.1 mL b) 0.25 mL c) 0.20 mL d) 0.15 mL

0.15 mL

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g and the physician orders 0.1 mL/kg. How much would the nurse administer? a) 0.25 mL b) 0.20 mL c) 0.15 mL d) 0.1 mL

0.15 mL Correct Explanation: The newborn weighs 1,500 g, which is equivalent to 1.5 kg. Calculating the dose based on 0.1 mL/kg, the nurse would administer 0.15 mL.

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule?

1 cm/hour for cervical dilation In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

engrossment behaviors

1. Visual awareness of the newborn 2. Tactile awareness of the newborn 3. Perception of the newborn as perfect 4. Strong attraction to the newborn 5Awareness of distinct features of the newborn 6. Extreme elation 7. Increased sense of self-esteem

When a newborn is experiencing physiologic depression, the Apgar characteristics will disappear in a predictable manner. In which order, will these characteristics disappear? a. Respiratory effort decreases b. Heart rate decreases c. Pink coloration is lost d. Muscle tone decreases e. Reflex irritability is noted

1. c. Pink coloration is lost 2. a. Respiratory effort decreases 3. d. Muscle tone decreases 4. e. Reflex irritability is noted 5. b. Heart rate decreases

How to assess the uterus?

1. have the woman empty her bladder before assessing the fundus and auscultate her bowel sounds prior to uterine palpation. 2. Using a two-handed approach with the woman in the supine position with her knees flexed slightly and the bed in a flat position or as low as possible 3. palpate the abdomen gently, feeling for the top of the uterus while the other hand is placed on the lower segment of the uterus to stabilize it 4. Once the fundus is located, place your index finger on the fundus and count the number of fingerbreadths between the fundus and the umbilicus (1 fingerbreadth is approximately equal to 1 cm)

phases of maternal adaptation

1. taking-in maternal role phase - the mother is very passive and is dependent on others to care for her for the first 24 to 48 hours after giving birth. 2. taking-hold phase - Gaining self-confidence - mother demonstrates mastery over her own body's functioning and feels more confident in caring for her newborn. 3. letting go phase -when the mother begins to separate from the symbiotic relationship she and her newborn enjoyed during pregnancy and birth. -Resuming control over her life would denote the second phase of taking hold, during which the mother does resume control over her life and gains self-confidence in her newborn care.

What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 10% c) 5% d) 50%

10%

What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 5% c) 10% d) 50%

10%

What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 10% c) 50% d) 5%

10% Correct Explanation: Most newborns transition to extrauterine life smoothly. About 10% of newborns need some type of assistance at birth.

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity?

100 mm Hg

The nurse is teaching an uncircumcised male to use a condom. Which of the following information should be included in the teaching plan? 1. Apply mineral oil to the shaft of the penis after applying the condom. 2. Pull back the foreskin before applying the condom. 3. Create a reservoir at the tip of the condom after putting it on. 4. Wait five minutes after ejaculating before removing the condom.

2. Pull back the foreskin before applying the condom.

Normal chest circumference

32-38 cm

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?

45 ml urine output in 2 hours The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.

Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a) 6 b) 3 c) 4 d) 5

5

The nurse is reviewing four prenatal charts. Which client would be an appropriate candidate for a contraction stress test (CST)? a)A client with intrauterine growth retardation b)A client with multiple gestation c)A client with an incompetent cervix d)A client with placenta previa

A A contraction stress test (CST) is indicated for a client with intrauterine growth retardation (IUGR), because it will assess the respiratory function of the placenta, which may be adversely affected by the conditions causing IUGR. The CST is contraindicated in third-trimester bleeding from placenta previa or marginal abruptio placentae, previous cesarean with classical incision (vertical incision in the fundus of the uterus), premature rupture of the membranes, incompetent cervix, anomalies of the maternal reproductive organs, history of preterm labor (if being done prior to term), or multiple gestation.

Understanding the transition from intrauterine to extrauterine life, what intervention is most appropriate when working with an infant of a diabetic mother? a)Frequent blood glucose checks b)Obtain lab work to look for infection. c)Administer IV fluids. d)Place under radiant warmer bed immediately.

A Lab work, IV fluids, and the radiant warmer bed may all be required for interventions for the infant of a diabetic mother, if the infant is experiencing signs of respiratory distress or sepsis. Frequent blood glucose checks need to be completed to ensure that blood glucose levels are being maintained.

A woman who delivered a healthy newborn several hours ago asks the nurse, "Why am I perspiring so much?" The nurse integrates knowledge that a decrease in which hormone plays a role in this occurrence? A) Estrogen B) hCG C) hPL D) Progesterone

A Although hCG, hPL, and progesterone decline rapidly after birth, decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy.

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which of the following would the nurse expect to find when assessing the client's fundus? A) Cannot be palpated B) 2 cm below the umbilicus C) 6 cm below the umbilicus D) 10 cm below the umbilicus

A By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

The nurse interprets which of the following as evidence that a client is in the taking-in phase? A) Client states, "He has my eyes and nose." B) Client shows interest in caring for the newborn. C) Client performs self-care independently. D) Client confidently cares for the newbor

A During the taking-in phase, new mothers when interacting with their newborns spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn such as "he has my nose" or "his fingers are long like his father's." Independence in self-care and interest in caring for the newborn are typical of the taking-hold phase. Confidence in caring for the newborn is demonstrated during the letting-go phase.

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following? A) Normal progression of behavior B) Probable hypoglycemia C) Physiological abnormality D) Inadequate oxygenation

A From 30 to 120 minutes of age, the newborn enters the second stage of transition, the period of decreased responsiveness or that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.

An LGA newborn has a blood glucose level of 23 mg/dL. Which of the following would the nurse do next? A) Administer intravenous glucose immediately. B) Feed the newborn 2 ounces of formula. C) Initiate blow-by oxygen therapy. D) Place the newborn under a radiant warmer.

A If an LGA newborn's blood glucose level is below 25 mg/dL, the nurse should institute immediate treatment with intravenous glucose regardless of the clinical symptoms. Oral feedings would be used to maintain the newborn's glucose level above 40 mg/dL. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress.

A nurse is developing a teaching plan for the parents of a newborn. When describing the neurologic development of a newborn to his parents, the nurse would explain that the development occurs in which fashion? A) Head-to-toe B) Lateral-to-medial C) Outward-to-inward D) Distal-to-caudal

A Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center to outside) pattern.

A new mother asks the nurse, "Why has my baby lost weight since he was born?" The nurse integrates knowledge of which of the following when responding to the new mother? A) Insufficient calorie intake B) Shift of water from extracellular space to intracellular space C) Increase in stool passage D) Overproduction of bilirubin

A Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth, shifting of intracellular water to extracellular space, and insensible water loss. Stool passage and bilirubin have no effect on weight loss.

While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen level and duration closely based on the understanding that the newborn is at risk for which of the following? A) Retinopathy of prematurity B) Metabolic acidosis C) Infection D) Cold stress

A Oxygen therapy has been implicated in the pathogenesis of retinopathy of prematurity (ROP). Therefore, the nurse monitors the newborn's oxygen therapy closely. Metabolic acidosis may occur due to anaerobic metabolism used for heat production. Infection may occur for numerous reasons, but they are unrelated to oxygen therapy. Cold stress results from problems due to the preterm newborn's inadequate supply of brown fat, decreased muscle tone, and large body surface area.

The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot when evaluating which reflex? A) Babinski B) Tonic neck C) Stepping D) Plantar grasp

A The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The tonic neck reflex is tested by having the newborn lie on his back and then turn his head to one side. The stepping reflex is elicited by holding the newborn upright and inclined forward with the soles of the feet on a flat surface. The plantar grasp reflex is elicited by placing a finger against the area just below the newborn's toes.

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as indicating which of the following? A) A good time to initiate breast-feeding B) The period of decreased responsiveness preceding sleep C) The need to be alert for gagging and vomiting D) Evidence that the newborn is becoming chilled

A The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breast-feeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. There is no indication that the newborn may experience gagging or vomiting. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as: A) A good time to initiate breast-feeding B) The period of decreased responsiveness preceding sleep C) The need to be alert for gagging and vomiting D) Evidence that the newborn is becoming chilled

A The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breast-feeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. There is no indication that the newborn may experience gagging or vomiting. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8 degrees F, an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes highest priority? A) Hypothermia related to heat loss during birthing process B) Impaired parenting related to addition of new family member C) Risk for deficient fluid volume related to insensible fluid loss D) Risk for infection related to transition to extrauterine environment

A The newborn's heart rate is slightly below the accepted range of 120 to 160 beats/minute; the respiratory rate is at the high end of the accepted range of 30 to 60 breaths per minute. However, the newborn's temperature is significantly below the accepted range of 97.7 to 99.7 degrees F. Therefore, the priority nursing diagnosis is hypothermia. There is no information to suggest impaired parenting. Additional information is needed to determine if there is a risk for deficient fluid volume or a risk for infection.

When planning the care for a SGA newborn, which action would the nurse determine as a priority? A) Preventing hypoglycemia with early feedings B) Observing for respiratory distress syndrome C) Promoting bonding between the parents and the newborn D) Monitoring vital signs every 2 hours

A With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for respiratory distress, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn.

While assessing a full-term neonate, which symptom would cause the nurse to suspect a neurologic impairment? a) A positive Babinski's reflex b) A positive rooting reflex c) A weak sucking reflex d) Startle reflex in response to a loud noise

A weak sucking reflex Correct Explanation: Normal neonates have a strong, vigorous sucking reflex. The rooting reflex is present at birth and disappears when the infant is between ages 3 and 4 months. A positive Babinski's reflex is present at birth and disappears by the time the infant is age 2. The startle reflex is present at birth and disappears when the infant is approximately age 4 months.

A nurse is teaching a group of student nurses about amniotic fluid. Which of the following statements by the student nurse reflects an understanding of the fetus's contribution to the quality of amniotic fluid? Select all that apply. a) "The fetus contributes to the volume of amniotic fluid by excreting urine." b) "Approximately 400 mL of amniotic fluid flows out of the fetal lungs each day." c) "The fetus swallows about 600 mL of the fluid in 24 hours." d) "A fetus can move freely and develop normally, even if there is no amniotic fluid."

A, B, C "The fetus contributes to the volume of amniotic fluid by excreting urine." Approximately 400 mL of amniotic fluid flows out of the fetal lungs each day. The fetus swallows about 600 mL of the fluid in 24 hours. A normal volume of amniotic fluid is necessary for good fetal movement. Normal movement is necessary for good musculoskeletal development.

The nurse is teaching a prenatal client about chorionic villus sampling (CVS). The nurse correctly teaches the client that risks related to CVS include which of the following? Select all that apply. a)Intrauterine infection b)Rupture of membranes c)Maternal hypertension d)Spontaneous abortion

A, B, D Risks of CVS include failure to obtain tissue, rupture of membranes, leakage of amniotic fluid, bleeding, intrauterine infection, maternal tissue contamination of the specimen, and Rh alloimmunization. CVS testing has a higher rate of spontaneous abortion than amniocentesis. Other complications include fetal limb defects and abnormalities of the fetal face and jaw.

A nurse is teaching a group of first-trimester prenatal clients about the discomforts of pregnancy. A client asks the nurse, "What causes my nausea and vomiting?" The nurse responds indicating which of the following as being contributing factors to first-trimester emesis? Select all that apply. a) Human chorionic gonadotropin b) Estrogen c) Alterations in carbohydrate metabolism d) Prostaglandins

A, C Nausea and vomiting are common during the first trimester because of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. Estrogen stimulates the growth of the uterus and breast tissue. Prostaglandins stimulate uterine contractions.

A nursing instructor is preparing a class on newborn adaptations. When describing the change from fetal to newborn circulation, which of the following would the instructor most likely include? (Select all that apply.) A) Decrease in right atrial pressure leads to closure of the foramen ovale. B) Increase in oxygen levels leads to a decrease in systemic vascular resistance. C) Onset of respirations leads to a decrease in pulmonary vascular resistance. D) Increase in pressure in the left atrium results from increases in pulmonary blood flow. E) Closure of the ductus venosus eventually forces closure of the ductus arteriosus.

A, C, D, E When the umbilical cord is clamped, the first breath is taken and the lungs begin to function. As a result, systemic vascular resistance increases and blood return to the heart via the inferior vena cava decreases. Concurrently with these changes, there is a rapid decrease in pulmonary vascular resistance and an increase in pulmonary blood flow (Boxwell, 2010). The foramen ovale functionally closes with a decrease in pulmonary vascular resistance, which leads to a decrease in right-sided heart pressures. An increase in systemic pressure, after clamping of the cord, leads to an increase in left-sided heart pressures. Ductus arteriosus, ductus venosus, and umbilical vessels that were vital during fetal life are no longer needed.

A newborn is experiencing cold stress. Which of the following would the nurse expect to assess? (Select all that apply.) A) Respiratory distress B) Decreased oxygen needs C) Hypoglycemia D) Metabolic alkalosis E) Jaundice

A, C, E Cold stress in the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production.

A prenatal client at 22 weeks gestation is scheduled for an amniocentesis. Which nursing action would apply to any client undergoing this procedure? Select all that apply. a)Assess for bleeding. b)Administer Rh immune globulin to the client. c)Cleanse skin with alcohol. d)Assess vital signs and fetal heart rate.

A, D The skin is cleaned with a betadine solution. The use of a local anesthesia at the needle insertion site is optional. A 22-gauge needle is then inserted into the uterine cavity and amniotic fluid is withdrawn. After 15-20 mL of fluid has been removed, the needle is withdrawn and the site is assessed for streaming (movement of fluid), which is an indication of bleeding. The fetal heart rate and maternal vital signs are then assessed. Rh immune globulin is given only to all Rh-negative women.

After teaching a group of nursing students about variations in newborn head size and appearance, the instructor determines that the teaching was successful when the students identify which of the following as a normal variation? (Select all that apply) A) Cephalhematoma B) Molding C) Closed fontanels D) Caput succedaneum E) Posterior fontanel diameter 1.5 cm

A,B,D

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

A. The foramen ovale is the fetal structure within the heart that allows blood to cross immediately to the left side and bypass the pulmonary circuit. When left side pressure gradients increase at birth, this opening closes, thereby establishing an extrauterine circulation pattern.

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

Administer 0.5 ml/kg/hr of breast milk enterally

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?

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

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate? a) Monitor the infant's hematocrit levels closely b) Place the infant on a radiant warmer c) Administer PO glucose water immediately d) Administer dextrose intravenously

Administer dextrose intravenously

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?

Administer oxytocin diluted as a "piggyback" infusion. Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

What factors influence the outcomes of the at-risk newborn? Select all that apply. a)Birth weight b)Gestational age c)Type and length of newborn illness d)Environmental factors e)Maternal factors

All are correct. Maternal factors such as age and parity, newborn weight, and gestational age also influence outcomes, as do environmental factors such as exposure to environmental dangers (toxic chemicals and illicit drugs). Evaluation; Physiological Integrity; Analysis

The nurse is assisting parents who have just experienced the death of their twin infants. What would be the most appropriate action for the nurse?

Allow the parents to be present at medical rounds and the resuscitation. In times of impending death and loss initiate spiritual comfort by calling the hospital clergy only if appropriate; offer to pray with the family only if appropriate. Have the parents participate in early and repeated care conferencing to reduce family stress. Allow the family to be present at both medical rounds and resuscitation; provide explanations of all procedures. Encourage the father to cry and grieve with his partner.

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

A postpartum woman who is breast-feeding tells the nurse that she is experiencing nipple pain. Which of the following would be least appropriate for the nurse to suggest? A) Use of a mild analgesic about 1 hour before breast-feeding B) Application of expressed breast milk to the nipples C) Application of glycerin-based gel to the nipples D) Reinstruction about proper latching-on technique

Ans: A Nipple pain is difficult to treat, although a wide variety of topical creams, ointments, and gels are available to do so. This group includes beeswax, glycerin-based products, petrolatum, lanolin, and hydrogel products. Many women find these products comforting. Beeswax, glycerin-based products, and petrolatum all need to be removed before breast-feeding. These products should be avoided in order to limit infant exposure because the process of removal may increase nipple irritation. Mild analgesics such as acetaminophen or ibuprofen are considered relatively safe for breast-feeding mothers. Applying expressed breast milk to nipples and allowing it to dry has been suggested to reduce nipple pain. Usually the pain is due to incorrect latch-on and/or removal of the nursing infant from the breast. Early assistance with breast-feeding to ensure correct positioning can help prevent nipple trauma. In addition, applying expressed milk to nipples and allowing it to dry has been suggested to result in less nipple pain for many women.

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take? A) Document the finding, as it is a normal finding at this time. B) Contact the physician, as it indicates early DIC. C) Contact the physician, as it is a first sign of postpartum eclampsia. D) Obtain an order for a CBC, as it suggests postpartum anemia.

Ans: A Pulse rates of 40 to 80 beats per minute (bmp) are normal during the first week after birth. This pulse rate is called puerperal bradycardia. During pregnancy, the heavy gravid uterus causes a decreased flow of venous blood to the heart. After giving birth, there is an increase in intravascular volume. The cardiac output is most likely caused by an increased stroke volume from the venous return now. The elevated stroke volume leads to a decreased heart rate.

The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following would be a priority? A) Placing the call light within her reach B) Teaching her how the sitz bath works C) Telling her to use the sitz bath for 30 minutes D) Cleaning the perineum with the peri-bottle

Ans: A Tremendous hemodynamic changes are taking place within the woman, and safety must be a priority. Therefore, the nurse makes sure that the emergency call light is within her reach should she become dizzy or lightheaded. Teaching her how to use the sitz bath, including using it for 15 to 20 minutes, is appropriate but can be done once the woman's safety is ensured. The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can be done once the woman's safety needs are met.

A nurse is developing a plan of care for a newborn with omphalocele. Which of the following would the nurse include? A) Placing the newborn into a sterile drawstring bowel bag B) Using clean technique for dressing changes C) Preparing the newborn for incision and drainage D) Instituting gavage feedings

Ans: A Feedback: An infant with an omphalocele is placed in a sterile drawstring bowel bag that maintains a sterile environment for the exposed contents, allows visualization, reduces heat and moisture loss, and allows heat from radiant warmers to reach the newborn. The newborn is placed feet-first into the bag and the drawstring is secured around the torso. Strict sterile technique is necessary to prevent contamination of the exposed abdominal contents. An orogastric tube attached to low suction is used to prevent intestinal distention. IV therapy is administered to maintain fluid and electrolyte balance and provide a route for antibiotic therapy. Surgery is done to repair the defect, not incise and drain it.

The nurse is assessing a preterm newborn who is in the neonatal intensive care unit (NICU) for signs and symptoms of overstimulation. Which of the following would the nurse be least likely to assess? A) Increased respirations B) Flaying hands C) Periods of apnea D) Decreased heart rate

Ans: A Feedback: Conversely, overstimulation may have negative effects by reducing oxygenation and causing stress. A newborn reacts to stress by flaying the hands or bringing an arm up to cover the face. When overstimulated, such as by noise, lights, excessive handling, alarms, and procedures, and stressed, heart and respiratory rates decrease and periods of apnea or bradycardia may occur.

A nurse is developing a plan of care for a preterm infant experiencing respiratory distress. Which of the following would the nurse be least likely to include in this plan? A) Stimulate the infant with frequent handling. B) Keep the newborn in a warmed isolette. C) Administer oxygen using an oxygen hood. D) Give gavage or continuous tube feedings.

Ans: A Feedback: For the preterm infant experiencing respiratory distress, the nurse would expect to handle the newborn as little as possible to reduce oxygen requirements. Other appropriate interventions include keeping the infant warm, preferably in a warmed isolette to conserve the baby's energy and prevent cold stress; administer oxygen using an oxygen hood; and provide energy through calories via intravenous dextrose or gavage or continuous tube feedings to prevent hypoglycemia.

An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting symptoms of hypoglycemia. Which of the following would the nurse do next? A) Administer intravenous glucose immediately. B) Feed the newborn 2 ounces of formula. C) Initiate blow-by oxygen therapy. D) Place the newborn under a radiant warmer.

Ans: A Feedback: If an LGA newborn's blood glucose level is below 40 mg/dL and is symptomatic, continuous infusion of parenteral glucose is needed. Supervised breast-feeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress.

A newborn with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which of the following would the nurse anticipate as possibly necessary for this newborn? A) Extracorporeal membrane oxygenation (ECMO) B) Respiratory support with a ventilator C) Insertion of a laryngoscope for deep suctioning D) Replacement of an endotracheal tube via x-ray

Ans: A Feedback: If conventional measures are ineffective, then the nurse would need to prepare the newborn for ECMO. Hyperoxygenation, ventilatory support, and suctioning are typically used initially to promote tissue perfusion. However, if these are ineffective, ECMO would be the next step.

After determining that a newborn is in need of resuscitation, which of the following would the nurse do first?4A) Dry the newborn thoroughly B) Suction the airway C) Administer ventilations D) Give volume expanders

Ans: A Feedback: If resuscitation is need, the nurse must first stabilize the newborn by drying the newborn thoroughly with a warm towel and provide warmth by placing him or her under a radiant heater to prevent rapid heat loss. Next the newborn's head is placed in a neutral position to open the airway and the airway is cleared with a bulb syringe or suction catheter. Breathing is stimulated. Often handling and rubbing the newborn with a dry towel may be all that is needed to stimulate respirations. Next ventilations and then chest compressions are done. Administration of epinephrine and/or volume expanders is the last step.

While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen therapy duration closely based on the understanding that the newborn is at risk for which of the following? A) Retinopathy of prematurity B) Metabolic acidosis C) Infection D) Cold stress

Ans: A Feedback: Oxygen therapy has been linked the pathogenesis of retinopathy of prematurity and is associated with the duration of oxygen use rather than the concentration of oxygen. Therefore, the nurse monitors the newborn's oxygen therapy closely. Metabolic acidosis may occur due to anaerobic metabolism used for heat production. Infection may occur for numerous reasons, but they are unrelated to oxygen therapy. Cold stress results from problems due to the preterm newborn's inadequate supply of brown fat, decreased muscle tone, and large body surface area.

After teaching the parents of a newborn with retinopathy of prematurity (ROP) about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A) "Can we schedule follow-up eye examinations with the pediatric ophthalmologist now?" B) "We can fix the problem with surgery." C) "We'll make sure to administer eye drops each day for the next few weeks." D) "I'm sure the baby will grow out of it."

Ans: A Feedback: Parents of a newborn with suspected retinopathy of prematurity (ROP) should schedule follow-up vision screenings with a pediatric ophthalmologist every 2 to 3 weeks, depending on the severity of the findings at the initial examination.

While reviewing a newborn's medical record, the nurse notes that the chest x-ray shows a ground glass pattern. The nurse interprets this as indicative of: A) Respiratory distress syndrome B) Transient tachypnea of the newborn C) Asphyxia D) Persistent pulmonary hypertension

Ans: A Feedback: The chest x-ray of a newborn with RDS reveals a reticular (ground glass) pattern. For TTN, the chest x-ray shows lung overaeration and prominent perihilar interstitial markings and streakings. A chest x-ray for asphyxia would reveal possible structural abnormalities that might interfere with respiration, but the results are highly variable. An echocardiogram would be done to evaluate persistent pulmonary hypertension.

Which action would be most appropriate for the nurse to take when a newborn has an unexpected anomaly at birth? A) Show the newborn to the parents as soon as possible while explaining the defect. B) Remove the newborn from the birthing area immediately. C) Inform the parents that there is nothing wrong at the moment. D) Tell the parents that the newborn must go to the nursery immediately.

Ans: A Feedback: When an anomaly is identified at or after birth, parents need to be informed promptly and given a realistic appraisal of the severity of the condition, the prognosis, and treatment options so that they can participate in all decisions concerning their child. Removing the newborn from the area or telling them that the newborn needs to go to the nursery immediately is inappropriate and would only add to the parents' anxieties and fears. Telling them that nothing is wrong is inappropriate because it violates their right to know.

When planning the care for an SGA newborn, which action would the nurse determine as a priority? A) Preventing hypoglycemia with early feedings B) Observing for respiratory distress syndrome C) Promoting bonding between the parents and the newborn D) Monitoring vital signs every 2 hours

Ans: A Feedback: With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for respiratory distress, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn.

A nursing instructor is describing common problems associated with preterm birth. When describing the preterm newborn's risk for perinatal asphyxia, the instructor includes which of the following as contributing to the newborn's risk? (Select all that apply.) A) Surfactant deficiency B) Placental deprivation C) Immaturity of the respiratory control centers D) Decreased amounts of brown fat E) Depleted glycogen stores

Ans: A, C Feedback: Preterm newborns are at risk for perinatal asphyxia due to surfactant deficiency, unstable chest wall, immaturity of the respiratory control centers, small respiratory passages, and inability to clear mucus from the airways. Placental deprivation places the postterm newborn at risk for perinatal asphyxia. Decreased amounts of brown fat and depleted glycogen stores place the SGA newborn at risk for problems with thermoregulation.

A nurse is explaining to the parents of a child with bladder exstrophy about the care their infant requires. Which of the following would the nurse include in the explanation? (Select all that apply.) A) Covering the area with a sterile, clear, nonadherent dressing B) Irrigating the surface with sterile saline twice a day C) Monitoring drainage through the suprapubic catheter D) Administering prescribed antibiotic therapy E) Preparing for surgical intervention in about 2 weeks

Ans: A, C, D Feedback: Care for an infant with bladder exstrophy includes covering the area with a sterile, clear, nonadherent dressing and irrigating the bladder surface with sterile saline after each diaper change to prevent infection, assisting with insertion and monitoring drainage from suprapubic catheter, administering prescribed antibiotic therapy, and preparing the parents and infant for surgery within 48 hours after birth.

The nurse is assessing a newborn and suspects that the newborn was exposed to drugs in utero because the newborn is exhibiting signs of neonatal abstinence syndrome. Which of the following would the nurse expect to assess? (Select all that apply.) A) Tremors B) Diminished sucking C) Regurgitation D) Shrill, high-pitched cry E) Hypothermia F) Frequent sneezing

Ans: A, C, D, F Feedback: Signs and symptoms of neonatal abstinence syndrome include tremors, frantic sucking, regurgitation or projectile vomiting, shrill high-pitched cry, fever, and frequent sneezing.

A newborn was diagnosed with a congenital heart defect and will undergo surgery at a later time. The nurse is teaching the parents about signs and symptoms that need to be reported. The nurse determines that the parents have understood the instructions when they state that they will report which of the following? (Select all that apply.) A) Weight loss B) Pale skin C) Fever D) Absence of edema E) Increased respiratory rate

Ans: A, C, E Feedback: Signs and symptoms that need to be reported include weight loss, poor feeding, cyanosis, breathing difficulties, irritability, increased respiratory rate, and fever.

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which of the following? (Select all that apply.) A) History of diabetes B) Labor of 12 hours C) Rupture of membranes for 16 hours D) Hemoglobin level 10 mg/dL E) Placenta requiring manual extraction

Ans: A, D, E Risk factors for postpartum infection include history of diabetes, labor over 24 hours, hemoglobin less than 10.5 mg/dL, prolonged rupture of membranes (more than 24 hours), and manual extraction of the placenta.

A nurse is working as part of a committee to establish policies to promote bonding and attachment. Which practice would be least effective in achieving this goal? A) Allowing unlimited visiting hours on maternity units B) Offering round-the-clock nursery care for all infants C) Promoting rooming-in D) Encouraging infant contact immediately after birth

Ans: B Factors that can affect attachment include separation of the infant and parents for long times during the day, such as if the infant was being cared for in the nursery throughout the day. Unlimited visiting hours, rooming-in, and infant contact immediately after birth promote bonding and attachment.

After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A) Presence of lochia serosa B) Frequent scant voiding C) Fundus firm, below umbilicus D) Milk filling in both breasts

Ans: B Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.

Which statement would alert the nurse to the potential for impaired bonding between mother and newborn? A) "You have your daddy's eyes." B) "He looks like a frog to me." C) "Where did you get all that hair?" D) "He seems to sleep a lot."

Ans: B Negative comments may indicate impaired bonding. Pointing out commonalities such as "daddy's eyes" and expressing pride such as "all that hair" are positive attachment behaviors. The statement about sleeping a lot indicates that the mother is assigning meaning to the newborn's actions, another positive attachment behavior.

The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which of the following? A) Scant B) Light C) Moderate D) Large

Ans: B The amount of lochia is described as light or small for an approximately 4-inch stain. Scant refers to a 1- to 2-inch stain of lochia; moderate refers to a 4- to 6-inch stain; and large or heavy refers to a pad that is saturated within 1 hour after changing.

A nurse is observing a postpartum client interacting with her newborn and notes that the mother is engaging with the newborn in the en face position. Which of the following would the nurse be observing? A) Mother placing the newborn next to bare breast. B) Mother making eye-to-eye contact with the newborn C) Mother gently stroking the newborn's face D) Mother holding the newborn upright at the shoulder

Ans: B The en face position is characterized by the mother interacting with the newborn through eye-to-eye contact while holding the newborn.

The nurse administers RhoGAM to an Rh-negative client after delivery of an Rh-positive newborn based on the understanding that this drug will prevent her from: A) Becoming Rh positive B) Developing Rh sensitivity C) Developing AB antigens in her blood D) Becoming pregnant with an Rh-positive fetus

Ans: B The woman who is Rh-negative and whose infant is Rh-positive should be given Rh immune globulin (RhoGAM) within 72 hours after childbirth to prevent sensitization.

After teaching a postpartum woman about breast-feeding, the nurse determines that the teaching was successful when the woman states which of the following? A) "I should notice a decrease in abdominal cramping during breast-feeding." B) "I should wash my hands before starting to breast-feed." C) "The baby can be awake or sleepy when I start to feed him." D) "The baby's mouth will open up once I put him to my breast."

Ans: B To promote successful breast-feeding, the mother should wash her hands before breast feeding, and make sure that the baby is awake and alert and showing hunger signs. In addition, the mother should lightly tickle the infant's upper lip with her nipple to stimulate the infant to open the mouth wide and then bring the infant rapidly to the breast with a wide-open mouth. The mother also needs to know that her afterpains will increase during breast-feeding.

A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? A) "You are lucky to have given birth to a term newborn." B) "We still need to monitor him closely for problems." C) "How do you feel about delivering your baby at 36 weeks?" D) "Your baby is premature and needs monitoring in the NICU."

Ans: B Feedback: A baby born at 36 weeks' gestation is considered a late preterm newborn. These newborns face similar challenges as those of preterm newborns and require similar care. Telling the mother that close monitoring is necessary can prevent any misconceptions that she might have and prepare her for what might arise. The baby is not considered a term newborn, nor is the baby considered premature. The decision for care in the NICU would depend on the newborn's status. Asking the woman how she feels about the delivery demonstrates caring but does not address the woman's lack of understanding about her newborn.

The nurse is reviewing the medical record of a newborn born 2 hours ago. The nurse notes that the newborn was delivered at 35 weeks' gestation. The nurse would classify this newborn as which of the following? A) Preterm B) Late preterm C) Full term D) Postterm

Ans: B Feedback: A late preterm infant is one born between 34 to 36 6/7 weeks of gestation. A preterm infant is one born before 37 completed weeks' gestation. A full-term infant is one born between 38 to 41 weeks' gestation. A postterm newborn is one born at 42 weeks' gestation or later.

When describing newborns with birth-weight variations to a group of nursing students, the instructor identifies which variation if the newborn weighs 5.2 lb at any gestational age? A) Small for gestational age B) Low birth weight C) Very low birth weight D) Extremely low birth weight

Ans: B Feedback: A low-birth-weight newborn weighs less than 5.5 lb (2,500 g) but more than 3 lb 5 oz. A very-low-birth-weight newborn would weigh less than 3 lb 5 oz but more than 2 lb 3 oz (1,000 g). An extremely-low-birth-weight newborn weighs less than 2 lb 3 oz (1,000g). A small-for-gestational-age newborn typically weighs less than 5 lb 8 oz (2,500 g) at term.

A nurse is assisting in the resuscitation of a newborn. The nurse would expect to stop resuscitation efforts when the newborn has no heartbeat and respiratory effort after which time frame? A) 5 minutes B) 10 minutes C) 15 minutes D) 20 minutes

Ans: B Feedback: According to the American Heart Association and American Academy of Pediatrics Guidelines for Neonatal Resuscitation, resuscitation efforts may be stopped if the newborn exhibits no heartbeat and no respiratory effort after 10 minutes of continuous and adequate resuscitation.

Which of the following would the nurse include in the plan of care for a newborn receiving phototherapy? A) Keeping the newborn in the supine position B) Covering the newborn's eyes while under the bililights C) Ensuring that the newborn is covered or clothed D) Reducing the amount of fluid intake to 8 ounces daily

Ans: B Feedback: During phototherapy, the newborn's eyes are covered to protect them from the lights. The newborn is turned every 2 hours to expose all areas of the body to the lights and is kept undressed, except for the diaper area, to provide maximum body exposure to the lights. Fluid intake is increased to allow for added fluid, protein, and calories.

The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea based on the understanding that this type of feeding is necessary for which reason? A) Lactase enzymatic activity is not adequate. B) Oxygen demands need to be reduced. C) Renal solute lead must be considered. D) Hyperbilirubinemia is likely to develop.

Ans: B Feedback: For the newborn with transient tachypnea, the newborn's respiratory rate is high, increasing his oxygen demand. Thus, measures are initiated to reduce this demand. Gavage feedings are one way to do so. With transient tachypnea, enzyme activity and kidney function are not affected. This condition typically resolves within 72 hours. The risk for hyperbilirubinemia is not increased.

Which of the following would not be considered a risk factor for bronchopulmonary dysplasia (chronic lung disease)? A) Preterm birth (less than 32 weeks) B) Female gender C) White race D) Sepsis

Ans: B Feedback: Male gender is more commonly associated with bronchopulmonary dysplasia. Preterm birth of less than 32 weeks' gestation, sepsis, white race, excessive fluid intake during the first few days of life, severe RDS with mechanical ventilation for more than 1 week, and patent ductus arteriosus are all risk factors associated with chronic lung disease in the newborn.

Which of the following, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of an LGA newborn? A) Drug abuse B) Diabetes C) Preeclampsia D) Infection

Ans: B Feedback: Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdated gestation, maternal obesity, male fetus, and genetics. Drug abuse is associated with SGA newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth.

A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how much should my newborn drink at each feeding?" The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding? A) 1 to 2 ounces B) 2 to 4 ounces C) 4 to 6 ounces D) 6 to 8 ounces

Ans: B Feedback: Newborns need about 108 cal/kg or approximately 650 cal/day (Dudek, 2010). Therefore, explain to parents that a newborn will need to 2 to 4 ounces to feel satisfied at each feeding.

Which of the following would the nurse include when teaching a new mother about the difference between pathologic and physiologic jaundice? A) Physiologic jaundice results in kernicterus. B) Pathologic jaundice appears within 24 hours after birth. C) Both are treated with exchange transfusions of maternal O- blood. D) Physiologic jaundice requires transfer to the NICU.

Ans: B Feedback: Pathologic jaundice appears within 24 hours after birth, whereas physiologic jaundice commonly appears around the third to fourth days of life. Kernicterus is more commonly associated with pathologic jaundice. An exchange transfusion is used only if the total serum bilirubin level remains elevated after intensive phototherapy. With this procedure, the newborn's blood is removed and replaced with nonhemolyzed red blood cells from a donor. Physiologic jaundice often is treated at home.

After teaching the parents of a newborn with periventricular hemorrhage about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A) "We'll make sure to cover both of his eyes to protect them." B) "Our newborn could develop a learning disability later on." C) "Once the bleeding ceases, there won't be any more worries." D) "We need to get family members to donate blood for transfusion."

Ans: B Feedback: Periventricular-intraventricular hemorrhage has long-term sequelae such as seizures, hydrocephalus, periventricular leukomalacia, cerebral palsy, learning disabilities, vision or hearing deficits, and mental retardation. Covering the eyes is more appropriate for the newborn receiving phototherapy. The bleeding in the brain can lead to serious long-term effects. Blood transfusions are not used to treat periventricular hemorrhage.

When developing the plan of care for a newborn with an acquired condition, which of the following would the nurse include to promote participation by the parents? A) Use verbal instructions primarily for explanations B) Assist with decision making process C) Provide personal views about their decisions D) Encourage them to refrain from showing emotions

Ans: B Feedback: To promote parental participation, the nurse should assist them with making decisions about treatment, and support their decisions for the newborn's care. Imposing personal views about their decisions is inappropriate and undermines the nurse-client relationship. In addition, the nurse would assess their ability to cope with the diagnosis, encourage them to verbalize their feelings about the newborn's condition and treatment and educate them about the newborn's condition using written information and pictures to enhance understanding.

After teaching a group of students about risk factors associated with postpartum hemorrhage, the instructor determines that the teaching was successful when the students identify which of the following as a risk factor? (Select all that apply.) A) Prolonged labor B) Placenta previa C) Null parity D) Hydramnios E) Labor augmentation

Ans: B, D, E Risk factors for postpartum hemorrhage include precipitous labor less than 3 hours, placenta previa or abruption, multiparity, uterine overdistention such as with a large infant, twins, or hydramnios, and labor induction or augmentation. Prolonged labor over 24 hours is a risk factor for postpartum infection.

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be ordered? A) Ferrous sulfate (Feosol) B) Methylergonovine (Methergine) C) Docusate (Colace) D) Bromocriptine (Parlodel)

Ans: C A stool softener such as docusate (Colace) may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.

When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which of the following? A) Superficial structures above the muscle B) Through the perineal muscles C) Through the anal sphincter muscle D) Through the anterior rectal wall

Ans: C A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only the skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

To decrease the pain associated with an episiotomy immediately after birth, which action by the nurse would be most appropriate? A) Offer warm blankets. B) Encourage the woman to void. C) Apply an ice pack to the site. D) Offer a warm sitz bath.

Ans: C An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.

Which of the following factors in a client's history would alert the nurse to an increased risk for postpartum hemorrhage? A) Multiparity, age of mother, operative delivery B) Size of placenta, small baby, operative delivery C) Uterine atony, placenta previa, operative procedures D) Prematurity, infection, length of labor

Ans: C Risk factors for postpartum hemorrhage include a precipitous labor less than 3 hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem? A) Lochia rubra with a fleshy odor B) Respiratory rate of 16 breaths per minute C) Temperature of 101° F D) Pain rating of 2 on a scale from 0 to 10

Ans: C : Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range. Some women experience a slight fever, up to 38º C (100.4º F), during the first 24 hours. A temperature above 38º C (100.4º F) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Foul-smelling lochia or lochia with an unexpected change in color or amount, shortness of breath, or respiratory rate below 16 or above 20 breaths per minute would also be a cause for concern. The goal of pain management is to have the woman's pain scale rating maintained between 0 to 2 points at all times, especially after breast-feeding.

A newborn is suspected of having fetal alcohol syndrome. Which of the following would the nurse expect to assess? A) Bradypnea B) Hydrocephaly C) Flattened maxilla D) Hypoactivity

Ans: C Feedback: A newborn with fetal alcohol syndrome exhibits characteristic facial features such as microcephaly (not hydrocephaly), small palpebral fissures, and abnormally small eyes, flattened or absent maxilla, epicanthal folds, thin upper lip, and missing vertical groove in the median portion of the upper lip. Bradypnea is not typically associated with fetal alcohol syndrome. Fine and gross motor development is delayed, and the newborn shows poor hand-eye coordination but not hypoactivity.

When assessing a postterm newborn, which of the following would the nurse correlate with this gestational age variation? A) Moist, supple, plum skin appearance B) Abundant lanugo and vernix C) Thin umbilical cord D) Absence of sole creases

Ans: C Feedback: A postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet.

The nurse is assessing a newborn who is large for gestational age. The newborn was born breech. The nurse suspects that the newborn may have experienced trauma to the upper brachial plexus based on which assessment findings? A) Absent grasp reflex B) Hand weakness C) Absent Moro reflex D) Facial asymmetry

Ans: C Feedback: An injury to the upper brachial plexus, or Erb's palsy, is manifested by adduction, pronation, and internal rotation of the affected extremity, absent shoulder movement, absent Moro reflex and positive grasp reflex. An absent grasp reflex and hand weakness is noted with a lower brachial plexus injury. Facial asymmetry is associated with a cranial nerve injury.

A group of pregnant women are discussing high-risk newborn conditions as part of a prenatal class. When describing the complications that can occur in these newborns to the group, which would the nurse include as being at lowest risk? A) Small-for-gestational-age (SGA) newborns B) Large-for-gestational-age (LGA) newborns C) Appropriate-for-gestational-age (AGA) newborns D) Low-birth-weight newborns

Ans: C Feedback: Appropriate-for-gestational-age (AGA) newborns are at the lowest risk for any problems. AGA characterizes approximately 80% of newborns and describes a newborn with a normal length, weight, head circumference, and body mass index. The other categories all have an increased risk of complications.

A group of nursing students are reviewing the literature in preparation for a class presentation on newborn pain prevention and management. Which of the following would the students be most likely to find about this topic? A) Newborn pain is frequently recognized and treated B) Newborns rarely experience pain with procedures C) Pain is frequently mistaken for irritability or agitation D) Newborns may be less sensitive to pain than adult.

Ans: C Feedback: Assessment of pain in the newborn remains a contentious and vexing problem. According to an international consortium, principles of newborn pain prevention and management include the following: newborn pain frequently goes unrecognized and undertreated; newborns experience pain and analgesics should be given; a procedure considered painful for an adults should also be considered painful for a newborn; newborns may be more sensitive to pain than adults; and pain behavior is frequently mistaken for irritability and agitation.

The nurse is assessing a preterm newborn's fluid and hydration status. Which of the following would alert the nurse to possible overhydration? A) Decreased urine output B) Tachypnea C) Bulging fontanels D) Elevated temperature

Ans: C Feedback: Bulging fontanels in a preterm newborn suggest overhydration. Sunken fontanels, decreased urine output, and elevated temperature would suggest dehydration.

A nursing student is preparing a presentation for the class on clubfoot. The student determines that the presentation was successful when the class states which of the following? A) Clubfoot is a common genetic disorder. B) The condition affects girls more often than boys. C) The exact cause of clubfoot is not known. D) The intrinsic form can be manually reduced.

Ans: C Feedback: Clubfoot is a complex, multifactorial deformity with genetic and intrauterine factors. Heredity and race seem to factor into the incidence, but the means of transmission and the etiology are unknown. Most newborns with clubfoot have no identifiable genetic, syndromal, or extrinsic cause. Clubfoot affects boys twice as often as girls. With the intrinsic type, manual reduction is not possible.

A nurse is teaching the mother of a newborn diagnosed with galactosemia about dietary restrictions. The nurse determines that the mother has understood the teaching when she identifies which of the following as needing to be restricted? A) Phenylalanine B) Protein C) Lactose D) Iodine

Ans: C Feedback: Lifelong restriction of lactose is required for galactosemia. Phenylalanine is restricted for those with phenylketonuria. Low protein is needed with maple syrup urine disease. Iodine would not be restricted for any inborn error of metabolism

Which of the following would the nurse expect to assess in a newborn who develops sepsis? A) Increased urinary output B) Interest in feeding C) Hypothermia D) Wakefulness

Ans: C Feedback: Manifestations of sepsis are typically nonspecific and may include hypothermia (temperature instability), oliguria or anuria, lack of interest in feeding, and lethargy.

A group of students are reviewing information about the effects of substances on the newborn. The students demonstrate understanding of the information when they identify which drug as not being associated with teratogenic effects on the fetus? A) Alcohol B) Nicotine C) Marijuana D) Cocaine

Ans: C Feedback: Marijuana has not been shown to have teratogenic effects on the fetus. Alcohol, nicotine and cocaine do affect the fetus.

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation and intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A) Suggest that the parents stay for just a few minutes to reduce their anxiety. B) Reassure them that their newborn is progressing well. C) Encourage the parents to touch their preterm newborn. D) Discuss the care they will be giving the newborn upon discharge.

Ans: C Feedback: The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated.

The nurse is teaching a group of students about the differences between a full-term newborn and a preterm newborn. The nurse determines that the teaching is effective when the students state that the preterm newborn has: A) Fewer visible blood vessels through the skin B) More subcutaneous fat in the neck and abdomen C) Well-developed flexor muscles in the extremities D) Greater surface area in proportion to weight

Ans: D Feedback: Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone.

Which of the following would alert the nurse to suspect that a newborn has developed NEC? A) Irritability B) Sunken abdomen C) Clay-colored stools D) Bilious vomiting

Ans: D Feedback: The newborn with NEC may exhibit bilious vomiting with lethargy, abdominal distention and tenderness, and bloody stools.

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Tachycardia b) Apnea c) Crying d) Sleepiness

Apnea

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Sleepiness b) Tachycardia c) Apnea d) Crying

Apnea Explanation: A premature infant has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress.

A newborn with high serum bilirubin is receiving phototherapy. Which of the following is the most appropriate nursing intervention for this client? a) Gentle shaking of the baby b) Placing light 6 inches above the newborn's bassinet c) Application of eye dressings to the infant d) Delay of feeding until bilirubin levels are normal

Application of eye dressings to the infant Correct Explanation: Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or formula), therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor. In a client with the risk for injury, continuous assessment of contractions using external monitor and palpation to ensure the presence of a low resting tone will assist in collecting information about labor and the need for further intervention. Turning down oxytocin administration by half is required if hyperstimulation occurs not to prevent it. Tocolytic therapy is generally employed when preterm labor has been definitively diagnosed. Administering hydration and sedation frequently and bedrest are employed to halt preterm labor since these stop uterine activity by increasing intravascular volume and uterine blood flow.

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.

What assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn? a) Monitor for fall in temperature, indicative of dehydration b) Assess for decrease in urinary output c) Assess for increased muscle tone d) Measure weight once every 2-3 days

Assess for decrease in urinary output

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth?

Assess uterine tone to determine fundal firmness. When caring for a client who has undergone a cesarean birth, the nurse should assess the client's uterine tone to determine fundal firmness. The nurse should assist with breastfeeding initiation and offer continued support. The nurse can also suggest alternate positioning techniques to reduce incisional discomfort while breastfeeding. Delaying breastfeeding may not be required. The nurse should encourage the client to cough, perform deep-breathing exercises, and use the incentive spirometer every 2 hours. The nurse should assist the client with early ambulation to prevent respiratory and cardiovascular problems.

Which of the following would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? a) Temperature instability b) Seizures c) Feeble sucking d) Asymmetrical movement

Asymmetrical movement Correct Explanation: A birth injury is typically characterized by asymmetrical movement. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.

_____________ is the development of strong affection between an infant and a significant other (mother, father, sibling, and caretaker).

Attachment

A newborn's condition is not improving after intubation. What assessment by the nurse would identify a possible problem?

Auscultate breath sounds.

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time?

Avoid any discussion of the situation with the couple. The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time.

At 17 weeks pregnant, a mother asks the nurse questions about the development of her baby. The mother states that it may be too early to visualize any body structures via ultrasound. The nurse's best response in relation to fetal development at 17 weeks is: a) Myelination of the spinal cord has occurred. b) Differentiation of hard and soft palate can be seen. c) The earlobes are soft with little cartilage. d) Hard tissue (enamel) for teeth has developed.

B Differentiation of hard and soft palate are structures developed by 16 weeks gestation. Myelination of the spinal cord begins at 20 weeks gestation. Soft earlobes with little cartilage develop at 36 weeks gestation. Teeth form hard tissue (enamel) at 18 weeks gestation.

A pregnant client is concerned about a blow to the abdomen if she continues to play basketball during her pregnancy. The nurse's response is based upon her knowledge of which of the following facts concerning amniotic fluid? a) The total amount of amniotic fluid during pregnancy is 300 mL. b) Amniotic fluid functions as a cushion to protect against mechanical injury. c) The fetus does not contribute to the production of amniotic fluid. d) Amniotic fluid is slightly acidic.

B During pregnancy, the amniotic fluid protects against injury. After 20 weeks of pregnancy, fluid volume ranges from 700-1000 mL. Some of the amniotic fluid is contributed by the fetus's excreting urine. Amniotic fluid is slightly alkaline.

Identify a complication of the small-for-gestational-age newborn. a)Hyperglycemia b)Cognitive difficulties c)Leukocytosis d)Hyperthermia

B SGA newborns often subsequently exhibit learning disabilities. The disabilities are characterized by hyperactivity, short attention span, and poor fine motor coordination. Some hearing loss and speech defects also occur. The SGA newborn does not exhibit symptoms of high blood sugars, increased temperatures, and high white blood cell counts.

The preterm newborn is experiencing vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea. What is the best explanation for these symptoms? a)Traumatic birth b)Maternal substance abuse c)Sepsis d)Gestational diabetes

B The severity of withdrawal that an infant experiences can be assessed by using a scoring system such as the Finnegan scale. This scale is based on observations and measurement of the responses to neonatal abstinence from substances. It evaluates the infant on potentially life-threatening signs such as vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea.

Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when Ortolani's maneuver is performed. Which of the following would the nurse suspect? A) Slipping of the periosteal joint B) Developmental hip dysplasia C) Normal newborn variation D) Overriding of the pelvic bone

B A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the area. This, along with uneven gluteal creases, suggests developmental hip dysplasia. These findings are not a normal variation and are not associated with slipping of the periosteal joint or overriding of the pelvic bone.

A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? A) "You are lucky to have given birth to a term newborn." B) "We still need to monitor him closely for problems." C) "How do you feel about delivering your baby at 36 weeks?" D) "Your baby is premature and needs monitoring in the NICU."

B A baby born at 36 weeks' gestation is considered a late-preterm newborn. These newborns face similar challenges as those of preterm newborns and require similar care. Telling the mother that close monitoring is necessary can prevent any misconceptions that she might have and prepare her for what might arise. The baby is not considered a term newborn, nor is the baby considered premature. The decision for care in the NICU would depend on the newborn's status. Asking the woman how she feels about the delivery demonstrates caring but does not address the woman's lack of understanding about her newborn.

Just after delivery, a newborn's axillary temperature is 94 degrees F. What action would be most appropriate? A) Assess the newborn's gestational age. B) Rewarm the newborn gradually. C) Observe the newborn every hour. D) Notify the physician if the temperature goes lower.

B A newborn's temperature is typically maintained at 36.5 to 37.5 degrees C (97.7 to 99.7 degrees F). Since this newborn's temperature is significantly lower, the nurse should institute measures to rewarm the newborn gradually. Assessment of gestational age is completed regardless of the newborn's temperature. Observation would be inappropriate because lack of action may lead to a further lowering of the temperature. The nurse should notify the physician of the newborn's current temperature since it is outside normal parameters.

The nurse observes the stool of a newborn who has begun to breast-feed. Which of the following would the nurse expect to find? A) Greenish black, tarry stool B) Yellowish-brown, seedy stool C) Yellow-gold, stringy stool D) Yellowish-green, pasty stool

B After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. Meconium stool is greenish black and tarry. The last development in the stool pattern is the milk stool. Milk stools of the breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically sour-smelling. The milk stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings by observing the newborn, which of the following actions would be most appropriate? A) Notify the health care provider immediately. B) Assess the newborn for signs of respiratory distress. C) Reassure the parents that this is an expected pattern. D) Tell the parents not to worry since his color is fine.

B Although periods of apnea of less than 20 seconds can occur, the nurse needs to gather additional information about the newborn's respiratory status to determine if this finding is indicative of a developing problem. Therefore, the nurse would need to assess for signs of respiratory distress. Once this information is obtained, then the nurse can notify the health care provider or explain that this finding is an expected one. However, it would be inappropriate to tell the parents not to worry, because additional information is needed. Also, telling them not to worry ignores their feelings and is not therapeutic.

A nurse is making a home visit to a postpartum woman who delivered a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as which of the following? A) Involution B) Engorgement C) Mastitis D) Engrossment

B Engorgement is the process of swelling of the breast tissue as a result of an increase in blood and lymph supply as a precursor to lactation (Figure 15.4). Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the next 24 to 36 hours (Chapman, 2011). Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. Involution refers to the process of the uterus returning to its prepregnant state. Mastitis refers to an infection of the breasts. Engrossment refers to the bond that develops between the father and the newborn.

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate? A) "It's difficult to say, but it will probably return in about 2 to 3 weeks." B) "It varies, but you can estimate it returning in about 7 to 9 weeks." C) "You won't have to worry about it returning for at least 3 months." D) "You don't have to worry about that now. It'll be quite a while."

B For the nonlactating woman, menstruation resumes 7 to 9 weeks after giving birth, with the first cycle being anovulatory. For the lactating woman, menses can return anytime from 2 to 18 months after childbirth.

Which of the following would the nurse interpret as being least indicative of paternal engrossment? A) Demonstrating pleasure when touching or holding the newborn B) Identifying imperfections in the newborn's appearance C) Being able to distinguish his newborn from others in the nursery D) Showing feelings of pride with the birth of the newborn

B Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.

A nurse is visiting a postpartum woman who delivered a healthy newborn 5 days ago. Which of the following would the nurse expect to find? A) Bright red discharge B) Pinkish brown discharge C) Deep red mucus-like discharge D) Creamy white discharge

B Lochia serosa is pinkish brown and is expelled 3 to 10 days postpartum. Lochia rubra is a deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after birth. Lochia alba is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content and occurs from days 10 to 14 but can last 3 to 6 weeks postpartum.

Which of the following, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of a LGA newborn? A) Drug abuse B) Diabetes C) Preeclampsia D) Infection

B Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdates gestation, maternal obesity, male fetus, and genetics. Drug abuse is associated with SGA newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth.

A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate? A) "You probably took iron during your pregnancy." B) "This is meconium stool, normal for a newborn." C) "I'll take a sample and check it for possible bleeding." D) "This is unusual and I need to report this."

B Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.

Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: A) Habituation B) Motor maturity C) Orientation D) Social behaviors

B Motor maturity is evidenced by rhythmic, spontaneous movements. Habituation is manifested by the newborn's ability to respond to the environment appropriately. Orientation involves the newborn's response to new stimuli, such as turning the head to a sound. Social behaviors involve cuddling and snuggling into the arms of a parent.

A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern? A) Hemoglobin 19 g/dL B) Platelets 75,000/uL C) White blood cells 20,000/mm3 D) Hematocrit 52%

B Normal newborn platelets range from 150,00 to 350,000/uL. Normal hemoglobin ranges from 17 to 23g/dL, and normal hematocrit ranges from 46% to 68%. Normal white blood cell count ranges from 10,000 to 30,000/mm3.

A group of nursing students are reviewing respiratory system adaptations that occur during the postpartum period. The students demonstrate understanding of the information when they identify which of the following as a postpartum adaptation? A) Continued shortness of breath B) Relief of rib aching C) Diaphragmatic elevation D) Decrease in respiratory rate

B Respirations usually remain within the normal adult range of 16 to 24 breaths per minute. As the abdominal organs resume their nonpregnant position, the diaphragm returns to its usual position. Anatomic changes in the thoracic cavity and rib cage caused by increasing uterine growth resolve quickly. As a result, discomforts such as shortness of breath and rib aches are relieved.

A postpartum woman who has experienced diastasis recti asks the nurse about what to expect related to this condition. Which response by the nurse would be most appropriate? A) "You'll notice that this will fade to silvery lines." B) "Exercise will help to improve the muscles." C) "Expect the color to lighten somewhat." D) "You'll notice that your shoe size will increase."

B Separation of the rectus abdominis muscles, called diastasis recti, is more common in women who have poor abdominal muscle tone before pregnancy. After birth, muscle tone is diminished and the abdominal muscles are soft and flabby. Specific exercises are necessary to help the woman regain muscle tone. Fortunately, diastasis responds well to exercise, and abdominal muscle tone can be improved. Stretch marks (striae gravidarum) fade to silvery lines. The darkened pigmentation of the abdomen (linea nigra), face (melasma), and nipples gradually fades. Parous women will note a permanent increase in shoe size.

A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm going to do the best I can for my son." The nurse interprets this as indicating the father is in which stage of adaptation? A) Expectations B) Transition to mastery C) Reality D) Taking-in

B The father's statement reflects transition to mastery because he is making a conscious decision to take control and be at the center of the newborn's life regardless of his preparedness. The expectations stage involves preconceptions about how life will be with a newborn. Reality occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal

The nurse is teaching a group of students about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed? A) The newborn's skin and that of an adult are similar in thickness. B) The newborn's sweat glands function fully, just like those of an adult. C) Skin development in the newborn is not complete at birth. D) The newborn has fewer fibrils connecting the dermis and epidermis

B The newborn has sweat glands, like an adult, but full adult functioning is not present until the second or third year of life. The newborn and adult epidermis is similar in thickness and lipid composition, but skin development is not complete at birth. Fewer fibrils connect the dermis and epidermis in the newborn when compared with the adult.

When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because of which of the following? A) The newborn should not be sleeping on his back. B) Stuffed animals should not be in areas where infants sleep. C) The bulb syringe should not be kept in the bassinet. D) This newborn should be sleeping in a crib.

B The nurse should instruct the mother to remove all fluffy bedding, quilts, stuffed animals, and pillows from the crib to prevent suffocation. Newborns and infants should be placed on their backs to sleep. Having the bulb syringe nearby in the bassinet is appropriate. Although a crib is the safest sleeping location, a bassinet is appropriate initially.

The partner of a woman who has given birth to a healthy newborn says to the nurse, "I want to be involved, but I'm not sure that I'm able to care for such a little baby." The nurse interprets this as indicating which of the following stages? A) Expectations B) Reality C) Transition to mastery D) Taking-hold

B The partner's statement reflects stage 2 (reality), which occurs when fathers or partners realize that their expectations in stage 1 are not realistic. Their feelings change from elation to sadness, ambivalence, jealousy, and frustration. Many wish to be more involved in the newborn's care and yet do not feel prepared to do so. New fathers or partners pass through stage 1 (expectations) with preconceptions about what home life will be like with a newborn. Many men may be unaware of the dramatic changes that can occur when this newborn comes home to live with them. In stage 3 (transition to mastery), the father or partner makes a conscious decision to take control and be at the center of his newborn's life regardless of his preparedness. Taking-hold is a stage of maternal adaptation.

After teaching a class about hepatic system adaptations after birth, the instructor determines that the teaching was successful when the class identifies which of the following as the process of changing bilirubin from a fat-soluble product to a water-soluble product? A) Hemolysis B) Conjugation C) Jaundice D) Hyperbilirubinemia

B The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is called conjugation. Hemolysis involves the breakdown of blood cells. In the newborn, hemolysis of the red blood cells is the principal source of bilirubin. Jaundice is the manifestation of increased bilirubin in the bloodstream. Hyperbilirubinemia refers to the increased level of bilirubin in the blood.

After teaching a class about hepatic system adaptations after birth, the instructor determines that the teaching was successful when the class identifies which of the following as the process of changing bilirubin from a fat-soluble product to a water-soluble product? A) Hemolysis B) Conjugation C) Jaundice D) Hyperbilirubinemia

B The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is called conjugation. Hemolysis involves the breakdown of blood cells. In the newborn, hemolysis of the red blood cells is the principal source of bilirubin. Jaundice is the manifestation of increased bilirubin in the bloodstream. Hyperbilirubinemia refers to the increased level of bilirubin in the blood.

The nurse observes a 2 in lochia stain on the perineal pad 1 day postpartum. Which of the following should the nurse do next? A. reassess the client in 1 hour. B. Document the lochia as scant c. ask when the peri pas was changed d. massage the fundus

B This is a normal finding postpartum. Scant is 1-2 inch spot on a pad approximately 10 ml loss

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? A) Evaporation B) Conduction C) Convection D) Radiation

B Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

The nurse places a warmed blanket on the scale when weighing a newborn. The nurse does so to minimize heat loss via which mechanism? A) Evaporation B) Conduction C) Convection D) Radiation

B Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

Which of the following would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A) Avoid using the terms "death" or "dying." B) Provide opportunities for them to hold the newborn. C) Refrain from initiating conversations with the parents. D) Quickly refocus the parents to a more pleasant topic.

B When dealing with grieving parents, nurses should provide them with opportunities to hold the newborn if they desire. In addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn. These interventions help to validate the parents' sense of loss, relive the experience, and attach significance to the meaning of loss. The nurse should use appropriate terminology, such as "dying," "died," and "death," to help the parents accept the reality of the death. Nurses need to demonstrate empathy and to respect the parents' feelings, responding to them in helpful and supportive ways. Active listening and allowing the parents to vent their frustrations and anger help validate the parents' feelings and facilitate the grieving process.

A nursing instructor is describing the advantages and disadvantages associated with newborn circumcision to a group of nursing students. Which statement by the students indicates effective teaching? A) "Sexually transmitted infections are more common in circumcised males." B) "The rate of penile cancer is less for circumcised males." C) "Urinary tract infections are more easily treated in circumcised males." D) "Circumcision is a risk factor for acquiring HIV infection."

B) "The rate of penile cancer is less for circumcised males."

A nurse is assessing a newborn who is about 41/2 hours old. The nurse would expect this newborn to exhibit which of the following? (Select all that apply.) A) Sleeping B) Interest in environmental stimuli C) Passage of meconium D) Difficulty arousing the newborn E) Spontaneous Moro reflexes

B, C The newborn is in the second period of reactivity, which begins as the newborn awakens and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal newborn (Boxwell, 2010). Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period. In addition, motor activity and muscle tone increase in conjunction with an increase in muscular coordination. Spontaneous Moro reflexes are noted during the first period of reactivity. Sleeping and difficulty arousing the newborn reflect the period of decreased responsiveness.

A prenatal client at 30 weeks gestation is scheduled for a nonstress test (NST) and asks the nurse, "What is this test for?" The nurse correctly responds that the test is used to determine which of the following? Select all that apply. a)Fetal lung maturity b)Adequate fetal oxygenation c)Accelerations of fetal heart rate d)Fetal well-being

B, C, D An NST documents fetal well-being by measuring fetal oxygenation and fetal heart rate accelerations, but not fetal lung maturity.

A nursing student is preparing a class presentation about changes in the various body systems during the postpartum period and their effects. Which of the following would the student include as influencing a postpartum woman's ability to void? (Select all that apply.) A) Use of an opioid anesthetic during labor B) Generalized swelling of the perineum C) Decreased bladder tone from regional anesthesia D) Use of oxytocin to augment labor E) Need for an episiotomy

B, C, D Many women have difficulty feeling the sensation to void after giving birth if they received an anesthetic block during labor (which inhibits neural functioning of the bladder) or if they received oxytocin to induce or augment their labor (antidiuretic effect). These women will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention. In addition, urination may be impeded by perineal lacerations; generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus; hematomas; decreased bladder tone as a result of regional anesthesia; and diminished sensation of bladder pressure as a result of swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor.

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

B,D,E The nurse should give the new- born oxygen, ensure the newborn's warmth, and observe the newborn's respiratory status frequently. The nurse need not give the newborn warm water to drink or massage the newborn's back."

A nurse has been assigned to care for a client who has just given birth. How frequently should the nurse perform assessments during the first hour of birth? A. every 30 minutes b. every 15 minutes c. every 30 minutes d. every 45 minutes

B. postpartum assessment is typically performed every 15 minutes fro the first hour. After the second hour assessment is performed every 30 minutes. the client has to be monitored closely during the first hour after birth .

When assessing the term newborn, the following are observed: newborn is alert, heart and respiratory rates have stabilized, and meconium has been passed. The nurse determines that the newborn is exhibiting behaviors indicating: a. Initial period of reactivity b. Second period of reactivity c. Decreased responsiveness period d. Sleep period for newborns

B. The behaviors demonstrated by the newborn, such as alertness, stabilized heart and respiratory rates, and passage of meconium are associated with the second period of reactivity.

A mother asks when a preterm infant receives basic immunizations. Which response by the nurse is most accurate?

Basic immunizations are given according to the chronologic age of an infant.

A mother asks when a preterm infant receives basic immunizations. Which response by the nurse is most accurate?

Basic immunizations are given according to the chronologic age of an infant. The infant will receive basic immunization based on chronologic age and standard criteria for administration.

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? a) Focus on decreasing blood viscosity by introducing feedings b) Give dextrose intravenously before oral feedings c) Place infant on radiant warmer immediately d) Begin early feedings either by the breast or bottle

Begin early feedings either by the breast or bottle

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 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. The nurse should provide some nutrition to any infant born with hypoglycemia. Dextrose should be given intravenously only if the infant refuses oral feedings, not before offering the infant oral feedings. Placing the infant on a radiant warmer will not help maintain blood glucose levels. The nurse should focus on decreasing blood viscosity in an infant who is at risk for polycythemia, not hypoglycemia.

The neonate's respirations are gasping and irregular with a rate of 24 bpm. Which circulatory alteration will the nurse assess for in this infant?

Blood flows from the aorta to the pulmonary artery. Inadequate respiratory effort results in hypoxia. During hypoxia, the ductus arteriosus does not close, resulting in blood flow from the aorta to the pulmonary artery and inadequate pump action of the heart. The pulmonary vein takes blood from the right ventricle to the lungs. The foramen ovale allows blood flow from right atrium to left atrium during fetal life and is not primarily impacted by hypoxia. Oxygenated blood flows from the lungs to the left ventricle to be pumped to the body.

__________ is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth.

Bonding

A mother of a 32-week-gestation neonate is encouraged to perform kangaroo care in the neonatal intensive care unit. What would best correlate with this suggestion?

Breastfeeding attempts will be enhanced. To promote nutrition in the preterm newborn the newborn will attempt nuzzling at the breast in conjunction with kangaroo care if the newborn is stable. Kangaroo care offers the most benefits for preterm and low-birth-weight infants with increased weight gain. Preterm infants who experience kangaroo care have improved sleep patterns and breastfeeding attempts. It will not assist in preventing apnea. At 32 weeks' gestation it will not be necessary to have the infant adjust to the environment. Nutrition through breastfeeding is the priority.

The nurse is preparing an educational workshop on fetal development. Which statement by the student would require the nurse to explain further? a) "True knots are usually associated with a cord that is too long." b) "The average cord length at term is 22 inches." c) "The umbilical cord normally contains two veins and one artery." d) "The high blood volume and Wharton's jelly content of the umbilical cord prevents compression of the cord."

C Umbilical cords appear twisted or spiraled. This is most likely caused by fetal movement. A true knot in the umbilical cord rarely occurs; if it does, the cord is usually long. More common are so-called false knots, caused by the folding of cord vessels. A nuchal cord is said to exist when the umbilical cord encircles the fetal neck. A normal umbilical cord contains one large vein and two smaller arteries. A specialized connective tissue known as Wharton's jelly surrounds the blood vessels in the umbilical cord. This tissue, plus the high blood volume pulsating through the vessels, prevents compression of the umbilical cord in utero.

When assessing a postterm newborn, which of the following would the nurse correlate with this gestational age variation? A) Moist, supple, plum skin appearance B) Abundant lanugo and vernix C) Thin umbilical cord D) Absence of sole creases

C A postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet.

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes? A) Gastrointestinal and hepatic B) Urinary and hematologic C) Respiratory and cardiovascular D) Neurological and integumentary

C Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

When describing the complications that can occur in newborns to a group of pregnant women, which would the nurse include as being at lowest risk? A) Small-for-gestational-age newborns B) Large-for-gestational-age newborns C) Appropriate-for-gestational-age newborns D) Low-birthweight newborns

C Appropriate-for-gestational-age newborns are at the lowest risk for any problems. The other categories all have an increased risk of complications.

A group of nursing students are reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as which of the following? A) Puerperium B) Lactation C) Attachment D) Engrossment

C Attachment is a formation of a relationship between a parent and her/his newborn through a process of physical and emotional interactions. Puerperium refers to the postpartum period. Lactation refers to the process of milk secretion by the breasts. Engrossment refers to the bond that develops between the father and the newborn.

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus, expecting it to be at which location? A) Two fingerbreadths above the umbilicus B) At the level of the umbilicus C) Two fingerbreadths below the umbilicus D) Four fingerbreadths below the umbilicus

C During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is about 2 fingerbreadths below the umbilicus.

The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform Kegel exercises. The nurse includes this information for which reason? A) Reduce lochia B) Promote uterine involution C) Improve pelvic floor tone D) Alleviate perineal pain

C Kegel exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.

The nurse assesses a 1-day-old newborn. Which finding indicates that the newborn's oxygen needs aren't being met? A) Respiratory rate of 54 breaths/minute B) Abdominal breathing C) Nasal flaring D) Acrocyanosis

C Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.

While observing the interaction between a newborn and his mother, the nurse notes the newborn nestling into the arms of his mother. The nurse identifies this behavior as which of the following? A) Habituation B) Self-quieting ability C) Social behaviors D) Orientation

C Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held. Habituation self-quieting ability refers to newborns' ability to quiet and comfort themselves, such as by hand-to-mouth movements and sucking, alerting to external stimuli and motor activity. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Orientation refers to the response of newborns to stimuli, becoming more alert when sensing a new stimulus in their environment.

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation and intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A) Suggest that the parents stay for just a few minutes to reduce their anxiety. B) Reassure them that their newborn is progressing well. C) Encourage the parents to touch their preterm newborn. D) Discuss the care they will be giving the newborn upon discharge.

C The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated.

A nurse is assessing a postpartum woman's adjustment to her maternal role. Which of the following would the nurse expect to occur first? A) Reestablishing relationships with others B) Demonstrating increasing confidence in care of the newborn C) Assuming a passive role in meeting her own needs D) Becoming preoccupied with the present

C The first task of adjusting to the maternal role is the taking-in phase in which the mother demonstrates dependent behaviors and assumes a passive role in meeting her own basic needs. During the taking-hold phase, the mother becomes preoccupied with the present. During the letting-go phase, the mother reestablishes relationships with others and demonstrates increased responsibility and confidence in caring for the newborn.

The nurse is teaching a group of students about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed? A) The newborn's skin and that of an adult are similar in thickness. B) The lipid composition of the skin of a newborn and adult is about the same. C) Skin development in the newborn is complete at birth. D) The newborn has more fibrils connecting the dermis and epidermis

C The newborn and adult epidermis is similar in thickness and lipid composition, but skin development is not complete at birth. Fewer fibrils connect the dermis and epidermis in the newborn when compared with the adult.

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation? A) Respiratory rate of 54 breaths/minute B) Abdominal breathing C) Nasal flaring D) Acrocyanosis

C) Nasal flaring

The nurse performs a physical examination on a newborn 2 hours after birth. Which of the following findings indicate a need for a pediatric consultation? (Select all that apply) a. Respiratory rate of 50 breaths per minute b. Intermittent episodes of apnea, lasting <10 seconds each c. Absent Moro reflex when startled d. Preauricular skin tag noted on left ear e. White raised bumps noted on nose and face f. Yellow blanching of the skin when pressure applied to the nos

C, F. - Absence of the Moro reflex might indicate a neurologic problem - yellow blanching of the skin over a bony prominence might indicate pathologic jaundice since it is before 24 hours old. Physiologic jaundice typically occurs after 24 hours old, but a pathologic jaundice occurs before 24 hours old.

After teaching a group of breast-feeding women about nutritional needs, the nurse determines that the teaching was successful when the women state that they need to increase their intake of which nutrients? a. Carbohydrates and fiber b. Fats and vitamins c. Calories and protein D. Iron-rich foods and minerals

C. Lactating mothers need an extra 500 calories to sustain breast-feeding. An additional 20 g of protein is also needed to help build and regenerate body cells for the lactating woman. *Additional intake of carbohydrates or fiber is not suggested for lactation.

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

C. The findings indicate a patent anus with no bowel obstruction and normal peristalsis.

Before calling the primary care provider to notify him or her of a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?

Check for a full bladder. A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.

The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?

Closely monitor temperature. Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also is associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority.

Which of the following is an example of developmental care in the NICU? a) Giving medications b) Holding the infant c) Giving a bath d) Cluster care and activities

Cluster care and activities Correct Explanation: Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.

The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care?

Clustering care and activities Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.

A nurse is working with a client who has just begun labor and who has given birth vaginally five previous times. Which of the following interventions will the nurse most likely need to implement to meet the needs of this particular client?

Convert the birthing room to birth readiness before full dilatation is obtained Both grand multiparas (women who have given birth five or more times) and women with histories of precipitate labor should have the birthing room converted to birth readiness before full dilatation is obtained. Then, even if a sudden birth should occur, it can be accomplished in a controlled surrounding. As the client is likely to give birth relatively quickly, there is no need for oxytocin or to darken the room lights. There is also no indication that cesarean birth will be necessary, particularly because all of the client's previous births were vaginal.

The nurse is preparing a prenatal client for a transvaginal ultrasound. What nursing action should the nurse include in the preparations? Select all that apply. a)Advise the client to empty her bladder. b)Encourage the client to drink 1.5 quarts of fluid. c)Apply transmission gel over the client's abdomen. d)Place client in lithotomy position.

D After having the client void, assist her to a lithotomy position for a transvaginal ultrasound. Preparation for a transabdominal ultrasound includes encouraging the client to drink 1.5 quarts of fluid, maintaining a full bladder, and applying transmission gel over the client's abdomen.

The nurse in the prenatal clinic assesses a 26-year-old client at 13 weeks gestation. Which presumptive (subjective) signs and symptoms of pregnancy should the nurse anticipate? a) Hegar's sign and quickening b) Ballottement and positive pregnancy test c) Chadwick's sign and uterine souffle d) Excessive fatigue and urinary frequency

D Excessive fatigue and urinary frequency both are presumptive (subjective) signs and symptoms of pregnancy. Hegar's sign, ballottement, a positive pregnancy test, Chadwick's sign, and uterine souffle are probable (objective) signs or symptoms of pregnancy.

When performing newborn resuscitation, which action would the nurse do first? A) Intubate with an appropriate-sized endotracheal tube. B) Give chest compressions at a rate of 80 times per minute. C) Administer epinephrine intravenously. D) Suction the mouth and then the nose.

D After placing the newborn's head in a neutral position, the nurse would suction the mouth and then the nose. This is followed by ventilation, circulation (chest compressions), and administration of epinephrine.

The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest? A) 38 breaths per minute B) 46 breaths per minute C) 54 breaths per minute D) 68 breaths per minute

D After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). Thus a newborn with a respiratory rate below 30 or above 60 breaths per minute would require further evaluation.

A nurse teaches a postpartum woman about her risk for thromboembolism. Which of the following would the nurse be least likely to include as a factor increasing her risk? A) Increased clotting factors B) Vessel damage C) Immobility D) Increased red blood cell production

D Clotting factors that increased during pregnancy tend to remain elevated during the early postpartum period. Giving birth stimulates this hypercoagulability state further. As a result, these coagulation factors remain elevated for 2 to 3 weeks postpartum (Silver & Major, 2010). This hypercoagulable state, combined with vessel damage during birth and immobility, places the woman at risk for thromboembolism (blood clots) in the lower extremities and the lungs. Red blood cell production ceases early in the puerperium, which causes mean hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly over the next 2 weeks

The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: A) Have a smaller body surface compared to body mass B) Lose more body heat when they sweat than adults C) Have an abundant amount of subcutaneous fat all over D) Are unable to shiver effectively to increase heat production

D Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.

A nurse is assessing a newborn and observes the newborn moving his head and eyes toward a loud sound. The nurse interprets this as which of the following? A) Habituation B) Motor maturity C) Social behavior D) Orientation

D Orientation refers to the response of newborns to stimuli. It reflects newborns' response to auditory and visual stimuli, demonstrated by their movement of head and eyes to focus on that stimulus. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held.

A group of students are reviewing the process of breast milk production. The students demonstrate understanding when they identify which hormone as responsible for milk let-down? A) Prolactin B) Estrogen C) Progesterone D) Oxytocin

D Oxytocin is released from the posterior pituitary to promote milk let-down. Prolactin levels increase at term with a decrease in estrogen and progesterone; estrogen and progesterone levels decrease after the placenta is delivered. Prolactin is released from the anterior pituitary gland and initiates milk production.

The nurse is teaching a group of students about the differences between a full-term newborn and a preterm newborn. The nurse determines that the teaching is effective when the students state that the preterm newborn has: A) Fewer visible blood vessels through the skin B) More subcutaneous fat in the neck and abdomen C) Well-developed flexor muscles in the extremities D) Greater surface area in proportion to weight

D Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone.

A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds, integrating understanding that this most likely is due to which of the following? A) Placing the newborn prone after feeding B) Limited ability of digestive enzymes C) Underdeveloped pyloric sphincter D) Relaxed cardiac sphincter

D The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in their ability to digest complex carbohydrates and fats; this results in fatty stools, not regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric contents.

A postpartum client comes to the clinic for her 6-week postpartum checkup. When assessing the client's cervix, the nurse would expect the external cervical os to appear: A) Shapeless B) Circular C) Triangular D) Slit-like

D The external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."

The nurse is caring for a client who has just recieved an episiodomy. The nurse observes that the laceration extends through the perneal area and continues through the anterior rectal wall. how does the nurse classify the laceration? A. 1st degree b. 2nd degree c. 3rd degree d. 4th degree

D The nurse should classify the laceration as 4th degree because it continues throught the anterior rectal wall. 1st degree involves only skin and superficial structures above muscles2nd degree extends through perineal muscles3rd degree lacerations extend through the anal sphincter but not through the anterior rectal wall

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first? A) Alert the physician stat and turn the newborn to her right side. B) Administer oxygen via facial mask by positive pressure. C) Lower the newborn's head to stimulate crying. D) Aspirate the oral and nasal pharynx with a bulb syringe.

D The nurse's first action would be to suction the oral and nasal pharynx with a bulb syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the blockage due to secretions. Administering oxygen via positive pressure is not indicated at this time. Lowering the newborn's head would be inappropriate.

A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? A) "Your uterus is still shrinking in size; that's why you're feeling this pain." B) "Let me check your vaginal discharge just to make sure everything is fine." C) "Your body is responding to the events of labor, just like after a tough workout." D) "The baby's sucking releases a hormone that causes the

D The woman is describing afterpains, which are usually stronger during breast-feeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breast-feeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.

After teaching new parents about the sensory capabilities of their newborn, the nurse determines that the teaching was successful when they identify which sense as being the least mature? A) Hearing B) Touch C) Taste D) Vision

D Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales? A) Stop Rh sensitization B) Increase erythopoiesis C) Enhance bilirubin breakdown D) Promote blood clotting

D Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the liver. RhoGAM prevents Rh sensitization. Erythropoietin stimulates erythropoiesis. Phototherapy enhances bilirubin breakdown.

During assessment of the mother during postpartum period, what sign should alert the nurse that the client is likely experiencing uterine atony? A. fundus feels firm b. foul-smelling urine c. purulent vaginal discharge d. boggy or relaxed uterus

D. A boggy or relaxed uterus is sign of uterine atony. this can be result of bladder distention, which displaces the uterus upward and to the right, or retained placental fragments. Foul- smelling urine and purulent drainage are signs of infection but are not related to uterine atony. The firm fundus is normal.

"A nurse is caring for a 5-hour-old newborn. The physician has asked the nurse to maintain the newborn's temperature between 97.7° and 99.5° F (between 36.5° and 37.5° C). What nursing intervention should the nurse perform to maintain the temperature within the recommended range? a. Avoid measuring the weight of the infant, as scales may be cold. b. Use the stethoscope over the baby's garment. c. Place the newborn close to the outer wall in the room. d. Place the newborn skin-to-skin with the mother."

D. The nurse should place the newborn skin-to-skin with mother. This would help to maintain baby's temperature as well as promote breastfeeding and bonding between the mother and baby. The nurse can weigh the infant as long as a warmed cover is placed on the scale. The stethoscope should be warmed before it makes contact with the infant's skin, rather than using the stethoscope over the garment because it may obscure the reading. The newborn's crib should not be placed close to the outer walls in the room to prevent heat loss through radiation."

After teaching a group of nursing students about thermoregulation and appropriate measures to prevent heat loss by evaporation, which of the following student behaviors would indicate successful teaching? a. Transporting the newborn in an isolette b. Maintaining a warm room temperature c. Placing the newborn on a warmed surface d. Drying the newborn immediately after birth

D. Evaporation is the loss of heat as water is lost from the skin to the environment. Drying the newborn at birth and after bathing, keeping linens dry, and using plastic wrap blankets and heat shields will all prevent heat loss through evaporation.

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

D. Normal breathing can be described as shallow, at a rate of 36 bpm, with short periods of apnea.

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. Which of the following is the priority nursing intervention? a) Palpation for a femoral pulse b) Administration of IV epinephrine, as prescribed c) Transfer to a transitional or high-risk nursery for continuous cardiac surveillance d) Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. What is the priority nursing intervention?

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats per minute, closed-chest massage should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both your thumbs, on the lower third of the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 times per minute. If the pressure and the rate of massage are adequate, it should be possible, in addition, to palpate a femoral pulse. If heart sounds are not resumed above 60 beats per minute after 30 seconds of combined positive-pressure ventilation and cardiac compressions, intravenous epinephrine may be prescribed. Following cardio-resuscitation, newborns need to be transferred to a transitional or high-risk nursery for continuous cardiac surveillance to be certain cardiac function is maintained.

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. Which of the following is the priority nursing intervention? a) Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute b) Transfer to a transitional or high-risk nursery for continuous cardiac surveillance c) Administration of IV epinephrine, as prescribed d) Palpation for a femoral pulse

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute Explanation: If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats per minute, closed-chest massage should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both your thumbs, on the lower third of the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 times per minute. If the pressure and the rate of massage are adequate, it should be possible, in addition, to palpate a femoral pulse. If heart sounds are not resumed above 60 beats per minute after 30 seconds of combined positive-pressure ventilation and cardiac compressions, intravenous epinephrine may be prescribed. Following cardio-resuscitation, newborns need to be transferred to a transitional or high-risk nursery for continuous cardiac surveillance to be certain cardiac function is maintained.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus.

If the nurse manages a new infant with low blood sugar, which of the following would be an appropriate intervention to prevent hypoglycemia? a) Check the heart rate. b) Hold all feedings. c) Feed the infant. d) Give antibiotics.

Feed the infant. Correct Explanation: The infant could be fed early either breast milk or formula to prevent low blood sugar. If unable to feed well, the infant can receive intravenous fluids. The other choices do not raise blood sugar.

What are the postpartum physiologic danger signs?

Fever more than 38 C (100.4 F) after the first 24 hours; foul-smelling lochia or an unexpected change in color or amount; visual changes, such as blurred vision or spots, or headaches; calf pain experienced with dorsiflexion of the foot; swelling, redness, or discharge at the episiotomy site; dysuria, burning, or incomplete emptying of the bladder; shortness of breath or difficulty breathing; depression or extreme mood swings.

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 should focus on decreasing blood viscosity by increasing fluid volume in the newborn with polycythemia. Checking blood glucose within 2 hours of birth by a reagent test strip and screening every 2 to 3 hours or before feeds are not interventions that will alleviate the condition of an infant with polycythemia. The nurse should monitor and maintain blood glucose levels when caring for a newborn with hypoglycemia, not polycythemia.

After teaching a group of students about the effects of prematurity on various body systems, the instructor determines that the class was successful when the students identify which of the following as an effect of prematurity? a) Fragile cerebral blood vessels b) Enhanced ability to digest proteins c) Enlarged respiratory passages d) Rapid glomerular filtration rate

Fragile cerebral blood vessels Explanation: Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate.

A client has delivered a small for gestation age (SGA) newborn. Which of the following would the nurse expect to assess? a) Head larger than body b) Brown lanugo body hair c) Round flushed face d) Protuberant abdomen

Head larger than body Explanation: Head being larger than the rest of the body is the characteristic feature of small for gestational age infants. Small for gestational age infants weigh below the 10th percentile on the intrauterine growth chart for gestational age. The heads of SGA infants appear larger in proportion to their body. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large for gestational age (LGA) infants. Preterm infants, and not SGA infants, are covered with brown lanugo hair all over the body.

Which of the following is a consequence of hypothermia in a newborn? a) Respirations of 46 b) Heart rate of 126 c) Skin pink and warm d) Holds breath 25 seconds

Holds breath 25 seconds

Which of the following is a consequence of hypothermia in a newborn? a) Skin pink and warm b) Holds breath 25 seconds c) Heart rate of 126 d) Respirations of 46

Holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

You care for a child born with a tracheoesophageal fistula. Which finding during pregnancy would have caused you to suspect this might be present? a) Oligohydramnios b) A difficult second stage of labor c) Hydramnios d) Bleeding at 32 weeks of pregnancy

Hydramnios

The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which of the following? a) Asphyxia b) Meconium aspiration c) Hypoglycemia d) Polycythemia

Hypoglycemia Correct Explanation: Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.

An obese woman with diabetes has just given birth to a term, large for gestational age (LGA) newborn. Which of the following conditions should the nurse most expect to find in this infant? a) Hypoglycemia b) Hypertension c) Hypotension d) Hyperglycemia

Hypoglycemia Correct Explanation: LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes which was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.

A nurse is explaining the benefits of breastfeeding to a client who has just delivered. Which statement correctly explains the benefits of breastfeeding to this mother?

Immunoglobulin IgA in breast milk boosts a newborn's immune system

In an infant who has hypothermia, what would be an appropriate nursing diagnosis? a) Ineffective parental attachment b) Impaired tissue perfusion c) Alteration in nutrition d) Impaired skin integrity

Impaired tissue perfusion Correct Explanation: Impaired tissue perfusion would be appropriate and may be related to cardiopulmonary, cerebral, gastrointestinal, peripheral, or renal issues.

The nurse is caring for a client who had been administered an anesthetic block during labor. Which of the following are risks that the nurse should watch for in the client? (Select all)

Incomplete emptying of the bladder; bladder distention; urinary retention

The nurse in a newborn nursery is observing for developmentally appropriate care. Which is an example of self-regulation?

Infant has hand in mouth Self-regulation is a form of self-soothing for an infant such as sucking on hands or putting hand to mouth type of movements.

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. Metabolic needs are increased for catch-up growth in the SGA newborn. Initiate early and frequent oral feedings. Neonatal hypoglycemia is a major cause of brain injury since the brain needs glucose continuously as a primary source of energy. A newborn stressed at birth uses up available glucose stores quickly with resulting hypoglycemia. A plasma glucose concentration at or below 40 mg/dL necessitates and frequent oral feedings. With the loss of the placenta at birth, the newborn now must assume control of glucose homeostasis through oral feedings. The others at this time are not a priority.

An infant that is diagnosed with meconium aspiration displays which symptom? a) Pink skin b) No heart murmur c) Respirations of 45 d) Intercostal and substernal retractions

Intercostal and substernal retractions

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being delivered. Which of the following interventions should the nurse implement as a result of this finding? a) Administration of oxygen via a bag and mask b) Intubation and suctioning of the trachea c) Gently shaking the infant d) Flicking the sole of the infant's foot

Intubation and suctioning of the trachea Correct Explanation: Although there is some dispute regarding whether all infants with meconium staining need intubation, those with severe staining are usually intubated and meconium is suctioned from their trachea and bronchi. Do not administer oxygen under pressure (bag and mask) until a meconium stained infant has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the infant and flicking the sole of his foot are methods of stimulating breathing in an infant experiencing apnea.

A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) More than 4,000 g b) Less than 1,500 g c) Less than 1,000 g d) Approximately 2,500 g

Less than 1,500 g

A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) Approximately 2,500 g b) More than 4,000 g c) Less than 1,500 g d) Less than 1,000 g

Less than 1,500 g Correct Explanation: A very-low-birthweight newborn weighs less than 1,500 g. A large-for-gestational-age newborn typically weighs more than 4,000 g. A small-for-gestational-age newborn or a low-birthweight newborn typically weighs about 2,500 g. An extremely-low-birthweight newborn weighs less than 1,500 g.

When reviewing the medical record of a newborn who is large for gestational age (LGA), which of the following factors would the nurse identify as having increased the newborn's risk for being LGA? a) Fetal exposure to low estrogen levels b) Low weight gain during pregnancy c) Maternal pregravid obesity d) Low maternal birth weight

Maternal pregravid obesity Correct Explanation: The nurse should identify maternal pregravid obesity as a risk factor for the development of LGA newborns. The other risk factors for the development of LGA newborns include fetal exposure to high estrogen, excess weight gain during pregnancy, gestational diabetes and high maternal birth weight.

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?

McRobert's maneuver The McRobert's maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the client in the lithotomy position, while each holds a leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. What is the first maneuver tried to deliver an infant with shoulder dystocia?

McRoberts maneuver McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. Which of the following should the nurse expect when assessing the condition of the newborn? a) Meconium aspiration in utero or at birth b) Yellow appearance of the newborn's skin c) Tremors, irritability, and high-pitched cry d) Seizures, respiratory distress, cyanosis, and shrill cry

Meconium aspiration in utero or at birth Correct Explanation: Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.

A nurse is caring for a newborn whose chest x-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. The nurse should prepare for the management of which dangerous conditions when providing care to this newborn? a) Choanal atresia b) Diaphragmatic hernia c) Meconium aspiration syndrome d) Pneumonia

Meconium aspiration syndrome

which symptom would MOST accurately indicate that a newborn has experienced meconium aspiration during the delivery process?

Meconium stained fluids followed by tachypnea

A perinatal nurse is providing care for a large for gestational age neonate admitted to the observational unit after a complicated vaginal birth resulting in shoulder dystocia. Which assessment would be a priority for the nurse to perform?

Moro assessment

A perinatal nurse is providing care for a large for gestational age neonate admitted to the observational unit after a complicated vaginal birth resulting in shoulder dystocia. Which assessment would be a priority for the nurse to perform?

Moro assessment Thoroughly assess the LGA newborn at birth to identify traumatic birth injuries such as fractured clavicles resulting from the trauma. Shoulder injury may result and can be identified with an absent Moro reflex on injured side. The Ballard Scale is a commonly used technique of gestational age assessment. The Dubowitz assessment is a neurological assessment included in the Ballard assessemnt. Testing the suck reflex would not be a priority.

Which of the following data is indicative of hypothermia of the preterm infant? a) Regular respirations b) Oxygen saturation of 95% c) Nasal flaring d) Pink skin

Nasal flaring

Which intervention should a nurse implement to promote thermal regulation in a preterm newborn? a) Observe for clinical signs of cold stress such as weak cry b) Check the blood pressure of the infant every 2 hours c) Assess the newborn's temperature every 8 hours until stable d) Set the temperature of the radiant warmer at a fixed level

Observe for clinical signs of cold stress such as weak cry

What is the first action the nurse takes in surfactant administration? a) Call pharmacy for medication. b) Obtain and document baseline vital signs. c) Change the infant's diaper. d) Hold feedings.

Obtain and document baseline vital signs.

What is the first action the nurse takes in surfactant administration?

Obtain and document baseline vital signs. Obtaining a baseline set of vital signs is the first step in surfactant administration. The nurse will need a baseline in case there is any reaction to the medication administration. The other choices are not the first thing done before instilling this medication.

A client with diabetes delivers a full-term neonate who weights 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse palpates the clavicles for which reason? a) Clavicles are commonly absent in neonates of mothers with diabetes. b) Neonates of mothers with diabetes have brittle bones. c) LGA neonates have glucose deposits on their clavicles. d) One of the neonate's clavicles may have been broken during delivery.

One of the neonate's clavicles may have been broken during delivery. Correct Explanation: Because of the neonate's large size, clavicular fractures are common during delivery. The nurse should assess all LGA neonates for this occurrence. None of the other options are true.

A nurse is caring for a client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. The nurse would be accurate in identifying which hormone as the cause of these after pains?

Oxytocin

AFTERPAINS

Painful contractions of the uterus that occur for several days after delivery

____________ jaundice is manifested within the first 24 hours of life when total bilirubin levels increase by more than 5 mg/dL/day and the total serum bilirubin level is higher than 17 mg/dL in a full-term infant. This condition requires intervention

Pathologic

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? a) A sleepy, lethargic neonate b) Vernix caseosa covering the neonate's body c) Peeling and wrinkling of the neonate's epidermis d) Lanugo covering the neonate's body

Peeling and wrinkling of the neonate's epidermis

________________, more appropriately known as hypoxic-ischemic encephalopathy, is characterized by clinical and laboratory evidence of acute or subacute brain injury due to systemic hypoxemia or reduced cerebral blood flow

Perinatal asphyxia

Which of the following places newborns at risk for ongoing health problems? a) Average weight b) Term birth c) Vaginal delivery d) Perinatal asphyxia

Perinatal asphyxia Correct Explanation: Several disorders can place newborns at risk for ongoing health problems such as prematurity, low birth weight, congenital abnormalities, perinatal asphyxia, and birth trauma. These conditions need further nursing assessment and care for optimal growth and healing. The other choices do not place a risk on the infant.

____________ jaundice typically starts after 72 hours of breast-feeding. There is an enzyme in breast milk that inhibits the breakdown of bilirubin, and it is reflected on the newborn skin as jaundice.

Physiologic

When preparing to resuscitate a preterm newborn, which of the following would the nurse do first? a) Administer epinephrine. b) Hyperextend the newborn's neck. c) Place the newborn's head in a neutral position. d) Use positive-pressure ventilation.

Place the newborn's head in a neutral position.

The small-for-gestation neonate is at increased risk for which complication during the transitional period? a) Hyperthermia due to decreased glycogen stores b) Polycythemia probably due to chronic fetal hypoxia c) Hyperglycemia due to decreased glycogen stores d) Anemia probably due to chronic fetal hypoxia

Polycythemia probably due to chronic fetal hypoxia Correct Explanation: The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores

The nurse caring for a small for gestational age newborn in the specialcare nursery. What characteristics are commonly documented? Select all that apply.

Poor skin turgor Sparse or absent hair Diminished muscle tissue

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.

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth. The findings are consistent with uterine rupture. An abrupt change in the fetal heart rate pattern is often the most significant finding associated with uterine rupture. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. Falling blood pressure and rising pulse may be associated with hypovolemia caused by occult bleeding. The treatment is immediate cesarean birth.

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.

An 18-year-old client has given birth to a very-low-birth-weight preterm infant. Which of the following should the nurse consider to prevent the newborn from losing body temperature? a) Hold the newborn close, rocking gently. b) Provide isolette or radiant warmer care to the newborn. c) Give the newborn a warm water bath. d) Administer vitamin K to the newborn.

Provide isolette or radiant warmer care to the newborn. Correct Explanation: The nurse should place the infant in an isolette to simulate the uterine environment as closely as possible and to keep the infant warm. The isolette maintains even levels of temperature, humidity, and oxygen. A hood covers it, and nurses can give care through portholes. Holding and frequent handling of the newborn should be avoided to prevent loss of energy. Minimal handling helps the neonate to conserve energy. Administration of vitamin K to the infant is necessary to prevent bleeding in the infant because the newborn is unable to produce its own vitamin K during the early stages of life. It does not help in providing warmth to the baby. The infant is not given baths until later because this often results in loss of body temperature.

A woman near term presents to the clinic highly agitated because her membranes have just ruptured and she felt something come out when they did. The nurse is alone with her and notices that the umbilical cord is hanging out of the vagina. What should the nurse do next?

Put her in bed immediately, call for help, and hold the presenting part of the cord. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, when the presenting part compresses the cord oxygen, and nutrients are cut off to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and the nurse does not leave the woman. A vaginal birth is contraindicated in this situation.

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. Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest X-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute).

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 is true for a newborn with RDS? a) Respiratory symptoms of RDS typically improve within a short period of time. b) RDS is caused by a lack of alveolar surfactant. c) Glucocorticosteroid is given to the newborn following birth. d) RDS is characterized by heart rates below 50 beats per minute.

RDS is caused by a lack of alveolar surfactant. Correct Explanation: Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest x-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute).

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer?

Radiation

What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? a) Skin as pink b) Respirations as increased and high c) Chest expansion as normal d) Heart rate as normal

Respirations as increased and high

What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? a) Respirations as increased and high b) Skin as pink c) Chest expansion as normal d) Heart rate as normal

Respirations as increased and high Correct Explanation: Infants with meconium aspiration syndrome may show signs of respiratory distress (tachypnea, cyanosis, retractions, chest retractions). The other choices document normal findings.

Seesaw respirations is seen in

Respiratory Distress Syndrome

A newborn is being monitored for retinopathy of prematurity. Which of the following conditions predisposes an infant to this condition? a) Down syndrome b) Esophageal atresia c) Hydrocephalus d) Respiratory distress syndrome

Respiratory distress syndrome

A newborn is being monitored for retinopathy of prematurity. Which of the following conditions predisposes an infant to this condition? a) Esophageal atresia b) Down syndrome c) Respiratory distress syndrome d) Hydrocephalus

Respiratory distress syndrome Correct Explanation: Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.

A client who has given birth is being discharges from the the health care facility. She wants to know how safe it would be for her to have intercourse. Which of the following instructions should the nurse provide to the client regarding intercourse after childbirth?

Resume intercourse if bright-red bleeding stops.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which of the following should the nurse consider as a complication of oxygen administration at a high concentration? a) Bronchopulmonary dysplasia b) Necrotizing enterocolitis c) Retinopathy of prematurity d) Diminished erythropoiesis

Retinopathy of prematurity

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 Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which of the following should the nurse consider as a complication of oxygen administration at a high concentration? a) Retinopathy of prematurity b) Diminished erythropoiesis c) Bronchopulmonary dysplasia d) Necrotizing enterocolitis

Retinopathy of prematurity Correct Explanation: Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.

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?

RoP

When caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant? a) Using minimal amount of tape b) Rocking and massaging c) Using distraction through objects d) Swaddling and positioning

Rocking and massaging

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression. Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.

A nurse is caring for a newborn with jaundice undergoing phototherapy. What intervention is appropriate when caring for the newborn? a) Shield the newborn's eyes b) Expose the newborn's skin minimally c) Discourage feeding the newborn d) Discontinue therapy if stools are loose, green, and frequent

Shield the newborn's eyes

A nurse is caring for a baby girl born at 34 weeks' gestation. Which of the following features should the nurse identify as those of a preterm newborn? a) Scant coating of vernix b) Closely approximated labia c) Paper-thin eyelids d) Shiny heels and palms

Shiny heels and palms Correct Explanation: A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in post-term newborns and is excessive in premature infants.

When teaching the new mother about breast-feeding, the nurse is correct when providing what instructions?

Show mothers how to initiate breast-feeding within 30 minutes of birth; Encourage breast-feeding of the newborn infant on demand; Place baby in uninterrupted skin-to-skin contact with the mother.

Esophageal Atresia and Tracheoesophageal Fistula what would the nurse notice?

Soon after birth, the newborn may exhibit copious, frothy bubbles of mucus in the mouth and nose, accompanied by drooling. *"the three Cs" (coughing, choking, and cyanosis)

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which of the following additional signs should the nurse consider as indications of respiratory distress syndrome (RDS) in the newborn? a) Sternal retraction b) Deep inspiration c) Expiratory lag d) Inspiratory grunt

Sternal retraction

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which of the following additional signs should the nurse consider as indications of respiratory distress syndrome (RDS) in the newborn? a) Inspiratory grunt b) Deep inspiration c) Sternal retraction d) Expiratory lag

Sternal retraction Correct Explanation: The nurse should consider sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration.

A nurse is assessing an infant who has experienced asphyxia at birth. Which finding indicates that the resuscitation methods have been successful? a) Heart rate of 80 bpm b) Jitteriness c) Hypotonia d) Strong cry

Strong cry

While caring for a client following a lengthy labor & delivery, the nurse notes that the client repeatedly reviews her labor & delivery and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?

Taking-in; this phase occurs during the first 24-48 hours. The second phase is the taking-hold phase and usually lasts several weeks after delivery and is characterized by both dependent & independent behavior. The letting-go phase is when the mother re-establishes relationships with others and accepts her new role as a parent.

A 39-year-old multigravida with diabetes presents to the clinic at 32 weeks' gestation because she has not felt the fetus moving lately. FHR is absent; sonogram confirms that the fetus has died. The nurse's institution has a policy of taking photographs of such fetuses once they are born. The nurse informs the woman that pictures have been taken and asks her if she wants them; she angrily tells the nurse no, then bursts into tears. How should the nurse respond?

Tell her that the hospital will keep the photos for her in case she changes her mind. Emotional care of the woman is complex. The woman may need time to move through the stages of grief and the responses of grief vary from person to person. The mother may request the items later and they should be stored or kept for a year after the delivery. There is no need to apologize to the client. It would be inappropriate to console her with the fact that she has other children. It negates her feelings and is not supportive of the woman at this time.

Engorgement of breasts

Temporary swelling or fullness of the breasts in response to increased blood flow when the milk begins to "come in". Usually on the second or third day after birth.

A woman gives birth to a newborn at 38 weeks' gestation. The nurse classifies this newborn as which of the following? a) Late preterm b) Term c) Preterm d) Postterm

Term Correct Explanation: A term newborn is one born from the first day of the 38th week of gestation through 42 weeks. A postterm newborn is one born after completion of 42 weeks' gestation. A preterm newborn is one born before completion of 37 weeks' gestation. A late preterm newborn is one who is bone between 34 and 36-6/7 weeks' gestation

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 most likely be classified as which of the following? a) Late preterm, large for gestational age, and low-birth-weight infant b) Term, small for gestational age, and low-birth-weight infant c) Late preterm and appropriate for gestational age d) Term, small for gestational age, and very-low-birth-weight infant

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

what's the most important thing nurse needs to know about managing newborn with persistent pulmonary hypertension

That Almost any procedure, such as suctioning, weighing, changing diapers, or positioning, can precipitate severe hypoxemia due to the instability of the pulmonary vasculature. Therefore, minimize the newborn's exposure to stimulation as much as possible.

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.

At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate?

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

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.

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

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

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. The ear has a soft pinna that is flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.

A preterm infant is transferred to a distant hospital for care. When her parents visit her, which of the following would be most important for you to urge them to do? a) Call the baby by her name. b) Touch and, if possible, hold her. c) Stand so the baby can see them. d) Bring a piece of clothing for her.

Touch and, if possible, hold her. Correct Explanation: Preterm infants may be hospitalized for an extended time, so parents need to be encouraged to touch and interact with the infant to begin bonding.

Preterm infant deaths account for 80% to 90% of infant mortality in the first year of life. a) False b) True

True

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the mid line to the right. What intervention will help the client most?

Urinary catheterization.

A client is undergoing a routine check-up 2 months after the birth of her child. The nurse understands that the client is not practicing Kegel exercises. Which of the following should the nurse tell the client is caused by poor perineal muscular tone?

Urinary incontinence.

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?

Use a fist to apply counter pressure to the lower back. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position.

A client delivers a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of: a) Normal birth weight b) Very low birth weight c) Extremely low birth weight d) Low birth weight

Very low birth weight Correct Explanation: A birth weight of 1.2 kg would be classified as very low birth weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low birth weight. A birth weight between 1,000 g and 1,500 g is termed a very low birth weight. A birth weight less than 1,000 g is termed an extremely low birth weight

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance.

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin, with so little muscle. The nurse responds based on the understanding about which of the following? a) The newborn was exposed to an infection while in utero. b) The newborn aspirated meconium, causing the wasted appearance. c) A postterm newborn has begun to break down red blood cells more quickly. d) With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. Explanation: After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance.

imperforate anus

a congenital defect in which the rectal opening is missing or blocked.

A nurse is caring for a newborn with transient tachypnea. Which is the priority nursing intervention? a) Administer IV fluids; gavage feedings. b) Monitor for signs of hypotonia. c) Perform gentle suctioning. d) Maintain adequate hydration.

a) Administer IV fluids; gavage feedings. The nurse should administer IV fluids and gavage feedings until the respiratory rate decreases enough to allow oral feedings when caring for a newborn with transient tachypnea. Maintaining adequate hydration and performing gentle suctioning are relevant nursing interventions when caring for a newborn with respiratory distress syndrome. The nurse need not monitor the newborn for signs and symptoms of hypotonia because hypotonia is not known to occur as a result of transient tachypnea. Hypotonia is observed in newborns with inborn errors of metabolism or in cases of periventricular hemorrhage/intravenricular hemorrhage

A client with group AB blood whose husband has group O blood has just given birth. Which complication or test result is a major sign of ABO blood incompatibility that the nurse should look for when assessing this neonate? a) Jaundice within the first 24 hours of life b) Jaundice after the first 24 hours of life c) Negative Coombs' test d) Bleeding from the nose or ear

a) Jaundice within the first 24 hours of life Explanation: The neonate with an ABO blood incompatibility with its mother will have jaundice within the first 24 hours of life. The neonate would have a positive Coombs' test result. Jaundice after the first 24 hours of life is physiologic jaundice. Bleeding from the nose and ear should be investigated for possible causes but probably isn't related to ABO incompatibility

When caring for a week-old infant with jaundice, the nurse observes the infant's urine to be dark in color. The nurse would also expect to assess what as indicative of significant hyperbilirubinemia? Select all that apply. a) Poor feeding and lethargy b) Decreased volume of urination c) Light, tan-colored stool after milk intake d) Jaundice limited to the nose, eyes, and ears e) Late passage of meconium stool

a) Poor feeding and lethargy c) Light, tan-colored stool after milk intake e) Late passage of meconium stool Poor feeding and lethargy, late passage of meconium stool, and light, tan-colored stool after milk intake are features of significant hyperbilirubinemia. Decrease in volume of urination is not seen with hyperbilirubinemia. Jaundice limited to the nose, eyes and ears is a physiologic jaundice, and does not indicate significant hyperbilirubinemia

The nurse is providing care to a newborn who was born at 36 weeks' gestation. Based on the nurse's understanding of gestational age, the nurse identifies this newborn as: a) late preterm. b) preterm. c) postterm. d) term.

a) late preterm. Gestational age is typically measured in weeks: a newborn born before completion of 37 weeks is classified as a preterm newborn, and one born after completion of 42 weeks is classified as a postterm newborn. An infant born from the first day of the 38th week through 42 weeks is classified as a term newborn. The late preterm newborn (near term) is one who is born between 34 weeks and 36 weeks, 6 days of gestation

The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn? Select all that apply. a) maternal smoking during pregnancy b) asthma exacerbations during pregnancy c) pregnancy weight gain of 25 lb (11 kg) d) drug abuse e) hypotension upon admission

a) maternal smoking during pregnancy b) asthma exacerbations during pregnancy d) drug abuse The nurse should be alert to the possibility of an SGA newborn if the history of the mother reveals smoking, chronic medical conditions (such as asthma), and drug abuse. Additional maternal factors that increase the risk for an SGA newborn include hypertension, genetic disorders, and multiple gestations

The nurse caring for newborns on an obstetrical ward assesses an SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) sparse or absent hair b) increased fatty tissue c) tight and moist skin d) poor skin turgor e) diminished muscle tissue f) narrow skull sutures

a) sparse or absent hair d) poor skin turgor e) diminished muscle tissue Characteristics of the SGA newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts

Which findings would the nurse expect in a newborn who is considered small for gestational age? Select all that apply. a) sunken abdomen b) increased subcutaneous fat stores c) poor muscle tone over buttocks d) narrow skull sutures e) dry or thin umbilical cord

a) sunken abdomen c) poor muscle tone over buttocks e) dry or thin umbilical cord A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.

"A mother who is 4 days postpartum, and is breastfeeding, expresses to the nurse that her breast seems to be tender and engorged. What education should the nurse give to the mother to relieve breast engorgement? Select all that apply. a. Take warm-to-hot showers to encourage milk release. b. Feed the newborn in the sitting position only. c. Express some milk manually before breastfeeding. d. Massage the breasts from the nipple toward the axillary area.e. Apply warm compresses to the

a, c, e To relieve breast engorgement in the client, the nurse should educate the cli- ent to take warm-to-hot showers to encourage milk release, express some milk manually before breastfeeding, and apply warm compresses to the breasts before nursing. The mother should be asked to feed the newborn in a variety of positions—sitting up and then lying down. The breasts should be massaged from under the axil- lary area, down toward the nipple."

"A nurse is performing a detailed newborn assessment of a female baby. Which of the following observations indicate a normal finding? Select all that apply. a. Mongolian spots b. Enlarged fontanelles c. Swollen genitals d. Low-set ears e. Short, creased neck"

a, c, e Mongolian spots, swollen genitals in the female baby, and a short, creased neck are normal findings in a newborn. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Female babies may have swollen genitals as a result of maternal estrogen. The newborn's neck will appear almost nonexistent because it is so short. Creases are usually noted. Enlarged fontanelles are associated with malnutrition; hydrocephaly; congenital hypothyroidism; triso- mies 13, 18, and 21; and various bone disorders such as osteogenesis imperfecta. Low-set ears are characteristic of many syndromes and genetic abnormalities such as trisomies 13 and 18 and internal organ abnormalities involving the renal system."

A nurse is educating the mother of a new- born about feeding and burping. Which of the following strategies should the nurse offer to the mother regarding burping? a. Hold the baby upright with the baby's head on her mother's shoulder. b. Lay the baby on its back on its mother's lap. c. Gently rub the baby's abdomen while the baby is in a sitting position. d. Lay the baby on its mother's lap and give it frequent sips of warm water."

a. The nurse should ask the mother to hold the baby upright with the baby's head on her mother's shoulder. Alternatively, the nurse can also suggest the mother sit with the newborn on her lap with the newborn lying face down. Gently rubbing the baby's abdomen or giving frequent sips of warm water to the infant will not significantly induce burping; burping is induced by the newborn's position. Placing the baby on her back while trying to elicit burping after feeding may cause choking or aspiration."

A first-time mother informs the nurse that she is unable to breastfeed her baby through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her baby. What instruction should the nurse offer the woman to ensure the safety of stored expressed breast milk? a. Use sealed and chilled milk within 24 hours b. Use frozen milk within 6 months of obtaining it c. Use microwave ovens to warm chilled milk d. Refreeze any unused milk for later use"

a. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it."

After teaching a class on ways to decrease the postpartum complication of thrombotic conditions, the nurse recognizes more teaching is needed when one of the participants states: a. "At least, I don't have to give up smoking for this one." b. "Using passive range-of-motion exercises in bed sounds easy enough." c. "He has to do the deep breathing exercises with me." d. "I can drink more, so I don't get dehydrated."

a. "At least, I don't have to give up smoking for this one."

Which of the following questions should be asked of women during all routine medical examinations? Select all that apply. a. "Has anyone ever forced you to have sex?" b. "Are you sexually active?" c. "Are you ever afraid to go home?" d. "Does anyone you know ever hit you?" e. "Have you ever breastfed a child?"

a. "Has anyone ever forced you to have sex?" b. "Are you sexually active?" c. "Are you ever afraid to go home?" d. "Does anyone you know ever hit you?"

A woman opts to use a diaphragm for contraception. Which instruction would be most important for the nurse to provide? a. "Have your diaphragm refitted if you lose 10 pounds or more." b. "Replace the diaphragm every six months" c. "Wet the diaphragm with water first before inserting it" d. "Keeping the diaphragm in place for no more than four hours after intercourse"

a. "Have your diaphragm refitted if you lose 10 pounds or more."

A client is being taught about the care and use of the diaphragm. Which of the following comments by the woman shows that she understands the teaching that was provided? a. "I should regularly put the diaphragm up to the light and look at it carefully." b. "This is one method that can be used during menstruation." c. "I can leave the diaphragm in place for a day or two." d. "The diaphragm should be well powdered before I put it back in the case."

a. "I should regularly put the diaphragm up to the light and look at it carefully."

After teaching a woman who has chosen the vaginal ring as her method of contraception, the nurse determines that the client needs additional teaching when she states which of the following? a. "I will insert a new ring at the same time and day of every week." b. "I'll compress the ring, inserting it as far back as possible." c. "Once I remove the ring, I'll discard it." d. "I don't have to worry so much about the exact placement."

a. "I will insert a new ring at the same time and day of every week."

A pregnant woman experiencing morning sickness has asked her nurse about ways to reduce or alleviate it. After receiving education and information from the nurse, which of the following statements would indicate that the client understood the information? a. "I'll discuss with my doctor whether it is a good idea for me to use sea-bands." b. "My mother told me that she took vitamins to reduce the sickness and there wasn't a problem" c. "I'll just drink less ginger tea than I used to" d. "I really don't think there's anything wrong with taking a few vitamins"

a. "I'll discuss with my doctor whether it is a good idea for me to use sea-bands."

After teaching a pregnant woman how to count fetal movements, the nurse determines that the teaching was successful when the client states which of the following? a. "I'll sit comfortably in a recliner or lie on my side when I do the counts." b. "I'll do the counts while I'm sitting and watching my son's basketball game." c. "I won't expect more than three movements to happen in an hour." d. "I'll do the count once a week on a morning that I'm not rushed for work."

a. "I'll sit comfortably in a recliner or lie on my side when I do the counts."

After a class on genetics, the nurse notices that the individuals understood the basics when one says: a. "My genome is my genetic blueprint." b. "A secondary goal of determining my genome is to find new treatments." c. "My parents gave me good phenotypes." d. "Your outward characteristics show some interesting genotypes."

a. "My genome is my genetic blueprint."

The family has decided to have a home birth with a midwife. Which of the following statements indicates to the home health nurse that they have considered all options? a. "Our midwife works with a local physician and hospital, in case there are any complications or concerns." b. "We live so far from the hospital, we just can't afford the gas to get there." c. "We do not like the rules at the local birth center. They are too rigid." d. "My previous pregnancies were low-risk"

a. "Our midwife works with a local physician and hospital, in case there are any complications or concerns."

The client is anxious about her prolonged pregnancy. She informs the nurse she has been doing research on the Internet and has read about certain herbs that can help. Which of the following would an appropriate response from the nurse? a. "Please talk to your physician first to ensure it is safe." b. "Why would you do something as stupid as that." c. "Personally, I would use them, but I cannot tell you to." d. "There is no scientific evidence they work. You will just complicate your situation more."

a. "Please talk to your physician first to ensure it is safe."

A nurse is providing contraceptive counseling to a perimenopausal client, G3 P2012, who is in a monogamous relationship. Which of the following comments by the woman indicates that further teaching is needed? a. "The calendar method is the most reliable method for me to use." b. "If I use the IUD, I am at minimal risk for pelvic inflammatory disease." c. "I should still use birth control even though I had only 2 periods last year." d. "The contraceptive patch contains both estrogen and progesterone."

a. "The calendar method is the most reliable method for me to use."

After teaching a group of students about the physiologic jaundice in breast-fed and bottle-fed newborns, the instructor determines that the teaching was successful when the students state which of the following? a. "The decline in bilirubin levels occurs more quickly in bottle-fed newborns." b. "Jaundice associated with bottle feeding occurs in two distinct patterns." c. "Breastfed newborns tend to have more frequent bowel movements." d. "Peak bilirubin levels occur earlier for bottle-fed newborns than for breast-fed newborns."

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

After a birthing class, the nurse recognizes additional education is needed when one of the participant's states: a. "We are going to save the cord blood, in case our baby needs it later" b. "We are going to donate our cord blood to the blood bank to help others" c. "We decided against signing the informed consent to save the cord blood" d. "We will be storing the cord blood at the local facility"

a. "We are going to save the cord blood, in cause our baby needs it later"

A client has just been told she is pregnant with twins. The ultrasound reveals that the babies are monozygotic. She has several questions about her babies. What information should be shared with the client by the nurse? (Select all that apply). a. "Your babies likely will share the same placenta" b. "We will need to wait for a few more weeks to determine if you have a boy and a girl or if both are the same gender" c. "Your babies have developed from a single fertilized egg" d. "Your babies will be very similar in appearance" e. "Your babies will share a single amniotic sac"

a. "Your babies likely will share the same placenta" c. "Your babies have developed from a single fertilized egg" d. "Your babies will be very similar in appearance"

A client is admitted to the unit in preterm labor. In preparing the client for tocolytic therapy, the nurse recognizes this will prolong the pregnancy for which of the following? a. 2 to 7 days b. 4 to 8 days c. 6 to 10 days d. 1 to 5 days

a. 2 to 7 days

A woman is in her early second trimester of pregnancy. The nurse would instruct the woman to return for a follow-up visit every: a. 4 weeks b. 3 weeks c. 2 weeks d. 1 week

a. 4 weeks

The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse would know that macrosomia would indicate the fetus weighs which of the following? a. 4,000 g or more b. 4,500 g or more c. 3,000 g or more d. 3,500 g or more

a. 4,000 g or more

During pregnancy a woman's blood volume increases to accommodate the growing fetus to the point that vital signs may remain within normal range without showing signs of shock until the woman has lost what percentage of her blood volume? a. 40% b. 30% c. 20% d. 50%

a. 40%

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

a. 5% to 10% of their birth weight

When teaching a class of new parents about the needs of their newborn, which of the following would the nurse suggest to be a good indicator of the infant getting enough fluids? a. 6 to 8 voidings per day b. 4 to 6 voidings per day c. 2 to 4 voidings per day d. 8 to 10 voidings per day

a. 6 to 8 voidings per day

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured when the result is which of the following? a. 6.5 b. 6.0 c. 5.5 d. 5.0

a. 6.5

At the first prenatal visit of all clients who come to your clinic, appropriate blood screenings are obtained. You realize that a hemoglobin A1c above which level is concerning for diabetes and warrants further testing? a. 6.5% b. 5.5% c. 5.0% d. 6.0%

a. 6.5%

A client is Rh-negative and has given birth to a newborn who is Rh-positive. Within how many hours should Rh immunoglobulin be injected in the mother? a. 72 b. 75 c. 78 d. 80

a. 72

A woman is to undergo karyotyping. The nurse best explains this testing as which of the following? a. A picture-like analysis of the number, form, and size of the woman's chromosomes b. The makeup of the gene pairs inherited from one's parents c. A representation of the observable characteristics of an individual d. A picture of a person's genetic blueprint

a. A picture-like analysis of the number, form, and size of the woman's chromosomes

A nurse is assigned to care for a client who has to undergo a forceps and vacuum-assisted birth. The nurse understands that which of the following factors has contributed to a forceps and vacuum-assisted birth? a. A prolonged second stage of labor b. Oligohydramnios due to placental insufficiency c. Preterm labor with premature rupture of membranes d. Rupture of uterus

a. A prolonged second stage of labor

New parents should be encouraged to keep follow-up appointments and to call their health care provider if they notice signs of illness in their newborn. Which of the following are warning signs of illness that parents should be aware of? (Select all that apply.) a. Abdominal distention b. General fussiness c. Refuse feeding d. Approximately 8 wet diapers a day e. Temperature of 38.3% C (101% F) or higher

a. Abdominal distention c. Refuse feeding

The client is single, admits to not using condoms during sexual intercourse, and has had multiple partners over the past year. Which of the following symptoms would alert the nurse to a possible gonorrheal infection? (Select all that apply.) a. Abnormal vaginal discharge b. Mild sore throat c. Abnormal uterine bleeding d. Dysuria

a. Abnormal vaginal discharge b. Mild sore throat c. Abnormal uterine bleeding d. Dysuria

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which of the following primary conditions? (Select all that apply.) a. Abruptio placenta b. Severe preeclampsia c. Isoimmunization d. Ectopic pregnancy e. Septicemia

a. Abruptio placenta b. Severe preeclampsia e. Septicemia

In preparing for a class for a group of new parents, the nurse should include that smoking can increase the risk of which of the following complications? (Select all that apply.) a. Abruptio placenta b. Premature rupture of membranes c. Spontaneous abortion d. High birth weight e. Maternal hypertension

a. Abruptio placenta c. Spontaneous abortion e. Maternal hypertension

Which of the following would the nurse expect to be included in the plan of care for an infant of a diabetic mother who has a serum calcium level of 6.2 mg/dL? a. Administration of calcium gluconate b. Initiation of phototherapy c. Initiation of oral feedings d. Infusions of intravenous glucose

a. Administration of calcium gluconate

A 24-year-old female client presents with various complaints. She admits to having unprotected sexual intercourse. Which of the following findings would indicate a possible PID? (Select all that apply.) a. Adnexal tenderness b. Cervical motion tenderness c. Lower abdominal tenderness d. Constipation

a. Adnexal tenderness b. Cervical motion tenderness c. Lower abdominal tenderness

A client with hypertension tells her nurse that she would like to use an herbal substance to lower her blood pressure instead of taking the prescribed antihypertensive medication. The nurse should: a. Advise the client to speak with her physician about substituting herbal substances with her medication. b. Tell the client that if she uses the herbal substance, she will need to check her blood pressure daily. c. Show the client how to take her blood pressure so she can monitor it closely. d. Tell the client that she should never use herbal substances, because they are dangerous.

a. Advise the client to speak with her physician about substituting herbal substances with her medication.

A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which of the following interventions should the nurse perform to evaluate the efficacy of the drug treatment? (Select all that apply) a. Assess client's uterine tone b. Monitor client's vital signs c. Assess client's skin turgor d. Get a pad count e. Assess deep tendon reflexes

a. Assess client's uterine tone b. Monitor client's vital signs d. Get a pad count

A pregnant client has come to the health care facility for a physical examination. Which of the following assessments should a nurse perform when doing a physical examination of the head and neck? (Select all that apply) a. Assess for previous injuries and sequelae b. Check the eye movements c. Check for levels of estrogen d. Evaluate for limitations in range of motion e. Palpate the thyroid gland for enlargement

a. Assess for previous injuries and sequelae d. Evaluate for limitations in range of motion e. Palpate the thyroid gland for enlargement

A nurse is caring for a client with CVD who has just delivered. What nursing intervention should the nurse perform when caring for this client? (Select all that apply). a. Assess for shortness of breath b. Assess for a moist cough c. Assess for edema and note any pitting d. Auscultate heart sounds for abnormalities e. Monitor the client's hemoglobin and hematocrit

a. Assess for shortness of breath b. Assess for a moist cough c. Assess for edema and note any pitting d. Auscultate heart sounds for abnormalities

Which of the following postoperative interventions should a nurse perform when caring for a client who has undergone a cesarean section? a. Assess uterine tone to determine fundal firmness b. Delay breastfeeding the newborn for a day c. Ensure that the client does not cough or breathe deeply d. Avoid early ambulation to prevent respiratory problems

a. Assess uterine tone to determine fundal firmness

A client who is in labor presents with shoulder dystocia of the fetus. Which of the following is an important nursing intervention? a. Assist with positioning the woman in squatting position b. Assess for complaints of intense back pain in first stage of labor c. Anticipate possible use of forceps to rotate to anterior position at birth d. Assess for prolonged second stage of labor with arrest of descent

a. Assist with positioning the woman in squatting position

At the first prenatal visit, the client reports her LMP was November 16, 2011. You determine the estimated date of birth (EDB) to be: a. August 23, 2012 b. August 13, 2012 c. September 1, 2012 d. August 3, 2012

a. August 23, 2012

Which precautions should a nurse take to prevent infection in a newborn? (Select all that apply) a. Avoid coming to work when ill b. Cover jewelry while washing hands c. Use sterile gloves for an invasive procedure d. Avoid using disposable equipment e. Monitor laboratory test results for changes

a. Avoid coming to work when ill c. Use sterile gloves for an invasive procedure e. Monitor laboratory test results for changes

A postpartum woman is using the lactational amenorrhea method of birth control. The nurse should advise the client that the method is effective only if which of the following conditions is present? Select all that apply. a. Being less than 6 months postpartum. b. Being amenorrheic since delivery of the baby. c. Supplementing with formula no more than once per day. d. Losing less than 10% of weight since delivery. e. Sleeping at least 8 hours every night.

a. Being less than 6 months postpartum. b. Being amenorrheic since delivery of the baby.

Encouraging routine prenatal visits is an important function for nurses to ensure the clients avoid complications or difficulties throughout the pregnancy and delivery. All clients should be screened for gestational diabetes at which time during the pregnancy? a. Between 24 and 28 weeks' gestation b. Between 20 and 24 weeks' gestation c. Between 15 and 19 weeks' gestation d. Between 29 and 32 weeks' gestation

a. Between 24 and 28 weeks' gestation

A high-risk pregnant client is determined to have gestational hypertension. Which of the following would the nurse interpret as indicating that she has developed severe preeclampsia? a. Blurred vision b. Proteinuria of 300 mg per 24 hours c. Blood pressure of 150/100 mm Hg d. Mild facial edema

a. Blurred vision

After teaching a class on the various structures formed by the embryonic membranes, the nurse determines that the teaching was successful when the class identifies which structure as being formed by the mesoderm? a. Bones b. Stomach c. Ears d. Lungs

a. Bones

A nurse is to care for a client during the postpartum period. The client complains of pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? (Select all that apply). a. Breasts are hard b. Breasts are tender c. Nipples are fissured d. Nipples are cracked e. Breasts are soft

a. Breasts are hard b. Breasts are tender

Your client, who is lactose intolerant, is concerned about getting enough calcium in her diet. Which of the following foods could you suggest she include in her diet to increase her calcium intake? (Select all that apply.) a. Broccoli b. Almonds c. Molasses d. Carrots e. Peanuts

a. Broccoli b. Almonds c. Molasses e. Peanuts

The nurse is teaching a pregnant woman with iron deficiency anemia about foods high in iron. Which food(s) if selected by the woman indicates a successful teaching program? (Select all that apply.) a. Broccoli b. Raisins c. Yogurt d. Peanut butter e. Potatoes

a. Broccoli b. Raisins d. Peanut butter

The nurse recognizes that one of the most common causes of vaginal discharge is: a. Candidiasis b. Chlamydia c. Gonorrhea d. Syphilis

a. Candidiasis

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

a. Caput succedaneum

The nurse is assessing the woman who has a forceps-assisted birth for complications. Which of the following would be least likely to occur in the mother? a. Caput succedaneum b. Perineal hematoma c. Infection of episiotomy d. Cervical lacerations

a. Caput succedaneum

On examination, the nurse determines the client is at 50% effacement. This means: a. Cervical canal is 1 cm long. b. Cervical canal is 2 cm long. c. Cervical canal is 1.5 cm long. d. Cervical canal is 2.5 cm long.

a. Cervical canal is 1 cm long.

A full-term pregnant client is being assessed for induction of labor. Her bishop score is less than 6. Which of the following does it indicate? a. Cervical ripening method should be used b. A cesarean may be required c. Vaginal birth will be successful d. Labor will occur spontaneously

a. Cervical ripening method should be used

A client presents to the clinic because she thinks she may be pregnant. On examination, the nurse notes that the client's cervix and vaginal mucosa appear a bluish-purple color. This is commonly referred to as: a. Chadwick's sign b. Braxton's sign c. Hegar's sign d. Goodell's sign

a. Chadwick's sign

Your client is in her second trimester and the health care provider has recommended she undergo an amniocentesis. You explain the procedure is used to diagnose which of the following? (Select all that apply.) a. Chromosomal abnormalities b. Neural tube defects c. HIV d. Rh incompatibility e. Inborn errors of metabolism

a. Chromosomal abnormalities b. Neural tube defects e. Inborn errors of metabolism

A woman with cardiac disease has come to the office for prenatal counseling. According to the functional classification system developed by the Criteria Committee of the New York Heart Association, which category of women should avoid pregnancy? a. Class IV b. Class III c. Class I d. Class II

a. Class IV

A pregnant client wishes to know if sexual intercourse would be safe during her pregnancy. Which of the following should the nurse confirm before educating the client regarding sexual behavior during pregnancy? a. Client does not have an incompetent cervix b. Client does not have anxieties and worries c. Client does not have anemia d. Client does not experience facial and hand edema

a. Client does not have an incompetent cervix

The nurse is teaching the parents of a newborn who was born with a high type of imperforated anus the care the newborn will need at home after surgery. Which of the following will the parents need to be aware that the newborn will have temporarily? a. Colostomy b. Nasogastric tube c. Nasal cannula for oxygen d. Intravenous fluids

a. Colostomy

The nurse is caring for a pregnant woman and her family who are immigrants. Which intervention would be the priority for helping to achieve a successful outcome? a. Communicating using understable terms b. Inquiring about the family's ability to buy medicine c. Referring them to state and local aid programs d. Asking how they got to the appointment

a. Communicating using understable terms

Throughout life, a woman's most proactive activity to promote her health would be to engage in: a. Consistent exercise b. Socialization with friends c. Quality quiet time with herself d. Consuming water

a. Consistent exercise

A woman gave birth vaginally approximately 12 hours ago and her temperature is now 100% F. Which action would be most appropriate for the nurse to take? a. Continue monitoring the woman's temperature every 4 hours; this finding is normal. b. Inspect the perineum for hematoma formation. c. Notify the health care provider about this elevation; this finding reflects infection. d. Obtain a urine culture; the woman most likely has a urinary tract infection.

a. Continue monitoring the woman's temperature every 4 hours; this finding is normal.

A young couple is exploring their contraceptive options and are curious about using an intrauterine contraceptive device. As their nurse you explain there are two types, one which uses hormones and the other one uses: a. Copper b. Magnesium c. Potassium d. Silicone

a. Copper

A new dad is alarmed at the shape of his newborn's head. You remind him this is due to: a. Cranial bones overlapping at the suture lines b. Prolonged labor c. A congenital defect d. Extreme pressure in the vaginal vault

a. Cranial bones overlapping at the suture lines

A nurse is caring for a client who is experiencing acute onset of dyspnea and hypotension. The physician suspects the client has amniotic fluid embolism. What other signs or symptoms should alert the nurse to the presence of this condition in the client? a. Cyanosis b. Arrhythmia c. Hyperglycemia d. Hematuria e. Pulmonary edema

a. Cyanosis e. Pulmonary edema

A woman, who wishes to use the calendar method for contraception, reports that her last 6 menstrual cycles were 28, 32, 29, 36, 30, and 27 days long, respectively. In the future, if used correctly, she should abstain from intercourse on which of the following days of her cycle? a. Days 9 to 25. b. Days 10 to 15. c. Days 11 to 20. d. Days 12 to 17.

a. Days 9 to 25.

Which of the following behaviors would indicate to a nurse that a gravid woman may be being abused? Select all that apply. a. Denies that any injuries occurred, even when bruising is visible. b. Gives an implausible explanation for any injuries. c. Gives the nurse eye contact while answering questions. d. Allows her partner to answer the nurse's questions. e. Frequently calls to change appointment times.

a. Denies that any injuries occurred, even when bruising is visible. b. Gives an implausible explanation for any injuries. d. Allows her partner to answer the nurse's questions. e. Frequently calls to change appointment times.

The nurse performing Leopold's maneuvers for a pregnant client explains to the client the purpose of the maneuvers. Which of the following is the purpose of the maneuvers? (Select all that apply) a. Determining the presentation of the fetus b. Determining the position of the fetus c. Determining the lie of the fetus d. Determining the weight of the fetus e. Determining the size of the fetus

a. Determining the presentation of the fetus b. Determining the position of the fetus c. Determining the lie of the fetus

Preexisting conditions in women can lead to complications during pregnancy. Hydramnios is often seen with which preexisting condition? a. Diabetes b. Hypertension c. Late maternal age d. Isoimmunization

a. Diabetes

The nurse recognizes that maternal factors can increase the chance of a large-for-gestational-age newborn. Which of the following would indicate that this can occur? (Select all that apply.) a. Diabetes mellitus b. History of postdates gestation c. Multiparity d. History of microsomic infant e. Female fetus

a. Diabetes mellitus b. History of postdates gestation c. Multiparity

Which maternal factors should the nurse consider that could lead to a newborn's being "large for gestational age"? (Select all that apply) a. Diabetes mellitus b. Postdates gestation c. Alcohol use d. Glucose intolerance e. Renal function

a. Diabetes mellitus b. Postdates gestation d. Glucose intolerance

A woman has a history of toxic shock syndrome. Which of the following forms of birth control should she be taught to avoid? Select all that apply. a. Diaphragm. b. Intrauterine device. c. Birth control pills (estrogen-progestin combination). d. Contraceptive sponge. e. Depo-Provera (medroxyprogesterone acetate).

a. Diaphragm. d. Contraceptive sponge

Four women who use superabsorbent tampons during their menses are being seen in the medical clinic. The woman with which of the following findings would lead the nurse to suspect that the woman's complaints are related to her use of tampons rather than to an unrelated medical problem? a. Diffuse rash with fever. b. Angina. c. Hypertension. d. Thrombocytopenia with pallor.

a. Diffuse rash with fever.

The nurse is caring for a pregnant client who indicates that she is fond of meat, works with children, and has a pet cat. Which of the following instructions should the nurse give this client to prevent toxoplasmosis? (Select all that apply). a. Eat meat cooked to 160 degrees b. Avoid cleaning the cat's litter box c. Keep the cat outdoors at all times d. Avoid contact with children when they have a cold e. Avoid outdoor activities such as gardening

a. Eat meat cooked to 160 degrees b. Avoid cleaning the cat's litter box e. Avoid outdoor activities such as gardening

Women who are on hormone replacement therapy (HRT) for an extended period of time have been shown to be high risk for which of the following complications? a. Endometrial cancer. b. Gynecomastia. c. Renal dysfunction. d. Mammary hypertrophy.

a. Endometrial cancer.

The nurse encourages a woman in labor to ambulate based on the understanding that it helps with which of the following? (Select all that apply.) a. Enhances the effectiveness of contractions b. Widens one side of the pelvis c. Encourages rotation of the fetus d. Enlists the aid of gravity to move the fetus e. Increases the urge to push during the second stage f. Helps the fetus line up with the angle of the pelvis

a. Enhances the effectiveness of contractions d. Enlists the aid of gravity to move the fetus e. Increases the urge to push during the second stage f. Helps the fetus line up with the angle of the pelvis

A client in her second trimester arrives at a health care facility for a follow-up visit. During the exam, the client complains of constipation. Which of the following instructions should the nurse offer to help alleviate constipation? a. Ensure adequate hydration and bulk in the diet b. Avoid spicy or greasy foods in meals c. Practice Kegel exercises d. Avoid lying down for 2 hours after meals

a. Ensure adequate hydration and bulk in the diet

A nurse is caring for a pregnant client who works at a daycare center and is in regular contact with children. What instructions should the nurse give this client in order to minimize risk of transmission of cytomegalovirus to the fetus? a. Ensure thorough hand-washing b. Seek consultation for antibiotics c. Avoid interacting with children d. Drink plenty of fluids

a. Ensure thorough hand-washing

When teaching a client about hormones, which of the following should the nurse identify as responsible in developing the ductal system of the breasts in preparation for lactation during pregnancy? a. Estrogen b. Prolactin c. Progesterone d. Oxytocin

a. Estrogen

Which placental hormone would the nurse identify as playing a key role in stimulating myometrial contractility? a. Estrogen b. Progesterone c. Relaxin d. hCG

a. Estrogen

A nurse is providing genetic counseling to a pregnant client. Which of the following are the nursing responsibilities related to counseling the client? (Select all that apply). a. Explaining basic concepts of probability and disorder susceptibility b. Ensuring complete informed consent to facilitate decisions about genetic testing c. Instructing the client on the appropriate decision to be taken d. Knowing basic genetic terminology and inheritance patterns e. Avoiding explaining ethical or legal issues and concentrating on genetic issues

a. Explaining basic concepts of probability and disorder susceptibility b. Ensuring complete informed consent to facilitate decisions about genetic testing d. Knowing basic genetic terminology and inheritance patterns

The mother of a newborn observes a diaper rash on her baby's skin. Which of the following should the nurse instruct the parent to prevent diaper rash? a. Expose the newborn's bottom to air several times a day b. Use plastic pants while bathing the newborn c. Use products such as powder and items with fragrance d. Place the newborn's buttocks in warm water often

a. Expose the newborn's bottom to air several times a day

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? a. External electronic fetal monitoring b. Fetal blood pH c. Fetal oxygen saturation d. Fetal position

a. External electronic fetal monitoring

As the nurse you understand that there are hormonal changes that occur during pregnancy. Which hormones are inhibited during the pregnancy? a. FSH and LH b. FSH and T4 c. LH and MSH d. T4 and GH

a. FSH and LH

A community-based nurse is involved in secondary prevention activities. Which activities might be included? Select all that apply. a. Fecal occult blood testing b. Hearing screening c. Smoking cessation program d. Cholesterol testing e. Hygiene program f. Pregnancy testing

a. Fecal occult blood testing b. Hearing screening d. Cholesterol testing f. Pregnancy testing

A nurse is caring for an antenatal mother diagnosed with umbilical cord prolapse. Which of the following should the nurse monitor for in a fetus in cases of umbilical cord prolapse? a. Fetal hypoxia b. Preeclampsia c. Coagulation defects d. Placental pathology

a. Fetal hypoxia

A nurse is conducting a class discussing newborns for expectant parents. Which of the following would the nurse use to indicate the neonatal period? a. First 28 days of life b. First 36 days of life c. First 2 months of life d. First 3 weeks of life

a. First 28 days of life

A woman has contracted herpes simplex 2 for the first time. Which of the following signs/symptoms is the client likely to complain of? a. Flu-like symptoms. b. Metrorrhagia. c. Amenorrhea. d. Abdominal cramping.

a. Flu-like symptoms.

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

a. Focus on decreasing blood viscosity by increasing fluid volume

Two weeks after a vaginal delivery, a client presents with low-grade fever. The client also complains of a loss of appetite and low energy levels. The physician suspects an infection of the episiotomy. Which sign or symptom is most indicative of an episiotomy infection? a. Foul-smelling vaginal discharge b. Sudden onset of shortness of breath c. Pain in the lower leg d. Apprehension and diaphoresis

a. Foul-smelling vaginal discharge

After teaching a group of students about the effects of prematurity on various body systems, the instructor determines that the class was successful when the students identify which of the following as an effect of prematurity? a. Fragile cerebral blood vessels b. Enhanced ability to digest proteins c. Rapid glomerular filtration rate d. Enlarged respiratory passages

a. Fragile cerebral blood vessels

When preparing for a class on genetic disorders, the participants should understand at the conclusion of the class that the most common form of male retardation is due to: a. Fragile-X Syndrome b. Patau Syndrome c. Down Syndrome d. Cri du Chat Syndrome

a. Fragile-X Syndrome

A client in her 39th week of gestation arrives at the maternity clinic stating that earlier in her pregnancy, she experienced shortness of breath. However, for the past few days, she's been able to breathe easily, but she has also begun to experience increased urinary frequency. A nurse is assigned to perform the physical examination of the client. Which of the following is the nurse most likely to observe? a. Fundal height has dropped since the last recording b. Fundal height is at its highest level at the xiphoid process c. The fundus is at the level of the umbilicus and measures 20 cm d. The lower uterine segment and cervix have softened

a. Fundal height has dropped since the last recording

A client at 33 weeks' gestation is calling the office with various complaints and is very concerned. The nurse recognizes which of the following as indicating the client is potentially going into preterm labor? (Select all that apply.) a. General sense of discomfort b. Irregular contractions c. GI upset (nausea, vomiting, diarrhea) d. Achiness in the thighs e. Low, dull backache

a. General sense of discomfort c. GI upset (nausea, vomiting, diarrhea) d. Achiness in the thighs e. Low, dull backache

During an initial newborn assessment, the nurse recognizes certain signs need to be reported to the physician as they indicate potential problems. Which of the following might indicate a problem? (Select all that apply.) a. Generalized cyanosis b. Tachycardia, greater than 140 beats per minute c. Flaccid body posture d. Labored breathing e. Tachypnea, greater than 50 breaths per minute

a. Generalized cyanosis c. Flaccid body posture d. Labored breathing

During a routine home visit, the couple is curious when it will be safe to resume full sexual relations. Which of the following would be the best answer? a. Generally after 6 weeks b. Generally after 12 weeks c. Whenever you want to d. Usually within a couple weeks

a. Generally after 6 weeks

A nurse is conducting an AIDS awareness program for women. Which of the following instructions should the nurse include in the teaching plan to empower women to develop control over their lives in a practical manner so that they can prevent becoming infected with HIV? Select the most appropriate responses. a. Give opportunities to practice negotiation techniques b. Encourage women to develop refusal skills c. Encourage women to use female condoms d. Support youth-development activities to reduce sexual risk-taking e. Encourage women to lead a healthy lifestyle

a. Give opportunities to practice negotiation techniques b. Encourage women to develop refusal skills c. Encourage women to use female condoms

A client has been admitted with abruptio placentae. What is her classification if she has lost 1,200 mL of blood, is normotensive, and ultrasound indicates approximately 30% separation? a. Grade 2 b. Grade 3 c. Grade 1 d. Grade 4

a. Grade 2

The nurse is caring for a 14-year-old girl who fears she might have a sexually transmitted infection. Which of the following assessments would be most indicative of trichomoniasis? a. Green vaginal discharge b. Urinary incontinence c. Flu-like symptoms d. Lesions on the vulva

a. Green vaginal discharge

A client delivers a baby in the maternity unit of a local health care facility. Which of the following behaviors of the newborn should the nurse identify as the self-quieting ability of a newborn? a. Hand-to-mouth movements b. Movement of head and eyes c. Hyperactivity d. Movements of the legs

a. Hand-to-mouth movements

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. This is referred to as which of the following? a. Harlequin sign b. Mongolian spots c. Stork bites d. Erythema toxicum

a. Harlequin sign

A client complaining of genital ulcers has been diagnosed with syphilis. Which of the following nursing interventions should the nurse implement when caring for the client? Select all that apply. a. Have the client urinate in water if urination is painful b. Suggest the client apply ice packs to the genital area for comfort c. Instruct the client to wash her hands with soap and water after touching lesions d. Instruct the client to wear nonconstricting, comfortable clothes e. Instruct the client to abstain from sex during the latency period

a. Have the client urinate in water if urination is painful c. Instruct the client to wash her hands with soap and water after touching lesions d. Instruct the client to wear nonconstricting, comfortable clothes

The nurse is preparing a teaching plan for a pregnant woman about the signs and symptoms to be reported immediately to her health care provider. Which of the following would the nurse include? (Select all that apply.) a. Headache with visual changes in the third trimester b. Urinary frequency in the third trimester c. Nausea with vomiting during the first trimester d. Lower abdominal pain with shoulder pain in the first trimester e. Sudden leakage of fluid during the second trimester

a. Headache with visual changes in the third trimester d. Lower abdominal pain with shoulder pain in the first trimester e. Sudden leakage of fluid during the second trimester

The nurse recognizes that a newborn with microcephaly have also been noted to have which of the following complications? (Select all that apply.) a. Hearing disorders b. Hydrocephalus c. Achondroplasia d. Cerebral palsy e. Epilepsy

a. Hearing disorders d. Cerebral palsy e. Epilepsy

A nurse is educating the mother of a newborn about feeding and burping. Which of the following strategies should the nurse offer to the mother regarding burping? a. Hold the baby upright with the baby's head on her mother's shoulder b. Lay the baby on its back on its mother's lap c. Gently rub the baby on its back and on its mother's lap d. Lay the baby on its mother's lap and give it frequent sips of warm water

a. Hold the baby upright with the baby's head on her mother's shoulder

Which of the following would the nurse assess as indicating positive bonding between the parents and their newborn? a. Holding the infant close to the body b. Having visitors hold the infant c. Buying expensive infant clothes d. Requesting that the nurses care for the infant

a. Holding the infant close to the body

When obtaining a blood test for pregnancy, which hormone would the nurse expect the test to measure? a. Human chorionic gonadotropin (hCG) b. Human placental lactogen (hPL) c. Follicle-stimulating hormone (FSH) d. Luteinizing hormone (LH)

a. Human chorionic gonadotropin (hCG)

A woman is noted to have multiple soft warts on her perineum and rectal areas. The nurse suspects that this client is infected with which of the following sexually transmitted infections? a. Human papillomavirus (HPV). b. Human immunodeficiency virus (HIV). c. Syphilis. d. Trichomoniasis.

a. Human papillomavirus (HPV).

A nurse is caring for a newborn with PVH/IVH in a local health care facility. Which of the following complications is/are likely to occur in a newborn with PVH/IVH that a nurse should assess for? (Select all that apply) a. Hydrocephalus b. Acid-base imbalances c. Pneumonitis d. Vision or hearing deficits e. Cerebral palsy

a. Hydrocephalus d. Vision or hearing deficits e. Cerebral palsy

Gestational diabetes increases the risk of various complications in both the mother and infant. Which of the following would not be an example of a neonatal complication? a. Hyperglycemia b. Hypoglycemia c. Birth trauma d. Macrosomia

a. Hyperglycemia

The major purpose of the first postpartum homecare visit is to: a. Identify complications that require interventions b. Obtain a blood specimen for PKU testing c. Complete the official birth certificate d. Support the new parents in their parenting roles

a. Identify complications that require interventions

A nurse is explaining the benefits of breastfeeding to a client who has just delivered. Which of the following immunoglobulins does breast milk contain that boost a newborn's immune system as opposed to formula? a. IgA b. IgD c. IgE d. IgM

a. IgA

A nurse is explaining the benefits of breastfeeding to a client who has just delivered. Which statement correctly explains the benefits of breastfeeding to this mother? a. Immunoglobulin IgA in breast milk boosts a newborn's immune system b. Breastfeeding provides more iron and calcium for the infant c. Mothers who breastfeed have increased breast size following nursing d. Breastfed infants gain weight faster than formula-fed infants after 6 months of age

a. Immunoglobulin IgA in breast milk boosts a newborn's immune system

A client in her 7th week of postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? (Select all that apply) a. Inability to concentrate b. Loss of confidence c. Manifestations of mania d. Decreased interest in life e. Bizarre behavior

a. Inability to concentrate b. Loss of confidence d. Decreased interest in life

A nurse is caring for a pregnant client who is in labor. Which of the following maternal physiologic responses should the nurse monitor for in the client as the client progresses through childbirth? (Select all that apply) a. Increase in heart rate b. Increase in blood pressure c. Increase in respiratory rate d. Slight decrease in body temperature e. Increase in gastric emptying and pH

a. Increase in heart rate b. Increase in blood pressure c. Increase in respiratory rate

The nurse is assessing a client who is in her 24th week of pregnancy. The nurse knows that which of the client's presenting symptoms should be further assessed as a possible sign of preterm labor? (Select all that apply) a. Increase in vaginal discharge b. Phrenic nerve irritation c. Rupture of membranes d. Uterine contractions e. Hypovolemic shock

a. Increase in vaginal discharge c. Rupture of membranes d. Uterine contractions

The local community health nurses are working with the surrounding clinics to initiate programs that will help develop policies to reflect the goals of Healthy People 2020 (HP 2020). Which of the following would be included in those policies? (Select all that apply.) a. Increase the quality of life and life expectancy b. Decrease the health disparities among the different populations c. Reinforce the availability of local health care programs d. Identify potential at-risk clients for pregnancy complications

a. Increase the quality of life and life expectancy b. Decrease the health disparities among the different populations

A client in labor is administered lorazepam to help her relax enough so that she can participate effectively during her labor process rather than fighting against it. Which of the following is an adverse effect of the drug that the nurse should monitor for? a. Increased sedation b. Newborn respiratory depression c. Nervous system depression d. Decreased alertness

a. Increased sedation

When caring for a client with PROM, the nurse observes an increase in the client's pulse. What does this increase in pulse indicate? a. Infection b. Preterm labor c. Cord compression d. Respiratory distress syndrome

a. Infection

A nurse is assessing the cause of multiple gestations in clients. Which of the following factors should the nurse assess as contributors to increased probability of multiple gestations? a. Infertility treatment b. Medications c. Advanced maternal age d. Adolescent pregnancies

a. Infertility treatment

A pregnant client has opted for hydrotherapy for pain management during labor. Which of the following should the nurse consider when assisting the client during the birthing process? a. Initiate the technique only when the client is in active labor b. Do not allow the client to stay in the bath for long c. Ensure that the water temperature exceeds body temperature d. Allow the client into the water only if her membranes have ruptured

a. Initiate the technique only when the client is in active labor

The health care provider is evaluating a high-risk woman for a continuous internal monitor. Which of the following would not be a criterion to make this decision? a. Insertion of spiral electrode by any staff b. The presenting fetal part is visible c. Rupture of membranes d. Cervical dilation of at least 2 cm

a. Insertion of spiral electrode by any staff

A client would like some information about the use of a cervical cap. Which of the following should the nurse include in the teaching plan of this client? Select all that apply. a. Inspect the cervical cap before insertion b. Apply spermicide to the rim of the cervical cap c. Wait for 30 minutes after insertion before engaging in intercourse d. Remove the cervical cap immediately after intercourse e. Do not use the cervical cap during menses

a. Inspect the cervical cap before insertion c. Wait for 30 minutes after insertion before engaging in intercourse e. Do not use the cervical cap during menses

The husband of a pregnant woman tells the nurse that his wife is increasingly preoccupied with herself and her fetus. The woman is in her first trimester of pregnancy. The nurse interprets this as which of the following? a. Introversion b. Emotional lability c. Ambivalence d. Acceptance

a. Introversion

A nurse who has been caring for a pregnant client understands that the client has pica and has been regularly consuming soil. Which of the following conditions should the nurse monitor for in the client as a manifestation of consuming soil? a. Iron-deficiency anemia b. Constipation c. Tooth fracture d. Inefficient protein metabolism

a. Iron-deficiency anemia

It is recognized that nutritional deficiencies are a common problem in the United States. A persistent problem that nurses should screen all prenatal clients for is: a. Iron-deficiency anemia b. Hypoglycemia c. Pernicious anemia d. Hypocholesterolemia

a. Iron-deficiency anemia

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

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

When assisting the parents in the grieving process after the death of their infant, which of the following is the most important for the nurse to do? a. Keep the communication lines open b. Remove the infant quickly c. Contact a grief counselor d. Leave the parents alone

a. Keep the communication lines open

The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which of the following actions would the nurse include in her discussion as possible strategies for the new mothers to do? (Select all that apply.) a. Kegel exercises b. Lose weight if obese c. Start jogging d. Avoid smoking e. Increase fluid intake

a. Kegel exercises b. Lose weight if obese d. Avoid smoking

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which of the following? a. Lack of thoracic compressions during delivery b. Loss of blood volume due to hemorrhage c. Prolonged unsuccessful vaginal delivery d. Inadequate suctioning of the mouth and nose of the newborn

a. Lack of thoracic compressions during delivery

To assess a newborn's gestational age, the nurse evaluates which of the following parameters to indicate physical maturity? (Select all that apply.) a. Lanugo b. Posture c. Scarf sign d. Arm recoil e. Genitals

a. Lanugo b. Posture e. Genitals

A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. The nurse tells the mother to: a. Lay the newborn on her back, rather than on her stomach b. Lay the newborn on her stomach, with her face turned c. Lay the newborn on her side d. Let the newborn sleep in the same bed as the parents

a. Lay the newborn on her back, rather than on her stomach

A nurse is caring for a Turkish client. The nurse understands that there could be major cultural differences between her and her client. What could be the consequence of a nurse assigning a client to a staff member who is of the same culture as the client? a. Lead to stereotyping b. Ensure better care and understanding c. Help in assessing client's culture d. Help build better nurse-client relationship

a. Lead to stereotyping

A newborn is designated as very low birth weight. The nurse understands that this newborn's weight is: a. Less than 1,500 g b. More than 4,000 g c. Approximately 2,500 g d. Less than 1,000 g

a. Less than 1,500 g

A client calls the clinic asking to come in to be evaluated. She states that when she went to bed last night, the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, you explain this is probably due to: a. Lightening b. Start of labor c. Placenta previa d. Rupture of the membranes

a. Lightening

Which of the following are factors that increase the risk of overheating in a newborn? (Select all that apply) a. Limited sweating ability b. Underdeveloped lungs c. Too-warm crib d. Limited insulation e. Lack of brown fat

a. Limited sweating ability c. Too-warm crib d. Limited insulation

A 52-year-old client is seeking treatment for menopause. She is not very active and has a history of cardiac problems. Which of the following therapy options should the nurse recognize as contraindicated for this client? a. Long-term hormone replacement therapy b. Selective estrogen receptor modulators c. Lipid-lowering agents d. Bisphosphonates

a. Long-term hormone replacement therapy

A client has had a forceps delivery which resulted in lacerations and bleeding. How can a nurse identify if the bleeding is due to laceration? a. Look for a contracted uterus with vaginal bleeding b. Look for a subinvoluted uterus with vaginal bleeding c. Look for a boggy uterus with vaginal bleeding d. Look for an inverted uterus with vaginal bleeding

a. Look for a contracted uterus with vaginal bleeding

A nurse is caring for a client who is in the first stage of labor. The client is experiencing extreme pain due to the labor. The nurse understands that which of the following is causing the extreme pain in the client? (Select all that apply) a. Lower uterine segment distention b. Fetus moving along the birth canal c. Stretching and tearing of structures d. Spontaneous placental expulsion e. Dilation of the cervix

a. Lower uterine segment distention c. Stretching and tearing of structures e. Dilation of the cervix

What important instruction should the nurse give a pregnant client with tuberculosis? a. Maintain adequate hydration b. Avoid direct sunlight c. Avoid red meat d. Wear light, cotton clothes

a. Maintain adequate hydration

A nurse is caring for an infant born with hypoglycemia. What care should the nurse administer to a newborn with hypoglycemia? a. Maintain fluid and electrolyte balance b. Give dextrose intravenously before oral feedings c. Place infant on radiant warmer immediately d. Focus on decreasing blood viscosity

a. Maintain fluid and electrolyte balance

The nurse has provided a single, perimenopausal woman, G3 P2012, with contraceptive counseling. The woman has four sex partners and smokes 1 pack of cigarettes per day. Which of the following methods is best suited for this client? a. Male condom. b. Intrauterine device. c. NuvaRing. d. Oral contraceptives.

a. Male condom.

A nurse recognizes that which of the following signs is usually the first indication of esophageal atresia? a. Maternal history of hydramnios b. Newborn with rattling respirations c. Maternal history of oligohydramnios d. Newborn unable to feed properly

a. Maternal history of hydramnios

After an examination, a client has been determined to have an unruptured ectopic pregnancy. Which of the following would the nurse prepare to administer? a. Methotrexate b. Ondansetron c. Oxytocin d. Promethazine

a. Methotrexate

Over the past 20 weeks, the following blood pressure readings are documented for a pregnant client: week 16 : 124/86; week 20 : 138/90; week 24 : 140/92; and week 28 : 142/94. Which of the following would be the correct classification of her blood pressure? a. Mild hypertensive b. Prehypertensive c. Severe hypertensive d. Normotensive

a. Mild hypertensive

A nurse is performing a detailed newborn assessment of a female baby. Which of the following observations indicate a normal finding? (Select all that apply) a. Mongolian spots b. Enlarged fontanelles c. Swollen genitals d. Low-set ears e. Short, creased neck

a. Mongolian spots c. Swollen genitals e. Short, creased neck

A nurse is assigned to educate a pregnant client regarding the changes in the structures of the respiratory system taking place during pregnancy. Which of the following conditions are associated with such changes? (Select all that apply) a. Nasal and sinus stuffiness b. Persistent cough c. Nosebleed d. Kussmaul's respirations e. Thoracic rather than abdominal breathing

a. Nasal and sinus stuffiness c. Nosebleed e. Thoracic rather than abdominal breathing

A newborn with feeding intolerance is suspected of having gastroschisis. Which of the following characteristics of gastroschisis should the nurse know when assessing the newborn? a. No peritoneal sac protecting herniated organs b. Normal herniated organs c. It is a defect of the umbilical ring d. Resolves with surgical correction

a. No peritoneal sac protecting herniated organs

Which of the following instructions should a nurse give an Rh-negative non-immunized client in her early weeks of pregnancy to prevent complications of blood incompatibility? a. Obtain RhoGAM at 28 weeks' gestation b. Consume a well-balanced, nutritional diet c. Avoid sexual activity until after 28 weeks d. Undergo periodic transvaginal ultrasound

a. Obtain RhoGAM at 28 weeks' gestation

A nurse is explaining the numerous changes that occur shortly after birth to the infant. When describing how the ductus arteriosus closes, the nurse explains that which of the following is the most important factor to assist its closure? a. Oxygen b. Start breastfeeding immediately c. Clamping the umbilical cord d. Breathing

a. Oxygen

You are a nurse working in a home health agency and your supervisor has asked you to develop some teaching aids that stress secondary prevention care. Which of the following topics might be included? (Select all that apply.) a. Pap smears b. Self-breast examinations c. Routine physical examinations d. Blood pressure evaluations

a. Pap smears b. Self-breast examinations d. Blood pressure evaluations

The nurse is preparing to administer medication therapy to a woman diagnosed with syphilis. The nurse would expect to administer: a. Penicillin G b. Doxycycline c. Metronidazole d. Miconazole

a. Penicillin G

A client has opted to use an intrauterine device for contraception. Which of the following effects of the device on monthly periods should the nurse inform the client about? a. Periods become lighter b. Periods become more painful c. Periods become longer d. Periods reduce in number

a. Periods become lighter

A nurse is caring for a client undergoing treatment for ectopic pregnancy. Which of the following symptoms is observed in a client if rupture or hemorrhaging occurs before the ectopic pregnancy is successfully treated? a. Phrenic nerve irritation b. Painless bright red vaginal bleeding c. Fetal distress d. Tetanic contractions

a. Phrenic nerve irritation

A nurse observes a 3-day-old term newborn who is starting to appear mildly jaundiced. What might explain this condition? a. Physiologic jaundice secondary to breast-feeding b. Hemolytic disease of the newborn due to blood incompatibility c. Exposing the newborn to high levels of oxygen d. Overfeeding the newborn with too much glucose water

a. Physiologic jaundice secondary to breast-feeding

As a part of the newborn assessment, the nurse determines the skin turgor. Which of the following nursing interventions is relevant when observing the turgor of the newborn's skin? a. Pinch skin and note return to original position b. Examine for stork bites or salmon patches c. Check for unopened sebaceous glands d. Inspect for blue or purple splotches on buttocks

a. Pinch skin and note return to original position

The nurse recognizes that a multiparous woman with a past history of cesarean births should be monitored for which of the following? a. Placenta accreta b. Oligohydramnios c. Placenta abruption d. Preeclampsia

a. Placenta accreta

After conducting a childbirth class, you recognize that students understand what was presented after correctly choosing which of the following factors that can affect the labor process? (Select all that apply.) a. Powers b. Place c. Participation d. Passenger e. Patience

a. Powers d. Passenger e. Patience

A nurse is caring for a client undergoing treatment for bacterial vaginosis. Which of the following instructions should the nurse give the client to prevent recurrence of bacterial vaginosis? Select all that apply. a. Practice monogamy b. Use oral contraceptives c. Avoid smoking d. Undergo colposcopy tests frequently e. Avoid foods containing excessive sugar

a. Practice monogamy

Which of the following newborns are at a greater risk for cold stress? a. Preterm newborns b. Newborns being fed formula c. Postterm newborns d. Larger-than-average newborns

a. Preterm newborns

A pregnant client is brought to the health care facility with signs of PROM. Which of the following are the associated conditions and complications of premature rupture of the membranes? (Select all that apply) a. Prolapsed cord b. Abruptio placenta c. Spontaneous abortion d. Placenta previa e. Preterm labor

a. Prolapsed cord b. Abruptio placenta e. Preterm labor

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What assessment finding will the nurse expect to find in the client? a. Prolonged bleeding time b. A fever of 100.4 F after the first 24 hours following childbirth c. Foul-smelling vaginal discharge d. Postpartum fundal height that is higher than expected

a. Prolonged bleeding time

Which of the following interventions can a nurse perform to maintain a neutral thermal environment? a. Promote early breastfeeding b. Avoid skin-to-skin contact with the mother c. Keep the infant transporter cool d. Avoid bathing the newborn

a. Promote early breastfeeding

The nurse wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met? a. Promote early breastfeeding for the infants b. Avoid skin-to-skin contact with the mother until the infants are 8 hours old c. Keep the infant transporter temperature between 80℉ and 85℉ d. Avoid bathing the newborn until they are 24 hours old

a. Promote early breastfeeding for the infants

A nurse is assigned the task of educating a pregnant client about childbirth. Which of the following nursing interventions should the nurse perform as a part of prenatal education for the client to ensure a positive childbirth experience? (Select all that apply) a. Provide the client clear information on procedures involved b. Encourage the client to have a sense of mastery and self-control c. Encourage the client to have a positive reaction to pregnancy d. Instruct the client to spend some time alone each day e. Instruct the client to begin changing the home environment

a. Provide the client clear information on procedures involved b. Encourage the client to have a sense of mastery and self-control c. Encourage the client to have a positive reaction to pregnancy

A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse initiate? a. Providing a comfortable environment with dim lighting b. Administering oxytocin c. Preparing the woman for an amniotomy d. Encouraging the woman to assume a hands-and-knees position

a. Providing a comfortable environment with dim lighting

A first-time mother is nervous about breastfeeding. Which of the following interventions should the nurse perform to reduce maternal anxiety about breastfeeding? a. Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience b. Explain that breastfeeding comes naturally to all mothers c. Tell her that breastfeeding is a mechanical procedure that involves burping once in a while and that she should try finishing it quickly. d. Ensure that the mother breastfeeds the newborn using the cradle method

a. Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience

The nurse is striving to form a partnership with the family of a medically fragile child being cared for at home. Which of the following activities is part of family-centered home care? a. Recognizing unique family strengths b. Ensuring a safe, nurturing environment c. Managing information given to parents d. Correcting inadequate coping methods

a. Recognizing unique family strengths

A woman diagnosed with preeclampsia is to receive magnesium sulfate. The rationale for this drug is to: a. Reduce CNS irritability to prevent seizures b. Provide supplementation of an important mineral she needs c. Prevent constipation during and after the birthing process d. Decrease musculoskeletal tone to augment labor

a. Reduce CNS irritability to prevent seizures

A 19-year-old nulliparous is in early labor with erratic contractions. An assessment notes that she is remaining at 3 cm. There is also a concern that the uterus is not fully relaxing between contractions. Which of the following complications is a concern? a. Reduced oxygen to the fetus b. Cephalopelvic disproportion c. Precipitate labor d. Ruptured uterus

a. Reduced oxygen to the fetus

A client in her 10th week of gestation arrives at the maternity clinic complaining of morning sickness. The nurse needs to inform the client about the body system adaptations during pregnancy. Which of the following factors corresponds to the morning sickness period during pregnancy? a. Reduced stomach acidity b. Elevation of human chorionic gonadotropin (hCG) c. Increase in RBC production d. Increase in estrogen level e. Elevation of human placental lactogen

a. Reduced stomach acidity b. Elevation of human chorionic gonadotropin (hCG) d. Increase in estrogen level

A 16-year-old girl is brought to the clinic by her mother because she has not had a menstrual period for the past 8 months. Which of the following findings might alert the nurse to the possibility that anorexia nervosa may be contributing to the client's amenorrhea? (Select all that apply.) a. Reduced subcutaneous fat b. Evidence of secondary sex characteristics c. Bradycardia d. Hypotension

a. Reduced subcutaneous fat c. Bradycardia d. Hypotension

The assessment of a pregnant client, who is toward the end of her third trimester, reveals that she has increased prostaglandin levels. Which of the following factors should the nurse assess for in the client? (Select all that apply) a. Reduction in cervical resistance b. Myometrial contractions c. Boggy appearance of the uterus d. Softening and thinning of the cervix e. Hypotonic character of the bladder

a. Reduction in cervical resistance b. Myometrial contractions d. Softening and thinning of the cervix

A woman has presented to the emergency department with symptoms that suggest an ectopic pregnancy. Which of the following would lead the nurse to suspect that the fallopian tube has ruptured? a. Referred shoulder pain b. Nausea c. Vaginal spotting d. Breast tenderness

a. Referred shoulder pain

The term evidence-based refers to the use of which of the following to validate a nurse's practice interventions? a. Research findings b. Written guidelines c. Unit procedure manual d. Institutional policies

a. Research findings

A nurse is caring for a client who has been administered an epidural block. Which of the following symptoms must the nurse monitor the client for? a. Respiratory depression b. Accidental intrathecal blockade c. Inadequate or failed block d. Postdural puncture headache

a. Respiratory depression

During the assessment of a pregnant client, the nurse learns that the client has CVD. Which of the following should the nurse identify as a major risk that can be faced by the newborn of this client? a. Respiratory distress syndrome b. Congenital varicella syndrome c. SIDS d. Prune belly syndrome

a. Respiratory distress syndrome

When caring for a preterm infant, what intervention will most address the sensorimotor needs of the infant? a. Rocking and massaging b. Swaddling and positioning c. Using minimal amount of tape d. Using distraction through objects

a. Rocking and massaging

There are multiple options for your clients to seek assistance at a community-based setting. As their nurse, you are aware these may include: (Select all that apply) a. School health b. Home health c. Hospital d. Hospice

a. School health b. Home health d. Hospice

Methylergonovine is ordered for a woman experiencing postpartum hemorrhage. The nurse monitors the woman closely for which of the following adverse effects? a. Seizures b. Uterine hyperstimulation c. Headache d. Flushing

a. Seizures

In teaching about human immunodeficiency virus (HIV) transmission, the nurse explains that the virus cannot be transmitted by: a. Shaking hands b. Sharing drug needles c. Sexual intercourse d. Breast-feeding

a. Shaking hands

Every postpartum client has the potential of hemorrhage. While assessing a client's status, the nurse recognizes which of the following would not be used as an indicator of possible hemorrhage? a. Signs of shock b. Uterine tone c. Estimated amount of blood loss d. Vital signs

a. Signs of shock

Massage is an effective nonpharmacologic technique that can help to decrease pain during labor. Which of the following would be a contraindication for massage? a. Skin rash b. Cultural beliefs c. Already given opioids d. Comfort level of woman

a. Skin rash

A nurse is caring for a newborn with fetal alcohol spectrum disorder. What characteristic of the fetal alcohol spectrum disorder should the nurse assess for in the newborn? a. Small head circumference b. Decreased blood glucose level c. Poor breathing pattern d. Wide eyes

a. Small head circumference

The nurse is caring for a client in the early stages of labor. What maternal factors will alert the nurse to plan for the possibility of a small-for-gestational-age newborn? (Select all that apply) a. Smoking b. Hypotension c. Asthma d. Drug abuse e. Pregnancy weight gain of 20 lbs

a. Smoking c. Asthma d. Drug abuse

A pregnant client requires administration of an epidural block for management of pain during labor. Which of the following conditions should the nurse check for in the client before administering the epidural block? (Select all that apply) a. Spinal abnormality b. Hypovolemia c. Varicose veins d. Coagulation defects e. Skin rashes or bruises

a. Spinal abnormality b. Hypovolemia d. Coagulation defects

When determining the frequency of contractions, the nurse would measure which of the following? a. Start of one contraction to the start of the next contraction b. Beginning of one contraction to the end of the same contraction c. Peak of one contraction to the peak of the next contraction d. End of one contraction to the beginning of the next contraction

a. Start of one contraction to the start of the next contraction

Infants born with a diaphragmatic hernia are given supportive treatment until they can have surgery to repair the defect. What are the medications usually given to those infants? (Select all that apply) a. Steroids b. Inotropics c. Surfactant d. Plasma expanders e. Bronchodilators

a. Steroids b. Inotropics c. Surfactant

A pregnant woman has just presented to the emergency department with various complaints and in distress. Which of the following would lead the nurse to suspect that she is experiencing an amniotic fluid embolism? (Select all that apply.) a. Sudden onset of respiratory distress b. Hypotension c. Acute, continuous abdominal pain d. Tachycardia e. Sudden onset of fetal distress

a. Sudden onset of respiratory distress b. Hypotension d. Tachycardia

Which of the following would the nurse expect to find in a newborn who is considered small-for-gestational-age? (Select all that apply.) a. Sunken abdomen b. Increased subcutaneous fat stores c. Poor muscle tone over buttocks d. Narrow skull sutures e. Thin umbilical cord

a. Sunken abdomen c. Poor muscle tone over buttocks e. Thin umbilical cord

The mother has delivered a premature infant at 30 weeks. The nurse is aware that the infant needs to be evaluated for which of the following to ensure the alveoli can function properly? a. Surfactant b. Oxygen c. Blood flow d. Hematocrit

a. Surfactant

The nurse needs to conduct a procedure on a preterm newborn. Which of the following would be most effective in reducing pain? (Select all that apply.) a. Swaddling the newborn closely b. Increasing the volume on device alarms c. Encouraging kangaroo care during procedures d. Removing tape quickly from the skin e. Offering a pacifier prior to a procedure

a. Swaddling the newborn closely c. Encouraging kangaroo care during procedures e. Offering a pacifier prior to a procedure

The nurse is caring for a pregnant client who is in her 30th week of gestation and has congenital heart disease. Which of the following should the nurse recognize as a symptom of cardiac decompensation with this client? a. Swelling of the face b. Dry, rasping cough c. Slow, labored respiration d. Elevated temperature

a. Swelling of the face

A newborn in a family maternity center is suspected of having a cardiopulmonary disorder. Which of the following symptoms of persistent pulmonary hypertension should the nurse assess for in the newborn? a. Systolic ejection murmur b. Respiratory alkalosis c. Rhinorrhea d. Lacrimation

a. Systolic ejection murmur

A group of nurses are running a campaign initiated by the Maternal and Child Health Bureau to educate women about better maternal and infant care. Which of the following measures should they advocate for the prevention of neural defects in infants? a. Take folic acid supplements b. Take vitamin E supplements c. Perform mild exercises during pregnancy d. Regularly eat citrus fruits during pregnancy

a. Take folic acid supplements

A woman is being issued a new prescription for a low-dose combination birth control pill. What advice should the nurse give the woman if she ever forgets to take a pill? a. Take it as soon as she remembers, even if that means taking two pills in one day. b. Skip that pill and refrain from intercourse for the remainder of the month. c. Wear a pad for the next week because she will experience vaginal bleeding. d. Take an at-home pregnancy test at the end of the month to check for a pregnancy.

a. Take it as soon as she remembers, even if that means taking two pills in one day.

A mother who is 4 days postpartum, and is breastfeeding, expresses to the nurse that her breast seems to be tender and engorged. What education should the nurse give to the mother to relieve breast engorgement? (Select all that apply) a. Take warm-to-hot showers to encourage milk release b. Feed the newborn in the sitting position only c. Express some milk manually before breastfeeding d. Massage the breasts from the nipple toward the axillary area e. Apply warm compresses to the breasts prior to nursing

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

A nurse is caring for a client who is pregnant with a female baby. The client and her husband are both Jewish. The client is in her early 30s. They are not directly related by blood. There has been an instance of Tay-Sachs disease occurring in the family. Which of the following information does the nurse need to give the client regarding Tay-Sachs disease? a. Tay-Sachs disease affects both male and female babies b. The age of the client increases the susceptibility of the baby to Tay-Sachs disease c. There is no risk of Tay-Sachs disease because the parents are not related by blood d. There is no risk of the baby developing Tay-Sachs disease because both parents are healthy

a. Tay-Sachs disease affects both male and female babies

A nurse in a woman's shelter is counseling a client who has been a victim of abuse. What type of prevention is this treatment? a. Tertiary b. Secondary c. Primary d. Community-based

a. Tertiary

When describing the characteristics of the amniotic fluid to a pregnant woman, which would the nurse include? a. The amount gradually fluctuates during pregnancy. b. It limits fetal movement in utero. c. It is usually an acidic fluid. d. It is composed primarily of organic substances.

a. The amount gradually fluctuates during pregnancy.

A nurse is caring for a client who is scheduled to undergo amnioinfusion. The nurse knows that the client will not be able to have this procedure if which condition is present? a. The client has uterine hypertonicity b. The client has an active genital herpes infection c. The client has signs of abruptio placentae d. The client has invasive cervical cancer

a. The client has uterine hypertonicity

When describing the role of a doula to a group of pregnant women, which of the following would the nurse include? a. The doula primarily focuses on providing continuous labor support. b. The doula is capable of handling high-risk births and emergencies. c. The doula is a professionally trained nurse hired to provide physical and emotional support. d. The doula can perform any necessary clinical procedures.

a. The doula primarily focuses on providing continuous labor support.

Genetic testing has revealed that a couple's unborn child shows the possibility of mosaicism. When counseling this couple, you explain this means: a. The genetic abnormality occurred after fertilization and during the mitotic cell division. b. This genetic abnormality is a recessive trait that is familial. c. This genetic trait is generally passed from the mother to the child. d. This genetic trait generally occurs when both parents have the recessive trait in their DNA and pass it to their offspring.

a. The genetic abnormality occurred after fertilization and during the mitotic cell division.

A gravid, married client, 24 weeks' gestation, is found to have bacterial vaginosis. Her health care practitioner has ordered metronidazole (Flagyl) to treat the problem. Which of the following educational information is important for the nurse to provide the woman at this time? a. The woman must be careful to observe for signs of preterm labor. b. The woman must advise her partner to seek therapy as soon as possible. c. A common side effect of the medicine is a copious vaginal discharge. d. A repeat culture should be taken two weeks after completing the therapy.

a. The woman must be careful to observe for signs of preterm labor.

Five women wish to use the Ortho Evra (patch) for family planning. Which of the women should be carefully counseled regarding the safety considerations of the method? Select all that apply. a. The woman who smokes 1 pack of cigarettes each day. b. The woman with a history of lung cancer. c. The woman with a history of deep vein thrombosis. d. The woman who runs at least 50 miles each week. e. The woman with a history of cholecystitis.

a. The woman who smokes 1 pack of cigarettes each day. c. The woman with a history of deep vein thrombosis.

RhoGAM is given to Rh-negative women to prevent maternal sensitization. In addition to pregnancy, Rh-negative women would also receive this medication after which of the following? a. Therapeutic or spontaneous abortion b. Head injury from a car accident c. Blood transfusion after a hemorrhage d. Unsuccesful artificial insemination procedure

a. Therapeutic or spontaneous abortion

A nurse is caring for a 37-year-old pregnant client who is expecting twins, both boys. The client used to smoke but has stopped during pregnancy. A relative of the client has Klinefelter syndrome, and the client wants to find out more about the disorder. Which of the following information will the nurse give to the client during genetic counseling? a. There is a greater risk of Klinefelter syndrome due to the client's age b. Klinefelter syndrome occurs only in girls and not boys c. Having twins increases the risk of Klinefelter syndrome d. The client's previous smoking habit will increase the risk of a genetic disorder

a. There is a greater risk of Klinefelter syndrome due to the client's age

A triage nurse answers a telephone call from the male partner of a woman who was recently diagnosed with cervical cancer. The man is requesting to be tested for human papillomavirus (HPV). The nurse's response should be based on which of the following? a. There is currently no approved test to detect HPV in men. b. A viral culture of the penis and rectum is used to detect HPV in men. c. A Pap smear of the meatus of the penis is used to detect HPV in men. d. There is no need for a test because men do not become infected with HPV.

a. There is currently no approved test to detect HPV in men.

A client experiencing contractions presents at a health care facility. Assessment conducted by the nurse reveals that the client has been experiencing Braxton Hicks contractions. The nurse has to educate the client on the usefulness of Braxton Hicks contractions. Which of the following is the role of Braxton Hicks contractions in aiding labor? a. These contractions help in softening and ripening the cervix b. These contractions increase the release of prostaglandins c. These contractions increase oxytocin sensitivity d. These contractions make maternal breathing easier

a. These contractions help in softening and ripening the cervix

A pregnant client has come to a health care provider for her first prenatal visit. The nurse needs to document useful information about the past health history. What are goals of the nurse in the history-taking process? (Select all that apply) a. To prepare a plan of care that suits the client's lifestyle b. To develop a trusting relationship with the client c. To prepare a plan of care for the pregnancy d. To assess the client's partner's sexual health e. To urge the client to achieve an optimal body weight

a. To prepare a plan of care that suits the client's lifestyle b. To develop a trusting relationship with the client c. To prepare a plan of care for the pregnancy

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. Which of the following would be expected when conducting the Babinski reflex? a. Toes fan out when sole of foot is stroked b. Infant makes stepping motion c. Infant throw arms outward and flex knees d. Infant's toes curl over the nurse's finger

a. Toes fan out when sole of foot is stroked

When teaching the client how to use a contraceptive sponge, it is important that she understand leaving the sponge in place longer than 30 hours may lead to: a. Toxic shock syndrome b. Pelvic inflammatory disorder c. Sexually transmitted infections d. Cervical inflammation

a. Toxic shock syndrome

Four women with significant health histories wish to use the diaphragm as a contraceptive method. The nurse should counsel the woman with which of the following histories that the diaphragm may lead to a recurrence of her problem? a. Urinary tract infections. b. Herpes simplex infections. c. Deep vein thromboses. d. Human papilloma warts.

a. Urinary tract infections.

An HIV-positive client who is on antiretroviral therapy complains of anorexia, nausea and vomiting. Which of the following suggestions should the nurse offer the client to cope with this condition? a. Use high-protein supplements b. Eat dry crackers after meals c. Limit number of meals to three a day d. Constantly drink fluids while eating

a. Use high-protein supplements

A first-time mother informs the nurse that she is unable to breastfeed her baby through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for the baby. What instruction should the nurse offer the woman to ensure the safety of stored expressed breast milk? a. Use sealed and chilled milk within 24 hours b. Use frozen milk within 6 months of obtaining it c. Use microwave ovens to warm chilled milk d. Refreeze any unused milk for later use

a. Use sealed and chilled milk within 24 hours

A nurse is caring for a pregnant client in her second trimester of pregnancy. The nurse educates the client to look for which of the following danger signs of pregnancy needing immediate attention by the physician. a. Vaginal bleeding b. Painful, urination c. Severe, persistent vomiting d. Lower, abdominal and shoulder pain

a. Vaginal bleeding

A 27-year-old female was just confirmed to be pregnant. She tells you she just switched to a vegan diet. You explain that she must pay special attention to her intake of which of the following to ensure she is getting adequate nutrition for her and the baby. (Select all that apply.) a. Vitamin B12 b. Folate c. Calcium d. Iron e. Protein

a. Vitamin B12 c. Calcium d. Iron e. Protein

A woman comes to the clinic complaining of intense pruritus and a thick curd-like vaginal discharge. On examination white plaques are observed on the vaginal wall. The nurse suspects which of the following? a. Vulvovaginal candidiasis b. Bacterial vaginosis c. Chlamydia d. Trichomoniasis

a. Vulvovaginal candidiasis

The nurse has determined that based on the client's physical examination, she is at high risk for developing varicose veins. Which of the following suggestions might the nurse teach the client to help prevent this? (Select all that apply.) a. Walk daily b. Use thigh-high support hose c. Use knee-high support hose d. Sit in a hot tub at least three times a week e. Elevate the feet and legs

a. Walk daily b. Use thigh-high support hose e. Elevate the feet and legs

The nurse would be most alert for the development of transient tachypnea in a newborn who: a. Was born by cesarean birth b. Received no sedation c. Has a mother with heart disease d. Is small for gestational age

a. Was born by cesarean birth

A pregnant woman who is 26 weeks pregnant arrives for a follow-up visit. Which of the following assessments, in addition to measuring fundal height and fetal heart rate, would the nurse expect to complete? (Select all that apply.) a. Weight b. Blood pressure c. Blood glucose level d. Edema e. Urine testing

a. Weight b. Blood pressure c. Blood glucose level e. Urine testing

Which of the following findings would the nurse identify as normal when assessing a newborn? (Select all that apply.) a. Weight of 3,300 grams b. Temperature of 37% C c. Chest circumference of 35 cm d. Head circumference of 30 cm e. Length of 54 cm

a. Weight of 3,300 grams b. Temperature of 37% C e. Length of 54 cm

A man has been diagnosed with a chlamydial infection. The nurse would expect the client to complain of pain at which of the following times? a. When urinating. b. When ejaculating. c. When the penis becomes erect. d. When the testicles are touched.

a. When urinating.

It is the nurse's first meeting with a pregnant client. What is the first point that the nurse needs to ascertain as part of the admission assessment to check whether the client needs to be admitted? a. Whether the client is in true or false labor b. Whether the client is pregnant for the first time c. Whether the client is addicted to drugs d. Whether the client has a history of drug allergy

a. Whether the client is in true or false labor

A pregnant client has tested positive for hepatitis B virus. When discussing the situation with the client, the nurse explains that her infant should be vaccinated with an initial HBV vaccine dose at which of the following? a. Within 12 hours of birth b. Within 36 hours of birth c. Within 24 hours of birth d. Within 48 hours of birth

a. Within 12 hours of birth

A 27-year-old G1, P1 woman arrives in the emergency department accompanied by her husband and new infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when? a. Within 3 months of giving birth b. Within 2 months of giving birth c. Within 5 months of giving birth d. Within 4 months of giving birth

a. Within 3 months of giving birth

In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, certain women should not breast-feed. Which of the following would be examples the nurse might mention? (Select all that apply.) a. Women on antithyroid medications b. Women who had difficulties with breastfeeding in the past c. Women using street drugs d. Women on antineoplastic medications e. Women with more than one infant

a. Women on antithyroid medications c. Women using street drugs d. Women on antineoplastic medications

A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment? a. Yellow sclera b. Abdominal distension c. Heart rate of 130 beats per minute d. Respiratory rate of 24

a. Yellow sclera

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem? a. apnea b. shivering c. hyperglycemia d. metabolic alkalosis

a. apnea

WITHDRAWAL ACRONYM

assess the newborn for signs of neonatal abstinence syndrome using the acronym WITHDRAWAL to focus the assessment: W: Wakefulness: sleep duration less than 3 hours after feeding I: Irritability T: Temperature variation, tachycardia, tremors H: Hyperactivity, high-pitched persistent cry, hyperreflexia, hypertonus D: Diarrhea, diaphoresis, disorganized suck R: Respiratory distress, rub marks, rhinorrhea A: Apneic attacks, autonomic dysfunction W: Weight loss or failure to gain weight A: Alkalosis (respiratory) L: Lacrimation

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to:

assess the rate of flow of the oxytocin infusion. A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.

Silverman-Anderson Index

assessment scoring system that can be used to evaluate five parameters of work of breathing as it assigns a numerical score for each parameter. *Respiratory Distress Syndrome

recommeded fluid intake for breastfeeding mother?

at least 2,500 mL (approximately 84 oz).

In addition to newborns of diabetic mothers being at risk for hypoglycemia, these newborns are also at risk for which condition? a) hypermagnesemia b) hypocalcemia c) hyperkalemia d) hypobilirubinemia

b) hypocalcemia The newborn of the diabetic mother is at risk for hypocalcemia, hypomagnesemia, polycythemia with hyperviscosity, and hyperbilirubinemia. Potassium concerns are not a risk for these newborns

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

b) shiny heels and palms A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in postterm newborns and is excessive in premature infants.

A nurse is teaching the mother of a newborn experiencing cocaine withdrawal about caring for the neonate at home. The mother stopped using cocaine near the end of her pregnancy. The nurse determines that additional teaching is needed when the mother identifies which action as appropriate for her newborn? a) offering a pacifier b) waking the newborn every hour c) checking the newborn's fontanels d) wrapping the newborn snugly in a blanket

b) waking the newborn every hour Stimuli need to be decreased. Waking the newborn every hour would most likely be too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive sucking. Checking the fontanels provides evidence of hydration

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

b. A sign of adequate formula intake is when the newborn seems satisfied and is gaining weight regularly. The formula fed newborn should take 30 minutes or less to finish a bottle, not less than 15 minutes. The newborn does normally produce several stools per day, but should wet 6 to 10 diapers rather than 3 to 4 per day. The newborn should consume approximately 2 oz of formula per pound of body weight per day, not per feeding."

A newborn is suspected of having gastroschisis at birth. How would the nurse differentiate this problem from other congenital defects? a) The umbilical cord comes out of middle of the defect b) The intestines appear reddened and swollen and have no sac around them c) The abdominal contents are contained within a thin, transparent sac d) The skin over the abdomen is wrinkled and looks like a prune

b. The intestines appear reddened and swollen and have no sac around them

The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location? A) Just superior to the nipple, at the midsternum B) Lateral to the midclavicular line at the fourth intercostal space C) At the fifth intercostal space to the left of the sternum D) Directly adjacent to the sternum at the second intercostals space

b. The point of maximal impulse in a newborn is lateral to the midclavicular line at the fourth intercostal space. A displaced PMI may indicate a tension pneumothorax or cardiomegaly.

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

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

A nurse caring for a pregnant client utilizes the RAFT screening instrument to assess the possibility of substance abuse. What question does the "R" in RAFT refer to? a. "Do you use drugs as a form of recreation?" b. "Do you drink or take drugs to relax?" c. "Do you have any relatives that abuse drugs?" d. "Do you ever rely on drugs to help you sleep?"

b. "Do you drink or take drugs to relax?"

A young couple is preparing to leave the hospital and go home after the birth of their baby. As the nurse, preparing their care plan, you can demonstrate the recognition of their cultural differences by asking: a. "Do you understand why the treatment plan must be followed carefully?" b. "Do you have any treatment preferences you would like me to include in the care plan?" c. "If you have any difficulties, do you remember whom to call?" d. "Do you agree to do exactly as the physician is asking?"

b. "Do you have any treatment preferences you would like me to include in the care plan?"

The community health nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, which of the following statements would indicate the need for more information? a. "My mom always used Nupercaine." b. "I only eat a low-fiber diet." c. "Sitz baths worked the last time." d. "I already have some Tucks pads at home."

b. "I only eat a low-fiber diet."

The nurse has given postvasectomy teaching to a client. Which of the following responses by the client indicates that the teaching was effective? a. "I will measure my urinary output for two days." b. "I will ejaculate the same amount of semen as I did before the surgery." c. "I will refrain from having an erection until next week." d. "I will irrigate the wound twice today and once more tomorrow."

b. "I will ejaculate the same amount of semen as I did before the surgery."

A nurse informs a 19-year-old client that she is pregnant. The client immediately states that she plans to have an abortion. What would be the most appropriate response from the nurse to this client? a. "I don't know of any doctors who will perform them." b. "I'll put together the information that you will need." c. "Have you notified the father?" d. "Are you sure you want to do that?"

b. "I'll put together the information that you will need."

The nurse is counseling a couple who are concerned that the woman has achondroplasia in her family. The woman is not affected. Which of the following statements by the couple indicates the need for more teaching? a. "If the mother has the gene, then there is a 50% chance of passing it on" b. "If the father doesn't have the gene, then his son won't have achondroplasia" c. "If the father has the gene, then there is a 50% chance of passing it on" d. "Since neither one of us has the disorder, we won't pass it on"

b. "If the father doesn't have the gene, then his son won't have achondroplasia."

A woman is suspected of having abruptio placentae. Which of the following would the nurse expect to assess as a classic symptom? a. Painless, bright-red bleeding b. "Knife-like" abdominal pain c. Excessive nausea and vomiting d. Hypertension and headache

b. "Knife-like" abdominal pain

A young woman is seen in the emergency department. She states, "I took a pregnancy test today. I'm pregnant. My parents will be furious with me!! I have to do something!" Which of the following responses by the nurse is most appropriate? a. "You can take medicine to abort the pregnancy so your parents won't know." b. "Let's talk about your options." c. "The best thing for you to do is to have the baby and to give it up for adoption." d. "I can help you tell your parents."

b. "Let's talk about your options."

After a sex education class, the school nurse overhears an adolescent woman discussing safe sex practices. Which of the following comments by the young woman indicates that teaching about infection control was effective? a. "I don't have to worry about getting infected if I have oral sex." b. "Teen women are most high risk for sexually transmitted infections (STI)." c. "The best thing to do if I have sex a lot is to use spermicide each and every time." d. "Boys get human immunodeficiency virus (HIV) easier than girls do."

b. "Teen women are most high risk for sexually transmitted infections (STI)."

A pregnant client asks the nurse about the relationship between her circulation and that of the unborn child. What response by the nurse is most appropriate? a. "The shared circulation between mother and unborn child begins at the time of conception" b. "There is no actual shared blood circulation but the substances in the mother's bloodstream may be filtered to the fetus through the placenta" c. "Shared circulation is greatest during the second trimester" d. "The sharing of circulation begins once the products of conception begin the embryonic stage of development"

b. "There is no actual shared blood circulation but the substances in the mother's bloodstream may be filtered to the fetus through the placenta"

Which of the following instructions would the nurse include in the teaching plan for a postpartum woman with mastitis? a. "You'll need to take this medication to stop the milk from being produced." b. "Try applying warm compresses to your breasts to encourage the milk to be released." c. "Limit the amount of fluid you drink so your breasts don't get much fuller." d. "Stop breastfeeding until the pain and swelling subside."

b. "Try applying warm compresses to your breasts to encourage the milk to be released."

As part of an education program for pregnant women and their partners, the nurse describes the various settings available for childbirth. The nurse determines that the program was successful when the group relates which of the following about home births? a. "There are very rigid screening procedures that must be followed." b. "Women giving birth at home have control over every part of labor." c. "A wide range of pain medications is readily available to the woman." d. "A home birth is probably the most expensive setting for childbirth."

b. "Women giving birth at home have control over every part of labor."

A woman is being seen in the gynecology clinic. The nurse notes that the woman has a swollen eye and a bruise on her cheek. Which of the following is an appropriate statement for the nurse to make? a. "I am required by law to notify the police department of your injuries." b. "Women who are abused often have injuries like yours." c. "You must leave your partner before you are injured again." d. "It is important that you refrain from doing things that anger your partner."

b. "Women who are abused often have injuries like yours."

When treating a postpartum woman for hemorrhage, the nurse will prepare the client for a blood transfusion once the estimates of blood loss reach which level? a. 1,000 mL b. 1,500 mL c. 1,750 mL d. 1,250 mL

b. 1,500 mL

A mother wants to know the caloric intake for her 2-week-old newborn. Which of the following should the nurse suggest as the ideal caloric intake for a term newborn to regain lost weight? a. 85 kcal/kg/day b. 108 kcal/kg/day c. 156 kcal/kg/day d. 212 kcal/kg/day

b. 108 kcal/kg/day

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

b. 12 months

The client is preparing to go home after a cesarean birth. As the nurse giving discharge instructions, you stress to the family the client should be seen by her doctor within what time interval? a. 3 weeks b. 2 weeks c. 5 weeks d. 4 weeks

b. 2 weeks

The client arrives in the office and is complaining of her feet and legs swelling. During a client evaluation, the nurse notes that she can elicit a 4-mm skin depression that disappears in 10 to 15 seconds. Which of the following would be the correct documentation? a. 1+ pitting edema b. 2+ pitting edema c. 4+ pitting edema d. 3+ pitting edema

b. 2+ pitting edema

Which of the following clients, who are all seeking a family planning method, is the best candidate for birth control pills? a. 19-year-old with multiple sex partners. b. 27-year-old who bottle feeds her newborn. c. 29-year-old with chronic hypertension. d. 37-year-old who smokes one pack per day.

b. 27-year-old who bottle feeds her newborn.

A 23-year-old female has come to your clinic for her first prenatal visit. After the examination reveals no concerns and potential low-risk pregnancy, you discuss nutritional needs for her and her growing baby. As per the Institute of Medicine, you suggest the client take which of the following on a daily basis? a. 20 mg ferrous iron daily b. 30 mg ferrous iron daily c. 10 mg ferrous iron daily d. 40 mg ferrous iron daily

b. 30 mg ferrous iron daily

The nurse recognizes the group of infants born during which time frame are at a higher risk for morbidity and mortality? a. 32 to 34 weeks b. 34 to 36-6/7 weeks c. 28 to 30 weeks d. 30 to 32 weeks

b. 34 to 36-6/7 weeks

The parents of a newborn with a cleft palate ask the nurse at what age the defect in the lip is usually repaired? Which response by the nurse is correct? a. 2 to 6 weeks b. 6 to 12 weeks c. 2 to 3 months d. 6 to 12 months

b. 6 to 12 weeks

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

b. 7

Following the birth, you are responsible for assessing the cord pH. You recognize which of the following would be considered a normal pH? a. 6.8 b. 7.2 c. 7.0 d. 7.4

b. 7.2

After teaching a class about the changes in the gastrointestinal system of a newborn, which of the following if stated by the class indicates the need for additional teaching? a. Oral intake is necessary for vitamin K production. b. A newborn's stomach capacity is approximately 300 mL. c. The cardiac sphincter is immature. d. The newborn's gut is sterile at birth

b. A newborn's stomach capacity is approximately 300 mL.

When evaluating a newborn with congenital clubfoot, the nurses recognizes this usually involves all except which of the following? a. Inversion of forefoot b. Abduction of forefoot c. Internal rotation of leg d. Inversion of hindfoot

b. Abduction of forefoot

When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which of the following? a. Above 95th percentile b. Above 90th percentile c. Above 85th percentile d. Above 80th percentile

b. Above 90th percentile

A laboring woman is admitted to the labor and birth suite at 6-cm dilation. She would be in which phase of the first stage of labor? a. Latent b. Active c. Transition d. Early

b. Active

A nurse is assessing a client during the postpartum period. Which of the following indicate normal postpartum adjustment? (Select all that apply) a. Abdominal pain b. Active bowel sounds c. Tender abdomen d. Passing gas e. Nondistended abdomen

b. Active bowel sounds d. Passing gas e. Nondistended abdomen

A nurse is caring for a preterm infant. Which intervention will prepare the preterm newborn's gut to overcome feeding difficulties? a. Administer Vitamin D supplements b. Administer 0.5 mL of breast milk enterally c. Administer iron supplements d. Administer dextrose intravenously

b. Administer 0.5 mL of breast milk enterally

A nurse is caring for a client with idiopathic thrombocytopenic purpura. The nurse is correct when performing which intervention? a. Administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) b. Administration of platelet transfusions as ordered c. Avoiding administration of oxytocics d. Continual firm massage of the uterus

b. Administration of platelet transfusions as ordered

A pregnant client arrives at the community health center for a routine check-up. She informs the nurse that a relative on her mother's side has hemophilia, and she wants to know the chances of her child acquiring hemophilia. Which of the following characteristics of hemophilia should the nurse explain to the client to help her understand the odds of acquiring the disease? (Select all that apply). a. Affected individuals will have affected parents b. Affected individuals are usually males c. Daughters of an affected male are unaffected and are not carriers d. Female carriers have a 50% chance of transmitting the disorder to their sons e. Females are affected by the condition if it is a dominant X-linked disorder.

b. Affected individuals are usually males d. Female carriers have a 50% chance of transmitting the disorder to their sons e. Females are affected by the condition if it is a dominant X-linked disorder.

The client presents with complaints of possible PMDD. According to the American Psychiatric Association, which of the symptoms are typical for this disorder? (Select all that apply.) a. Dysuria b. Affective liability c. Diarrhea d. Sleep difficulties

b. Affective liability c. Diarrhea d. Sleep difficulties

Which of the following would be least effective in promoting a positive birth outcome for a woman in labor? a. Promoting the woman's feelings of control b. Allowing the woman time to be alone c. Providing clear information about procedures d. Encouraging the woman to use relaxation techniques

b. Allowing the woman time to be alone

After teaching a class about various methods for cervical ripening, the instructor determines that the teaching was successful when the class identifies which of the following as a surgical method? a. Laminaria b. Amniotomy c. Breast stimulation d. Prostaglandin

b. Amniotomy

As a nurse at the local health clinic, you recognize that STIs can often result in PID. When a client with a history with repeat STIs presents to the clinic with complaints of severe abdominal cramping and bleeding, the immediate concern is to ensure the client does not have: a. Endometriosis b. An ectopic pregnancy c. Secondary urinary tract infection d. PID

b. An ectopic pregnancy

When reviewing the history of a woman in labor, the nurse notes that the client has a funnel-shaped pelvis. The nurse would identify this pelvic shape as which of the following? a. Platypelloid b. Android c. Gynecoid d. Anthropoid

b. Android

During a routine examination, the nurse suspects a teenager is having unprotected sex. To encourage discussion, the nurse must: a. Alert the parents b. Appear nonjudgmental but direct in the conversation c. Lecture the teen on the dangers of unprotected sex d. Report the teen to Child Protective Services

b. Appear nonjudgmental but direct in the conversation

The prenatal education at your clinic includes emphasizing routine prenatal visits, because most pregnancy-related complications: a. Are predictable b. Are preventable c. Can be better controlled d. Can be treated earlier

b. Are preventable

When communicating with a client who speaks a different language, the best practice for the nurse is to: a. Speak loudly and slowly b. Arrange for an interpreter when communicating with the client c. Stand close to the client and talk loudly d. Speak with a family member about the client's condition

b. Arrange for an interpreter when communicating with the client

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? a. Echocardiogram b. Arterial blood gases c. Chest x-rays d. Angiography

b. Arterial blood gases

During an admission assessment of a client in labor, the nurse observes that there is no vaginal bleeding yet. What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor? a. Monitor vital signs b. Assess amount of cervical dilation c. Obtain urine specimen for urinalysis d. Monitor hydration status

b. Assess amount of cervical dilation

A nurse is caring for a pregnant client with asthma. Which of the following interventions should the nurse include during physical examination of this client? a. Monitoring temperature frequently b. Assessing for signs of fatigue c. Monitoring frequency of headache d. Assessing for feeling nauseated

b. Assessing for signs of fatigue

The nurse in a free clinic is caring for a 1-year-old girl and her single mother. Which action would be most important initially? a. Observing the mother/child interaction b. Assessing the child's cognitive level c. Discussing family beliefs d. Assessment is the priority

b. Assessing the child's cognitive level

The nurse realizes that accommodating for the various cultural differences in her clients is an important aspect in providing their care. When caring for a postpartum woman who is Muslim, which of the following would be a priority? a. Allowing time for the numerous visitors who come to see the woman and newborn b. Assigning a female nurse to care for her c. Providing time for prayers to be performed at the bedside d. Ensuring that the newborn's daily bath is performed by the nurses

b. Assigning a female nurse to care for her

Which of the following suggestions would be most appropriate to include in the teaching plan for a postpartum woman who needs to lose weight? a. Increase fluid intake and acid-producing foods in her diet b. Avoid empty-calorie foods and increase exercise c. Start a high-protein diet and restrict fluids d. Eat no snacks or carbohydrates

b. Avoid empty-calorie foods and increase exercise

The nurse recognizes that documenting accurate blood pressures is vital in the diagnosing of preeclampsia and eclampsia. To be diagnostic of preeclampsia, which of the following should occur? a. BP of 140/90 mm Hg on two occasions after 28 weeks' gestation b. BP of 140/90 mm Hg on two occasions 6 hours apart c. BP of 140/90 mm Hg on three occasions 3 hours apart d. BP of 140/90 mm Hg on three occasions after 20 weeks' gestation

b. BP of 140/90 mm Hg on two occasions 6 hours apart

The nurse is preparing her teaching plan for a woman who has just had her pregnancy confirmed. Which of the following should be included in it? (Select all that apply). a. Prevent constipation by taking a daily laxative b. Balance your dietary intake by increasing your calories by 300 to 500 daily c. Continue your daily walking routine as you did before this pregnancy d. Tetanus, measles, mumps, and rubella vaccines will be given to you now e. Avoid tub baths now that you are pregnant to prevent vaginal infections f. Sexual activity is permitted as long as your membranes are intact g. Increase your consumption of milk to meet your iron needs

b. Balance your dietary intake by increasing your calories by 300 to 500 daily c. Continue your daily walking routine as you did before this pregnancy e. Avoid tub baths now that you are pregnant to prevent vaginal infections f. Sexual activity is permitted as long as your membranes are intact

A woman with diabetes is in labor. The nurse monitors her blood glucose level closely with the goal to maintaining her glucose level at which of the following to reduce the likelihood of neonatal hypoglycemia? a. Below 115 mg/dL b. Below 110 mg/dL c. Below 120 mg/dL d. Below 105 mg/dL

b. Below 110 mg/dL

The nurse is concerned that a newborn is hypoglycemic. Which of the following blood glucose values would indicate that? a. Below 50 mg/dL b. Below 40 mg/dL c. Below 30 mg/dL d. Below 60 mg/dL

b. Below 40 mg/dL

When assessing the effectiveness of the obstetrical regional analgesia received by a client, you recognize it is successful by the complete loss of pain sensation at which level of the spinal cord? a. Below T7 level b. Below T8 level c .Below T5 level d. Below T6 level

b. Below T8 level

You are leading a discussion among couples who are thinking about getting pregnant. As the nurse you stress that preconception counseling helps to identify risks and encourages modification by the couple before conception. You consider the discussion successful when the couples realize that the greatest risk to the embryo is: a. Between 4 and 17 days after conception b. Between 17 and 56 days after conception c. Between 17 and 56 hours after conception d. Between 4 and 17 hours after conception

b. Between 17 and 56 days after conception

The nurse administers a single dose of Vitamin K intramuscularly to a newborn after birth to promote: a. Conjugation of bilirubin b. Blood clotting c. Foreman ovale closure d. Digestion of complex proteins

b. Blood clotting

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? a. The mother pump her breast milk and measure it before feeding b. Breastfeed the infant every 2 to 3 hours on demand c. Weigh the infant daily to ensure that she is gaining 1 1/2 to 2 oz per day d. Add cereal to the newborn's feedings twice a day

b. Breastfeed the infant every 2 to 3 hours on demand

Client advocacy, utilization management and coordination of care describe which of the following? a. Primary nursing care b. Case management c. Family-centered care d. Patient-focused care

b. Case management

A primiparous mother delivered a 8lb 12oz (4kg) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine lase evening. Which factor places the newborn at risk for the development of jaundice? a. Formula feeding b. Cephalohematoma c. Female gender d. Hepatitis A vaccinee. Rh-positive blood type

b. Cephalohematoma

A 25-year-old client wants to know if her baby boy is at risk for Down syndrome, as one of her distant relatives was born with it. Which of the following will the nurse tell the client while counseling her about Down syndrome? a. Instances of Down syndrome in the family increases the risk for the baby b. Children with Down syndrome have 47 chromosomes instead of 46 c. Down syndrome occurs only in females, and there is no risk as the baby is male d. Children with Down syndrome are intellectually normal

b. Children with Down syndrome have 47 chromosomes instead of 46

What is the leading cause of infant mortality in the United States? a. Low birth weight b. Congenital abnormalities c. Prematurity d. Respiratory distress syndrome

b. Congenital abnormalities

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

b. Convection

The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which of the following? a. Restitution b. Crowning c. Descent d. Engagement

b. Crowning

The ability of the nurse to identify irregular findings during a physical assessment aids in rapid diagnosis and treatment of possible complications. Tachycardia may indicate which of the following situations that would require further assessment and intervention? a. Anemia b. Drug withdrawal c. Infection d. Hypothermia

b. Drug withdrawal

A nurse is monitoring a client with spontaneous abortion who has been prescribed misoprostol. The nurse knows that which of the following symptoms are common adverse effects associated with misoprostol? (Select all that apply) a. Constipation b. Dyspepsia c. Headache d. Hypotension e. Tachycardia

b. Dyspepsia

A client presents at the clinic and is interested in obtaining emergency contraception. The nurse explains that they must be used within 72 hours of unprotected sex to be effective. This is due to: a. ECs can help prevent STIs b. ECs simply prevent embryo creation and uterine implantation from occurring in the first place c. ECs can induce an abortion of a recently implanted embryo d. ECs are more effective than regular birth control

b. ECs simply prevent embryo creation and uterine implantation from occurring in the first place

Various conditions or syndromes are given acronyms to name them. Which of the following is not a part of the acronym HELLP? a. Hemolysis b. Elevated lipoproteins c. Liver enzyme elevation d. Low platelet count

b. Elevated lipoproteins

A woman states that she feels "dirty" during her menses so she often douches to "clean myself." The nurse advises the woman that it is especially important to refrain from douching while menstruating because douching will increase the likelihood of her developing which of the following gynecological complications? a. Fibroids. b. Endometritis. c. Cervical cancer. d. Polyps.

b. Endometritis.

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

b. Escherichia coli

A client complaining of genital warts has been diagnosed with HPV. The genital warts have been treated, and they have disappeared. Which of the following should the nurse include in the teaching plan when educating the client about the condition? a. Applying steroid creams in affected area promotes comfort b. Even after warts are removed, HPV still remains c. All women above the age of 30 should get themselves vaccinated against HPV d. Use of latex condoms is associated with increased risk of cervical cancer

b. Even after warts are removed, HPV still remains

A nurse has been assigned to the care of a client who has just given birth. How frequently should the nurse perform the assessments during the first hour after delivery? a. Every 30 minutes b. Every 15 minutes c. After 60 minutes d. After 45 minutes

b. Every 15 minutes

A nurse is caring for a pregnant client who is in the active phase of labor. At what intervals should the nurse monitor the client's vital signs? a. Every 15 to 30 minutes b. Every 30 minutes c. Every 30 to 60 minutes d. Every 4 hours

b. Every 30 minutes

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition? a) Intermittent tachypnea b) Expiratory grunting c) High-pitched shrill cry d) Bile-stained emesis

b. Expiratory grunting

The nurse is caring for a client with end-stage breast cancer. When she takes chemotherapy medication into the client's room, the client states, "I'm too tired to fight any more. I don't want any more medication that may prolong my life." The client's husband is at the bedside and states, "No! You have to give my wife her medication. I can't let her go." What action by the nurse is most appropriate? a. Giving the medication b. Explaining to the husband that his wife has the right to refuse medication and care c. Encouraging the client to heed her husband's wishes d. Stating that she has to give the medication unless the doctor orders the medication stopped

b. Explaining to the husband that his wife has the right to refuse medication and care

The nurse is working with a client who states that she has multiple sex partners. Which of the following contraceptive methods would be best for the nurse to recommend to this client? a. Intrauterine device. b. Female condom. c. Bilateral tubal ligation. d. Birth control pills.

b. Female condom.

A pregnant client in labor has to undergo a sonogram to confirm the fetal position of a shoulder presentation. The nurse should assess for which of the following conditions associated with shoulder presentation during a vaginal birth? a. Uterine abnormalities b. Fetal anomalies c. Congenital anomalies d. Prematurity

b. Fetal anomalies

A woman at 15 weeks' gestation asks the nurse what the fetus looks like. Which response by the nurse would be most accurate? a. The fetus is covered with a white, greasy film called vernix. b. Fingernails and toenails are present. c. Rhythmic breathing movements are occurring. d. The fetus is about 15 inches in length.

b. Fingernails and toenails are present.

A pregnant woman is diagnosed with abruptio placentae. When reviewing the woman's physical assessment in her medical record, which of the following would the nurse expect to find? a. Fetal heart rate within normal range b. Firm, rigid uterus on palpation c. Bright red vaginal bleeding d. Absence of pain

b. Firm, rigid uterus on palpation

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 should explain which of the following has possibly occurred? a. Alkalosis has occurred b. Foramen ovale has not closed c. There is a mitral insufficiency murmur d. There is a left-to-right shunting occurring in the heart

b. Foramen ovale has not closed

A preterm newborn is being monitored for potential necrotizing enterocolitis. The nurse recognizes which of the following as a major pathologic mechanism that could lead to this complication? (Select all that apply.) a. Uncontrolled diarrhea b. Formula feeding c. Maternal infection d. Perinatal stressors e. Bowel ischemia

b. Formula feeding d. Perinatal stressors e. Bowel ischemia

The nurse should encourage all new clients who present for their initial prenatal screening to include screening for: a. HCV b. HBV c. HAV d. HPV

b. HBV

When explaining to a pregnant woman about HIV infection and transmission, which of the following would the nurse include? a. It primarily occurs when there is a large viral load in the blood b. HIV is most commonly transmitted via sexual contact c. It affects the majority of infants of mothers with HIV infections d. Nurses are most frequently affected due to needlesticks

b. HIV is most commonly transmitted via sexual contact

The nurse would anticipate a cesarean birth for a client who has which active infection present at the onset of labor? a. Hepatitis b. Herpes simplex virus c. Toxoplasmosis d. Human papillomavirus

b. Herpes simplex virus

A pregnant woman, approximately 12 weeks' gestation, comes to the emergency department after calling her health care provider's office and reporting moderate vaginal bleeding. Assessment reveals cervical dilation and moderately strong abdominal cramps. She reports that she has passed some tissue with the bleeding. THe nurse interprets these findings to suggest which of the following? a. Threatened abortion b. Inevitable abortion c. Incomplete abortion d. Missed abortion

b. Inevitable abortion

A client who is in her 6th week of gestation is being seen for a routine prenatal care visit. The client asks the nurse about changes in her eating habits that she should make during her pregnancy. The client informs the nurse that she is a vegetarian. The nurse knows that she has to monitor the client for which of the following risks arising from her vegetarian diet? (Select all that apply) a. Risk of epistaxis b. Iron-deficiency anemia c. Decreased mineral absorption d. Increased risk of constipation e. Low gestational weight gain

b. Iron-deficiency anemia c. Decreased mineral absorption e. Low gestational weight gain

A client delivers a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home? a. Ensure cool air is circulating over the newborn to prevent overheating b. Keep the newborn wrapped in a blanket, with a cap on its head c. Encourage the mother to keep the infant in her bed to ensure that the infant stays warm d. Keep the infant's room temperature at least 80 degrees

b. Keep the newborn wrapped in a blanket, with a cap on its head

A client delivers a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding care of the newborn at home? a. Ensure cool air is circulating over the newborn to prevent excess heat b. Keep the newborn wrapped in a blanket, with a cap on its head. c. Hold the newborn close to the body after taking a shower d. Refrain from using clothing and blankets in the crib

b. Keep the newborn wrapped in a blanket, with a cap on its head.

A nurse needs to ensure an informed consent has been obtained to provide care to a young client. Which aspect would be the most important for the nurse to consider related to the informed consent? a. Determining if the child is emancipated b. Knowing the laws in the state where care is being provided c. Contacting the parents prior to giving emergency care d. Establishing if the parents are competent

b. Knowing the laws in the state where care is being provided

A client is seeking advice for his pregnant wife, who is experiencing mild elevations in blood pressure. In which of the following positions should a nurse recommend the pregnant client rest? a. Supine position b. Lateral recumbent position c. Left lateral lying position d. Head of the bed slightly elevated

b. Lateral recumbent position

A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which of the following? a. Increased feelings of control b. Less anxiety c. Decreased sedation d. Increased cervical dilation

b. Less anxiety

Some women experience a rupture of their membranes before going into true labor. A nurse recognizes that a woman who presents with PPROM has completed how many weeks of gestation? a. Less than 35 weeks b. Less than 37 weeks c. Less than 36 weeks d. Less than 38 weeks

b. Less than 37 weeks

The nurse is updating the records of a woman who recently gave birth to a healthy 7-lb newborn. Which of the following actions could jeopardize the privacy of the woman's medical records? a. Printing out confidential information for transmittal b. Letting another nurse use the nurse's long-in session c. Closing files before stepping away from the computer d. Changing identification and passwords monthly

b. Letting another nurse use the nurse's long-in session

A client in her third trimester of pregnancy arrives at a health care facility complaining of cramping and low back pain; she also notes that she is urinating more frequently and that her breathing has become easier the past few days. Physical examination conducted by the nurse indicates the client has edema of the lower extremities, along with an increase in vaginal discharge. The nurse knows that the client is experiencing which of the following conditions? a. Nesting b. Lightening c. Braxton Hicks contractions d. Bloody show

b. Lightening

Which fetal lie is most conductive to a spontaneous vaginal birth? a. Transverse b. Longitudinal c. Perpendicular d. Oblique

b. Longitudinal

A nurse is caring for a critically ill female client who has recently been diagnosed with advanced lung cancer. Which of the following reasons could have contributed to the late detection and diagnosis? a. Women have a stronger resistance against lung cancer b. Lung cancer has no early symptoms c. Lung cancer is considered more deadly in men than in women d. Lung cancer is more challenging to diagnose in women than in men

b. Lung cancer has no early symptoms

Prevention and early identification of newborns at risk are necessary nursing functions. Which of the following are prenatal risk factors that may indicate a newborn will need resuscitation at birth secondary to asphyxia? (Select all that apply.) a. Nulliparous mother b. Maternal infection c. Congenital heart disease d. Gestational hypertension e. Labor and delivery without anesthesia

b. Maternal infection c. Congenital heart disease d. Gestational hypertension

A client in her second trimester of pregnancy complains of discomfort during sexual activity. Which of the following instructions should the nurse provide? a. Perform frequent douching, and use lubricants b. Modify sexual positions to increase comfort c. Restrict contact to alternative, noncoital modes of sexual expression d. Perform stress-relieving and relaxing exercises

b. Modify sexual positions to increase comfort

The nurse has to prepare a discharge plan as a part of her postpartum care of a client, whom she is caring for in a home-based setting. Which of the following aspects of care should the nurse include in her postpartum care in this environment? a. Provide the client with self-help books about infant care b. Monitor the physical and emotional well-being of family members c. Recognize infant needs in the discharge plan d. Identify developing complications in the infant

b. Monitor the physical and emotional well-being of family members

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

b. No action is needed; this is normal

A couple reports that their condom broke while they were having sexual intercourse last night. What would you advise to prevent pregnancy? a. Inject a spermicidal agent into the woman's vagina immediately b. Obtain emergency contraceptives and take them immediately c. Douche with a solution of vinegar and hot water tonight d. Take a strong laxative now and again at bedtime

b. Obtain emergency contraceptives and take them immediately

A nurse is caring for a female client who is undergoing treatment for genital warts due to HPV. Which of the following information should the nurse include when educating the client about the risk of cervical cancer? Select all that apply. a. Use of broad-spectrum antibiotics increases risk of cervical cancer b. Obtaining Pap smears regularly helps early detection of cervical cancer c. Abnormal vaginal discharge is a sign of cervical cancer d. Recurrence of genital warts increases risk of cervical cancer e. Use of latex condoms is associated with a lower rate of cervical cancer

b. Obtaining Pap smears regularly helps early detection of cervical cancer d. Recurrence of genital warts increases risk of cervical cancer e. Use of latex condoms is associated with a lower rate of cervical cancer

Which of the following would the nurse most likely include when planning the care for a woman requiring hospitalization for hyperemesis gravidarum? (Select all that apply.) a. Preparing the woman for insertion of a feeding tube b. Obtaining baseline blood electrolyte levels c. Monitoring intake and output d. Maintaining NPO status for the first day or two e. Administering antiemetic agents

b. Obtaining baseline blood electrolyte levels c. Monitoring intake and output d. Maintaining NPO status for the first day or two e. Administering antiemetic agents

The nurse teaches a pregnant woman about breast-feeding, stating that stimulation of the breast through sucking or touching stimulates the secretion of which hormone? a. FSH b. Oxytocin c. Cortisol d. ADH

b. Oxytocin

Which of the following is a risk factor for the development of jaundice in a newborn? a. Formula feeding b. Oxytocin usage in the mother c. Female gender d. Hepatitis A vaccine

b. Oxytocin usage in the mother

A woman has been diagnosed with primary syphilis. Which of the following physical findings would the nurse expect to see? a. Cluster of vesicles. b. Pain-free lesion. c. Macular rash. d. Foul-smelling discharge.

b. Pain-free lesion.

After conducting a class on fetal growth and development, the class should recognize that fetal growth is less likely dependent on which of the following? a. Maternal factors b. Paternal factors c. Placental factors d. Genetic factors

b. Paternal factors

When discussing a health concern with a client, the nurse recognizes that the cornerstone of all disease management programs is: a. Early detection b. Patient education c. Patient cooperation d. Rapid treatment

b. Patient education

The nurse is helping the client understand the possible diagnosis of endometriosis. The nurse realizes that this diagnosis is definitively confirmed by: a. Bimanual examination b. Pelvic laparoscopy c. Pelvic ultrasound d. Pap smear

b. Pelvic laparoscopy

A postpartum woman has been unable to urinate since giving birth. When assessing the woman, which finding would indicate to the nurse that this client is experiencing bladder distention? a. Uterus is firm b. Percussion reveals dullness c. Bladder is nonpalpable d. Lochia is less than usual

b. Percussion reveals dullness

A nurse is caring for a newborn with meconium aspiration syndrome. Which of the following interventions should the nurse perform when caring for this newborn? (Select all that apply) a. Perform repeated suctioning and stimulation b. Place the newborn under a radiant warmer or in a warmed Isolette c. Handle and rub the newborn well with a dry towel d. Administer oxygen therapy e. Administer broad-spectrum antibiotics

b. Place the newborn under a radiant warmer or in a warmed Isolette d. Administer oxygen therapy e. Administer broad-spectrum antibiotics

The birth center recognizes that attachment is very important in the early stages after delivery. To assist new parents in this process, which of the following policies would the birth center try to avoid? a. Policies that allow flexibility for cultural differences b. Policies that discourage unwrapping and exploring the infant c. Policies that allow visitors d. Policies that allow rooming the infant and mother together

b. Policies that discourage unwrapping and exploring the infant

While discussing labor with your client and her partner, they ask what the best position is for delivering the baby. You provide them with information that indicates research has shown which of the following to be the best? a. Lying on her back with feet in stirrups b. Position of comfort for the mother c. Squatting d. Semi-Fowler's position

b. Position of comfort for the mother

As the nurse is explaining the difference between true versus false labor to her childbirth class, she states that the major difference between them is: a. Discomfort level is greater with false labor b. Progressive cervical changes occur in true labor c. There is a feeling of nausea with false labor d. There is more fetal movement in true labor

b. Progressive cervical changes occur in true labor

Nurses play important roles in a variety of community settings. Which of the following goals is common to all community settings? a. Remove or minimize health barriers to learning b. Promote the health of a specific group of clients c. Determine initially the type of care a client needs d. Ensure the health and well-being of women and their families

b. Promote the health of a specific group of clients

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

b. Provide oxygen supplement d. Ensure the newborn's warmth e. Observe the respiratory status frequently

A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated FHR changes. What interventions should the nurse perform to manage the changes? a. Assist client to a supine position b. Provide supplemental oxygen c. Discontinue IV fluid d. Turn client on her left side

b. Provide supplemental oxygen

A nurse is caring for a client in her second trimester of pregnancy. During a regular follow-up visit, the client complains of varicosities of the legs. Which of the following instructions should the nurse provide to help the client alleviate varicosities of the legs? a. Avoid sitting in one position for long b. Refrain from crossing legs when sitting for long periods c. Apply heating pads on the extremities d. Refrain from wearing any kind of stockings

b. Refrain from crossing legs when sitting for long periods

A couple has just experienced intrauterine fetal demise. Which action by the nurse would be least effective in assisting them? a. Give the parents a lock of the infant's hair. b. Refrain from discussing the situation with the couple. c. Allow the couple to spend as much time as they want with their stillborn infant. d. Assist the family in making arrangements for their stillborn infant.

b. Refrain from discussing the situation with the couple.

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which of the following instructions should the nurse provide to the client regarding intercourse after childbirth? a. Avoid use of water-based gel lubricants b. Resume intercourse if bright-red bleeding stops c. Avoid performing pelvic floor exercises d. Use oral contraceptives for contraception

b. Resume intercourse if bright-red bleeding stops

RhoGAM is the therapy of choice for isoimmunization in Rh-negative women. RhoGAM is also indicated for other conditions. Which of the following would not be an indication for administering RhoGAM? a. Maternal trauma b. STIs c. Amniocentesis d. Molar pregnancy

b. STIs

The nurse observes a 2-in lochia stain on the perineal pad of a postpartum client. Which of the following terms should the nurse use to describe the amount of lochia present? a. Light b. Scant c. Moderate d. Large

b. Scant

When assessing the term newborn, the following are observed: newborn is alert, heart and respiratory rates have stabilized, and meconium has been passed. The nurse determines that the newborn is exhibiting behaviors indicating: a. Initial period of reactivity b. Second period of reactivity c. Decreased responsiveness period d. Sleep period for newborns

b. Second period of reactivity

A nurse is caring for a newborn with jaundice undergoing phototherapy. What intervention is appropriate when caring for the newborn? a. Expose the newborn's skin minimally b. Shield the newborn's eyes c. Discourage feeding the newborn d. Discontinue therapy if stools are loose, green, and frequent

b. Shield the newborn's eyes

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? (Select all that apply). a. Give newborns water and other foods to balance nutritional needs b. Show mothers how to initiate breastfeeding within 30 minutes of birth c. Encourage breastfeeding of the newborn infant on demand d. Provide breastfeeding newborns with pacifiers e. Place baby in uninterrupted skin-to-skin contact with the mother

b. Show mothers how to initiate breastfeeding within 30 minutes of birth c. Encourage breastfeeding of the newborn infant on demand e. Place baby in uninterrupted skin-to-skin contact with the mother

The clinic nurse is interviewing a client preceding her annual checkup. Which of the following findings would make the nurse suspicious that the client is an anorexic? a. Aversion to exercise and food allergies. b. Significant weight loss and amenorrhea. c. Respiratory distress and thick oral mucus. d. Cardiac arrhythmias and anasarca.

b. Significant weight loss and amenorrhea.

A pregnant 36-year-old woman has presented to the emergency department with vaginal bleeding. While reviewing the client's history, the nurse notices which of the following risk factors in her record? (Select all that apply.) a. Hypotension b. Smoking c. Previous induced surgical abortion d. Advancing maternal age e. Infertility treatment

b. Smoking c. Previous induced surgical abortion d. Advancing maternal age e. Infertility treatment

Which of the following activities will increase a woman's risk of cardiovascular disease if she is taking oral contraceptives? a. Eating a high-fiber diet b. Smoking cigarettes c. Taking daily multivitamins d. Drinking alcohol

b. Smoking cigarettes

There are some common congenital malformations that can occur and are recognized to be caused by multiple genetic and environmental factors. One such malformation is: a. Hemophilia b. Spina bifida c. Cystic fibrosis d. Color blindness

b. Spina bifida

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?a. Stools should be greenish and formed in consistency.b. Stools should be yellow-gold, loose, and stringy to pasty.c. Stools should be brown and loose.d. Stools should be yellow-green and loose.

b. Stools should be yellow-gold, loose, and stringy to pasty.

What is the role of the nurse during the preconception counseling of a pregnant client with chronic hypertension? a. Stressing the avoidance of dairy products b. Stressing the positive benefits of a healthy lifestyle c. Stressing the increased use of Vitamin D supplements d. Stressing regular walks and exercise

b. Stressing the positive benefits of a healthy lifestyle

A nurse is teaching a female client about fertility awareness as a method of contraception. Which of the following should the nurse mention as an assumption for this method? a. Sperm can live up to 24 hours after intercourse b. The "unsafe period" is approximately 6 days c. The exact time of ovulation can be determined d. The "safe period" is 3 days after ovulation

b. The "unsafe period" is approximately 6 days

The nurse is administering Depo-Provera (medroxyprogesterone acetate) to a postpartum client. Which of the following data must the nurse consider before administering the medication? a. The capsule must be taken at the same time each day. b. The client must be taught to use sunscreen whenever in the sunlight. c. The medicine is contraindicated if the woman has lung or esophageal cancer. d. The client must use an alternate form of birth control for the first two months.

b. The client must be taught to use sunscreen whenever in the sunlight.

The nurse has taught a couple about the temperature rhythm method of fertility control. Which of the following behaviors would indicate that the teaching was effective? a. The woman takes her basal body temperature before retiring each evening. b. The couple charts information from at least six menstrual cycles before using the method. c. The couple resumes having intercourse as soon as they see a rise in the basal body temperature. d. The woman assesses her vaginal discharge daily for changes in color and odor.

b. The couple charts information from at least six menstrual cycles before using the method.

A woman is being taught how to use the diaphragm as a contraceptive device. Which of the following statements by the woman indicates that the teaching was effective? Select all that apply. a. Petroleum-based lubricants may be used with the device. b. The device must be refitted if the woman gains or loses 10 pounds or more. c. The anterior lip must be pushed under the symphysis pubis. d. Additional spermicide must be added if the device has been in place over 6 hours. e. The diaphragm should be cleaned with a 10% bleach solution after every use.

b. The device must be refitted if the woman gains or loses 10 pounds or more. c. The anterior lip must be pushed under the symphysis pubis. d. Additional spermicide must be added if the device has been in place over 6 hours.

A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings?a. The infant is displaying a state of alertness.b. The infant is attempting self-consoling maneuvers.c. The infant is in a state of hyperactivity.d. The infant is entering the habituation state.

b. The infant is attempting self-consoling maneuvers.

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What would have most likely happened to have caused these conditions to occur in the infant? a. The infant's mother must have had a low birth weight b. The infant's mother must have been a diabetic c. The infant must have experienced birth trauma d. The infant's mother must have abused alcohol

b. The infant's mother must have been a diabetic

In preparing for a preconception class, it will be important to include a discussion of potential risk factors. Which of the following would be included? a. The importance of healthy lifestyle b. The use of OTC drugs with teratogens c. Importance of taking adequate vitamin and mineral supplements d. Family history of pregnancy complications

b. The use of OTC drugs with teratogens

What factors would change during a pregnancy if the hormone progesterone were reduced or withdrawn? a. The woman's gums would become red and swollen and would bleed easily b. The uterus would contract more and peristalsis would increase c. Morning sickness would increase and would be prolonged d. The secretion of prolactin by the pituitary gland would be inhibited

b. The uterus would contract more and peristalsis would increase

Which of the following would the nurse include when teaching a pregnant woman about the pathophysiologic mechanisms associated with gestational diabetes? a. Pregnancy fosters the development of carbohydrate cravings b. There is progressive resistance to the effects of insulin c. Hypoinsulinemia develops early in the first trimester d. Glucose levels decrease to accommodate fetal growth

b. There is progressive resistance to the effects of insulin

A client in her second trimester of pregnancy asks the nurse for information regarding certain oral medications to induce a miscarriage. What information should this client be given about such medications? a. They are available only in the form of suppositories b. They can be taken only in the first trimester c. They present a high risk of respiratory failure d. They are considered a permanent end to fertility

b. They can be taken only in the first trimester

The nurse is preparing a class about homelessness. Which factors contribute to homelessness? Select all that apply. a. Decrease in the number of people living in poverty b. Unemployment c. Exposure to abuse or neglect d. Cutbacks in public welfare programs e. Establishment of community crisis centers

b. Unemployment c. Exposure to abuse or neglect d. Cutbacks in public welfare programs

A 28-year-old client complains of skipping her menses and suspects she is pregnant. When assessing this client, which of the following would the nurse identify as a presumptive sign of pregnancy? a. Positive home pregnancy test b. Urinary frequency c. Abdominal enlargement d. Softening of the cervix

b. Urinary frequency

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage? a. Uterine prolapse b. Uterine atony c. Uterine contraction d. Uterine subinvolution

b. Uterine atony

During the fourth stage of labor, the nurse assess the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern? a. Moderate amount of dark red lochia drainage on peripad b. Uterine fundus palpated to the right of the umbilicus c. An oral temperature reading of 100.6 F d. Perineal area bruised and edematous beneath her ice pack

b. Uterine fundus palpated to the right of the umbilicus

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. What complications associated with general anesthesia should the nurse monitor for? a. Pruritis b. Uterine relaxation c. Inadequate or failed block d. Maternal hypotension

b. Uterine relaxation

A nurse is caring for a client who has just delivered a baby. Which of the following information should the nurse give the client regarding hepatitis B vaccination for the baby? a. Vaccine may not be safe for underweight or premature babies b. Vaccine consists of a series of three injections given within 6 months c. Vaccine is administered only after the infant is at least 6 months old d. Vaccine is required only if mother is identified as high-risk for hepatitis B

b. Vaccine consists of a series of three injections given within 6 months

When teaching a woman diagnosed with genital ulcers, which of the following would the nurse include? a. Drying lesions with a hair dryer set on high b. Washing hands with soap and water after touching lesions c. Applying ice packs to the area for comfort d. Refraining from using condoms during sexual intercourse

b. Washing hands with soap and water after touching lesions

A client asks a nurse to express an opinion on the value of taking hormone replacement therapy (HRT). The nurse should be aware that it is recognized that HRT is effective in which of the following situations? a. No woman should ever take hormone replacement therapy. b. Women experiencing severe menopausal symptoms. c. Women with severe coronary artery disease. d. Women with a history of breast cancer.

b. Women experiencing severe menopausal symptoms.

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?a. enhanced shivering abilityb. limited voluntary muscle activityc. thick skin with deep lying blood vesselsd. expanded stores of glucose and glycogen

b. limited voluntary muscle activity

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?a. nonshivering thermogenesisb. radiation, convection, and conductionc. sweating and peripheral vasoconstrictiond. lack of brown adipose tissue

b. radiation, convection, and conduction

During the first few days after birth, the uterus typically descends from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day. By 3 days, the fundus lies 2 to 3 fingerbreadths below the umbilicus (or slightly higher in multiparous women). By the end of 10 days, the fundus usually cannot be palpated. Why?

because it has descended into the true pelvis.

puerperium period

begins after the delivery of the placenta and lasts approximately 6 weeks. *During this period the woman's body begins to return to its prepregnant state, and these changes generally resolve by the sixth week after giving birth.

Respiratory Distress Syndrome medication

betamethasone stimulates the synthesis and release of surfactant (2), which lubricates the lungs, allowing the air sacs to slide against one another without sticking when the infant breathes. *surfactant replacement (minutes after birth)

postmature babies

born after 42 weeks

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?

brachial plexus assessment The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

A nurse is to care for a client during the postpartum period. The client complains of pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts?

breast are hard and tender

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation?

breech presentation Breech presentation is when the fetal buttocks present first rather than the head. Face and brow presentation has complete extension of the fetal head. Brow presentation is when the fetal head is between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis. Persistent occiput posterior position is the engagement of fetal head in the left or right occiputo-transverse position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position. Normal presentation is head first or occiput anterior.

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? a) Small pink or red patches on the baby's eyelids, and back of the neck b) Bright red, raised bumpy area noted above the right eye c) Blue or purplish splotches on buttocks d) Fine red rash noted over the chest and back

bright red, raised bumpy area noted above the right eye

"A nurse observes that a newborn has a 1-minute Apgar score of 5 points. What should the nurse conclude from the observed Apgar score? a. Severe distress in adjusting to extrauter- ine life b. Better condition of the newborn c. Moderate difficulty in adjusting to extra-uterine life d. Abnormal central nervous system status"

c The nurse should conclude that the newborn is facing moderate difficulty in adjusting to extrauterine life. The nurse need not conclude severe distress in adjusting to extra- uterine life, better condition of the newborn, or abnormal central nervous system status. If the Apgar score is 8 points or higher, it indicates that the condition of the newborn is better. An Apgar score of 0 to 3 points represents severe distress in adjusting to extrauterine life."

A client just gave birth to a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Carry and handle the baby frequently. b) Dress the baby to keep the body warm. c) Estimate the urinary flow by weighing the diaper. d) Place the baby under isolette care. e) Dress the baby in a stockinette cap.

c) Estimate the urinary flow by weighing the diaper. d) Place the baby under isolette care. e) Dress the baby in a stockinette cap. The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature often. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the child. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing

When preparing to resuscitate a preterm newborn, the nurse would perform which action first? a) Administer epinephrine. b) Use positive-pressure ventilation. c) Place the newborn's head in a neutral position. d) Hyperextend the newborn's neck.

c) Place the newborn's head in a neutral position. When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation

A nurse is conducting an in-service presentation for a group of neonatal nurses. After teaching the group about the effects of prematurity on various body systems, the nurse determines that the class was successful when the group identifies which condition as an effect of prematurity? a) enhanced ability to digest proteins b) rapid glomerular filtration rate c) fragile cerebral blood vessels d) enlarged respiratory passages

c) fragile cerebral blood vessels Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate

What medication does the nurse anticipate administering to the preterm newborn as an inhalant to improve the lungs' ability to mature? a) heparin b) neomycin c) surfactant d) Rho(D) immune globulin

c) surfactant Treatment begins shortly after birth with synthetic or natural surfactant, obtained from animal sources or extracted from human amniotic fluid. The newborn receives surfactant as an inhalant through a catheter inserted into an endotracheal tube. The therapy may be preventive for development of respiratory distress syndrome in the newborn at risk.

A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which of the following would the nurse be most likely to include in the teaching? (Select all that apply.) A) Supplementing with iron if the woman is breast-feeding B) Providing supplemental water intake with feedings C) Feeding the newborn every 2 to 4 hours during the day D) Burping the newborns frequently throughout each feeding E) Usingfeeding time for promoting closeness

c,D,e

A new mother who is breast-feeding her newborn asks the nurse, "How will I know if my baby is drinking enough?"Which response by the nurse would be most appropriate? A) "If he seems content after feeding, that should be a sign." B) "Make sure he drinks at least 5 minutes on each breast." C) "He should wet between 6 to 12 diapers each day." D) "If his lips are moist, then he's okay.

c. "He should wet between 6 to 12 diapers each day."

"A nurse is required to obtain the temperature of a healthy newborn who is placed in an open crib. Which of the following is the most appropriate method for measuring a newborn's temperature? a. Tape electronic thermistor probe to the abdominal skin. b. Obtain temperature orally. c. Place electronic temperature probe in themidaxillary area. d. Obtain temperature rectally."

c. The nurse should obtain a new- born's temperature by placing an electronic tem- perature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns

A nursing student questions the nursery nurse why they don't bathe the newborn immediately upon admission to the nursery observation area after birth. The nurse states that this would increase the risk of: a. Jaundice b. Infection c. Hypothermia d. Anemia

c. . since newborns can rapidly become stressed by changes in environmental temperatures that bathing would cause through conduction. Postponing the newborn bath until the temperature has stabilized will help prevent newborn hypothermia.

"Which of the following information should the nurse give to a client who is breastfeeding her newborn regarding the nutritional requirements of newborns, as per the recommendations of the American Academy of Pediatrics (AAP)? a. Feed the infant at least 10 mL per kg of water daily."" b. Give iron supplements to the newborn daily. c. Give vitamin D supplements daily for the first 2 months. d. Ensure adequate fluoride supplementation."

c. As per the recommendations of AAP, all newborns should receive a daily supplement of vitamin D during the first 2 months of life to prevent rickets and vitamin D deficiency. There is no need to feed the newborn water, as breast milk contains enough water to meet the newborn's needs. Iron supplements need not be given, as the newborn is being breastfed. Infants over 6 months of age are given fluoride supplementation if they are not receiving fluoridated water."

A woman is to undergo chorionic villus sampling as part of a risk assessment for genetic disorders. Which of the following would the nurse include when describing this test to the woman? a. "A needle will be inserted directly into your fetus's umbilical vessel to collect blood for testing." b. "An intravaginal ultrasound measures fluid in the space between the skin and spine." c. "A small piece of tissue from the fetal placenta will be removed and analyzed." d. "A small amount of amniotic fluid will be withdrawn and collected for analysis."

c. "A small piece of tissue from the fetal placenta will be removed and analyzed."

A client who has been taking birth control pills for 2 months calls the clinic with the following complaint: "I have had a bad headache for the past couple of days and I now have pain in my right leg." Which of the following responses should the nurse make? a. "Continue the pill, but take one aspirin tablet with it each day from now on." b. "Stop taking the pill, and start using a condom for contraception." c. "Come to the clinic this afternoon so that we can see what is going on." d. "Those are common side effects that should disappear in a month or so."

c. "Come to the clinic this afternoon so that we can see what is going on."

The nurse is teaching a postpartum woman and her spouse about postpartum blues. Which statement indicates the teaching has been effective? a. "I should call this support line only if I hear voices." b. "I'll need to take medication to treat the anxiety and sadness." c. "I might feel like laughing one minute and crying the next." d. "If the symptoms last more than a few days, I need to call my doctor."

c. "I might feel like laughing one minute and crying the next."

The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received? a) "I will feed him at least 30 cc of water daily." b) "Since we live in a rural area, I must ensure he receives adequate fluoride supplementation." c) "I need to give him iron supplements daily." d) "I will give him vitamin D supplements daily for the first 2 months of life."

c. "I will give him vitamin D supplements daily for the first 2 months of life."

A nurse has been assigned to assess a pregnant client for abruptio placenta. Which of the following is a classic manifestation of this condition that the nurse should assess for? a. Painless bright red vaginal bleeding b. Increased fetal movement c. "Knife-like" abdominal pain with vaginal bleeding d. Generalized vasospasm

c. "Knife-like" abdominal pain with vaginal bleeding

An asymptomatic woman is being treated for HIV infection at the women's health clinic. Which of the following comments by the woman shows that she understands her care? a. "If I get pregnant, my baby will be HIV positive." b. "I should have my viral load and antibody levels checked every day." c. "Since my partner and I are both HIV positive, we use a condom." d. "To be safe, my partner and I engage only in oral sex."

c. "Since my partner and I are both HIV positive, we use a condom."

A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." Which response by the nurse would be least helpful? a. "Breastfeeding takes time. Let's see what's happening." b. "Some babies latch on and catch on quickly; others take a little more time." c. "Some women just can't breastfeed. Maybe you're one of these women." d. "Let me contact our lactation specialist and together maybe we can work through this."

c. "Some women just can't breastfeed. Maybe you're one of these women."

The public health nurse calls a woman and states, "I am afraid that I have some disturbing news. A man who has been treated for gonorrhea by the health department has told them that he had intercourse with you. It is very important that you seek medical attention." The woman replies, "There is no reason for me to go to the doctor! I feel fine!" Which of the following replies by the nurse is appropriate at this time? a. "I am sure that you are upset by the disturbing news, but there is no reason to be angry with me." b. "I am sorry. We must have received the wrong information." c. "That certainly could be the case. Women often report no symptoms." d. "All right, but please tell me your contacts because it is possible for you to pass the disease on even if you have no symptoms."

c. "That certainly could be the case. Women often report no symptoms."

A mother is concerned because her 2-day-old newborn's birth weight was 8 lb (3584 g) and his current weight is 7 lb 8 oz (3360 g). What would be the nurse's response to the mother's concern?a. "The weight loss may be indicative of some underlying health problem. I need to notify the doctor."b. "The newborn needs to be fed more frequently to stop this weight loss pattern."c. "The weight loss is a normal finding, since newborns lose 5% to 10% of their birth weight in the first few days after birth."d. "Although newborns lose some weight after birth due to poor nutrition, this amount is concerning."

c. "The weight loss is a normal finding, since newborns lose 5% to 10% of their birth weight in the first few days after birth."

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

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

A young mother is concerned for her baby and asks the nurse if her baby is okay. What is the best response if the nurse notes: RR 66, nostrils flaring, and grunting sounds during respiration? a. "Your baby is fine, just learning how to breath." b. "Let's put a blanket around the baby; the baby is cold." c. "Your baby is having a little trouble breathing. I'll let the RN know." d. "Your baby is too warm. Let's take the blanket off."

c. "Your baby is having a little trouble breathing. I'll let the RN know."

Premenstrual syndrome (PMS) affects millions of women during their reproductive years. As a nurse you realize that approximately ______ of the women in the United States report disabling, incapacitating symptoms. a. 55% b. 40% c. 10% d. 25%

c. 10%

The heart rate of the newborn in the first few minutes after birth will be in which range?a. 180 to 220 bpmb. 120 to 130 bpmc. 120 to 180 bpmd. 80 to 120 bpm

c. 120 to 180 bpm

Your client is anxious to have an ultrasound at each visit. You explain that it isn't necessary and schedule a second ultrasound to be performed when she is about: a. 21 to 23 weeks pregnant b. 15 to 17 weeks pregnant c. 18 to 20 weeks pregnant d. 24 to 26 weeks pregnant

c. 18 to 20 weeks pregnant

A mother comes in with her 17-year-old daughter to find out why she has not had a menstrual cycle for a few months. Examination confirms the daughter is pregnant with a fundal height of approximately 24 cm. This can indicate that the young female is approximately how many weeks pregnant? a. 20 b. 18 c. 24 d. 22

c. 24

A pregnant woman is determined to be at high risk for gestational diabetes. At which time would the nurse schedule a rescreening for the client? a. 20 to 24 weeks b. 16 to 20 weeks c. 24 to 28 weeks d. 28 to 32 weeks

c. 24 to 28 weeks

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? a. 300 mL b. 100 mL c. 500 mL d. 250 mL

c. 500 mL

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

c. A nontender, indurated ulcer

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

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

There are many skills a successful nurse must develop to be prepared to help his or her client. A very important skill involving communication is: a. Reflective listening b. Being prepared to answer all questions and concerns c. Active listening d. Paraphrasing comments

c. Active listening

Which of the following is a risk to newborns because of meconium in the amniotic fluid? a. Bradycardia b. Perinatal asphyxia c. Acute respiratory complications d. Polycythemia

c. Acute respiratory complications

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

c. Apply warm or cold compresses and administer analgesics

Which action by a nurse would best demonstrate cultural competence? a. Being well versed in the customs and beliefs of his or her own culture b. Demonstrating an openness to the values and beliefs of other cultures c. Applying knowledge about various cultures in the practice setting d. Playing a role in establishing policies to address diverse cultures

c. Applying knowledge about various cultures in the practice setting

A new dad appears very concerned that his newborn's head looks too big. The nurse assures him there is no need for concern, explaining that the head circumference should typically be which of the following? a. Approximately 1/3 of the length b. Approximately 1/2 the abdominal girth c. Approximately1/4 of the length d. Approximately 1/4 the abdominal girth

c. Approximately1/4 of the length

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

c. Assess for decrease in urinary output

Infants born with spina bifida are at increased risk for hydrocephalus. What is the priority nursing assessment for an infant at risk for hydrocephalus? a. Assess the level of irritability b. Assess the weight c. Assess head circumference d. Assess movement of the lower extremities

c. Assess head circumference

A postpartum mother appears very pale and states she is bleeding heavily. The nurse should first: a. Call the client's health care provider immediately b. Immediately set up an intravenous infusion of magnesium sulfate c. Assess the fundus and ask her about her voiding status d. Reassure the mother that this is a normal finding after childbirth

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

Which of the following would alert the nurse to suspect that a newborn is experiencing respiratory distress? a. Acrocyanosis b. Respiratory rate of 50 breaths per minute c. Asymmetrical chest movement d. Short periods of apnea (less than 15 seconds)

c. Asymmetrical chest movement

While monitoring a preterm newborn's status, the nurse recognizes the newborn is at the greatest risk for which of the following complications? a. Hypoglycemia b. Intracranial hemorrhage c. Atelectasis d. Infection

c. Atelectasis

Losing a newborn is perhaps one of the most difficult situations for a family. Which of the following would be the least appropriate reaction by the nurse if a newborn dies? a. Offer mementos to the family of the newborn. b. Inquire about culturally appropriate way to handle the body. c. Avoid contact with the family. d. Allow the parents time to spend with their infant.

c. Avoid contact with the family.

A pregnant client in her first trimester of pregnancy complains of spontaneous, irregular, painless contractions. What does this indicate? a. Preterm labor b. Infection of the GI tract c. Braxton Hicks contractions d. Acid indigestion

c. Braxton Hicks contractions

A breastfeeding woman is requesting that she be prescribed Seasonale (ethinyl estradiol and levonorgestrel) as a birth control method. Which of the following information should be included in the patient teaching session? a. The woman will menstruate every 8 to 9 weeks. b. The pills are taken for 3 out of every 4 weeks. c. Breakthrough bleeding is a common side effect. d. Breastfeeding is compatible with the medication.

c. Breakthrough bleeding is a common side effect.

Which of the following would the nurse include in the teaching plan for an infant with cleft lip and palate? a. Feed the infant in a semi-lying position b. Continue feeding the infant for as long as it takes c. Burp the infant frequently during feedings d. Avoid use of high-calorie formulas

c. Burp the infant frequently during feedings

A nurse is caring for a client who has just undergone delivery. What is the best method for the nurse to assess this client for postpartum hemorrhage? a. By assessing skin turgor b. By assessing blood pressure c. By frequently assessing uterine involvement d. By monitoring hCG titers

c. By frequently assessing uterine involvement

A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism? a. Sudden change in mental status b. Difficulty in breathing c. Calf swelling d. Sudden chest pain

c. Calf swelling

A woman is to receive methotrexate and misoprostol to terminate a first-trimester pregnancy. When preparing the teaching plan for this client, the nurse understands that misoprostol works by: a. Blocking the action of progesterone on the endometrium b. Acting as a toxin to the trophoblastic tissue c. Causing uterine contractions to expel the uterine contents d. DIlating the cervix

c. Causing uterine contractions to expel the uterine contents

As a nurse working at the college health care clinic, you recognize the importance of educating the students that the human papillomavirus has been confirmed to be the cause of essentially all cases of: a. Ovarian cancer b. Uterine cancer c. Cervical cancer d. Vaginal cancer

c. Cervical cancer

Which assessment would indicate that a woman is in true labor? a. Membranes are ruptured and fluid is clear b. Presenting part is engaged and not floating c. Cervix is 4 cm dilated, 90% effaced d. Contractions last 30 seconds, every 5 to 10 minutes

c. Cervix is 4 cm dilated, 90% effaced

A client needs additional information about the cervical mucus ovulation method after having read about it in a magazine. She asks the nurse about cervical changes during ovulation. Which of the following should the nurse inform the client about? a. Cervical os is slightly closed b. Cervical mucus is dry and thick c. Cervix is high or deep in the vagina d. Cervical mucus breaks when stretched

c. Cervix is high or deep in the vagina

When explaining to a class why labor begins, the nurse will include the fact that there are several theories that have been proposed to explain why labor begins, although none have been proven scientifically. Which of the following is one of those theories? a. Number of oxytocin receptors decrease. b. The level of estrogen decreases. c. Change in estrogen-to-progesterone ratio d. Prostaglandins decrease, leading to myometrium contractions.

c. Change in estrogen-to-progesterone ratio

The CDC has identified the most common bacterial STI in the United States to be: a. Vaginosis b. Syphilis c. Chlamydia d. Gonorrhea

c. Chlamydia

A woman has been diagnosed with pelvic inflammatory disease (PID). Which of the following organisms are the most likely causative agents? Select all that apply. a. Gardnerella vaginalis. b. Candida albicans. c. Chlamydia trachomatis. d. Neisseria gonorrhoeae. e. Treponema pallidum.

c. Chlamydia trachomatis. d. Neisseria gonorrhoeae.

A nonpregnant young woman has been diagnosed with bacterial vaginosis (BV). The nurse questions the woman regarding her sexual history, including her frequency of intercourse, how many sexual partners she has, and her use of contraceptives. What is the rationale for the nurse's questions? a. Clients with BV can infect their sexual partners. b. The nurse is required by law to ask the questions. c. Clients with BV can become infected with HIV and other sexually transmitted infections more easily than uninfected women. d. The laboratory needs a full client history to know for which organisms and antibiotic sensitivities it should test.

c. Clients with BV can become infected with HIV and other sexually transmitted infections more easily than uninfected women.

A nurse is caring for a pregnant client with eclamptic seizure. Which of the following should the nurse know as a characteristic of eclampsia? a. Muscle rigidity is followed by facial twitching b. Respirations are rapid during the seizure c. Coma occurs after seizure d. Respiration fails after the seizure

c. Coma occurs after seizure

A 19-year-old client with multiple sex partners is being counseled about the hepatitis B vaccination. During the counseling sessions, which of the following should the nurse advise the client to receive? a. Hepatitis B immune globulin before receiving the vaccine. b. Vaccine booster every 10 years. c. Complete series of three intramuscular injections. d. Vaccine as soon as she becomes 21.

c. Complete series of three intramuscular injections.

A recently licensed nurse is orienting to a pediatric unit in an acute care facility. The nurse is discussing causes of infant mortality with her preceptor. Which of the following should be included as the leading cause of infant mortality? a. Cardiac disease b. Respiratory infection c. Congenital anomalies d. SIDS

c. Congenital anomalies

While preparing a young couple for the upcoming birth of their child, the mother expresses concern for needing pain medications and the effects on the fetus. You explain that with your experience and recent research, which of the following helps contribute to the decreased requests for pain medication? a. Sitting in a hot tub helps decrease the need for pain medication. b. Lying on an ice pack can help decrease the need for pain medication. c. Continuous support through the labor process d. A quick epidural can replace the need for pain medication.

c. Continuous support through the labor process

Periventricular hemorrhage is suspected in a newborn of 30 weeks' gestation. The nurse would anticipate preparing the newborn for which of the following to confirm the diagnosis? a. Arterial blood gases b. Chest X-ray c. Cranial ultrasound d. Blood glucose levels

c. Cranial ultrasound

The symptoms of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) can be categorized using the following tool: ACDHO. The nurse recognizes the C represents: a. Constipation b. Cramping c. Cravings d. Crying

c. Cravings

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

c. Creases on two-thirds of the foot

When working with a couple dealing with infertility, it is important for the nurse to work with their: a. Emotional limits b. Insurance restrictions c. Cultural considerations d. Family budget

c. Cultural considerations

The nurse is caring for an Arab American woman. Which approach would be most successful? a. Inquiring about folk remedies used b. Coordinating care through the client's mother c. Dealing exclusively with the husband d. Promoting preventive health care

c. Dealing exclusively with the husband

A postpartum client had a difficult labor. Which assessment finding will alert the nurse that the client is most likely hemorrhaging? a. Decreased heart rate b. Increased urinary output c. Decreased blood pressure d. Increased body temperature

c. Decreased blood pressure

The nurse should suspect that a client is bulimic when the client exhibits which of the following signs/symptoms? a. Significant weight loss and hyperkalemia. b. Respiratory acidosis and hypoxemia. c. Dental caries and scars on her knuckles. d. Hyperglycemia and large urine output.

c. Dental caries and scars on her knuckles.

The client is interested in using an injectable contraceptive that works by suppressing pituitary secretions. The nurse provides the client with literature and discusses which of the following with her? a. Lybel b. Ortho Evra c. Depo-Provera d. Lunelle

c. Depo-Provera

Which of the following measures would be most effective for a nurse to utilize in preventing STIs? a. Interfering with the mode of transmission b. Increasing the availability of resources c. Education to promote sexual health d. Getting individuals to change their behaviors

c. Education to promote sexual health

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: a. Acupressure b. Patterned breathing c. Effleurage d. Therapeutic touch

c. Effleurage

In dealing with parents experiencing a perinatal loss, which of the following nursing interventions would be most appropriate? a. Sheltering the parents from the bad news b. Making all the decisions regarding care c. Encouraging them to participate in the newborns care d. Leaving them by themselves to allow time to grieve

c. Encouraging them to participate in the newborns care

A nurse is evaluating the client to determine the possible cause of her dysmenorrhea. The nurse is aware that the most common etiology for secondary dysmenorrhea is due to: a. Multigravida b. Hormonal imbalance c. Endometriosis d. Perimenopause

c. Endometriosis

The nurse is assessing the skin of a newborn and notes a rash on the newborn's face, and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as which of the following? A) Harlequin sign B) Nevus flammeus C) Erythema toxicum D) Port wine stain

c. Erythema toxicum

It is important to be able to measure the health status of a group of people or a nation so that the number of people who die prematurely will decrease over time. How does the United States measure the health status of its people? a. Tracks the incidence of violent crime b. Examines health disparities between ethnic groups c. Examines mortality and morbidity data d. Identifies specific national health goals related to maternal and infant health

c. Examines mortality and morbidity data

A client in her second trimester of pregnancy is anxious about the blotchy, brown pigmentation appearing on her forehead and cheeks. She also complains of increased pigmentation on her breasts and genitalia. When educating the client, which of the following would the nurse identify as the condition experienced by the client? a. Linea nigra b. Striae gravidarum c. Facial melisma (chloasma) d. Vascular spiders

c. Facial melisma (chloasma)

The client has been diagnosed with trichomoniasis. The nurse recognizes one of the treatments of choice is: a. Diflucan b. Monistat c. Flagyl d. Penicillin G

c. Flagyl

In the course of proper prenatal care, the nurse should include risk assessment for: a. Family dynamics b. Infant nutritional needs c. Genetic conditions and disorders d. Cultural differences

c. Genetic conditions and disorders

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

c. Gently stroke the newborn's cheek.

A client has come to the office for a prenatal visit during her 22nd week of gestation. On examination, it is noted that her blood pressure has increased to 138/90. Her urine is negative for proteinuria. The nurse recognizes which of the following as the potential cause? a. Preeclampsia b. Chronic hypertension c. Gestational hypertension d. HELLP

c. Gestational hypertension

Which of the following information should the nurse give to a client who is breastfeeding her newborn regarding the nutritional requirements of newborns, as per the recommendations of the American Academy of Pediatrics (AAP)? a. Feed the infant at least 10 mL per kg of water daily b. Give iron supplements to the newborn daily c. Give vitamin D supplements daily for the first 2 months d. Ensure adequate fluoride supplementation

c. Give vitamin D supplements daily for the first 2 months

A newborn is diagnosed with ophthalmia neonatorum. The nurse understands that this newborn was exposed to which infection? a. Human immunodeficiency virus b. Syphilis c. Gonorrhea d. Candida albicans

c. Gonorrhea

A nurse is working in a women's health clinic. Genetic counseling would be most appropriate for the woman who: a. Just had her first miscarriage at 10 weeks b. Is 30 years old and planning to conceive c. Has a history that reveals a close relative with Down syndrome d. Is 18 weeks pregnant with a normal triple screen result

c. Has a history that reveals a close relative with Down syndrome

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. Which of the following is the most common birth defect? a. Genetic-linked b. Skeletal malformations c. Hearing d. Vision

c. Hearing

The nurse is preparing to teach a class to a group of middle aged women regarding the most common vasomotor symptoms experienced during menopause and possible modalities of treatment available. Which of the following would be a vasomotor symptom experienced by menopausal women? a. Weight gain b. Bone density c. Hot flashes d. Heart disease

c. Hot flashes

The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which of the following? a. Asphyxia b. Meconium aspiration c. Hypoglycemia d. Polycythemia

c. Hypoglycemia

A client who was in active labor and whose cervix had dilated to 4 cm experiences a weakening in the intensity and frequency of her contractions and exhibits no further progress in labor. The nurse interprets this as a sign of: a. Hypertonic labor b. Precipitate labor c. Hypotonic labor d. Dysfunctional labor

c. Hypotonic labor

A client is complaining about shortness of breath. To ensure there are no developing complications, a tidal volume is obtained. Due to her pregnancy, the health care provider would expect to see what type of results on the tidal volume? a. Increase of 20% b. Decrease of 20% c. Increase of 40% d. Decrease of 40%

c. Increase of 40%

As the client gets closer to her due date, it is important to stress that the woman seek assessment after spontaneous rupture of the membranes due to: a. Potential rapid delivery of fetus b. Potential placenta previa c. Increased risk of infection d. Increased risk of breech presentation

c. Increased risk of infection

The nurse is teaching a group of students about factors that place a pregnant woman at risk for infection in the postpartum period. Which of the following would the nurse be least likely to include? a. Prolonged labor with multiple vaginal examinations to evaluate progress b. Retained placental fragments c. Increased vaginal acidity leading to growth of bacteria d. Loss of protection with premature rupture of membranes

c. Increased vaginal acidity leading to growth of bacteria

When assessing the substance-exposed newborn, which finding would the nurse expect? a. Calm facial appearance b. Daily weight gain c. Increasing irritability d. Feeding and sleeping well

c. Increasing irritability

A client has been informed that the result of the pregnancy test indicates that she is 3 weeks pregnant. Which of the following instructions should the nurse give to the client that is most appropriate given her condition? a. Avoid exercising during pregnancy b. Stay indoors and avoid going out for the duration of pregnancy c. Instruct client to stop using drugs, alcohol and tobacco d. Wear comfortable clothes that are not tight or restrictive

c. Instruct client to stop using drugs, alcohol and tobacco

A 28-year-old client who has just conceived arrives at a health care facility for her first prenatal visit to undergo a physical examination. Which of the following interventions should the nurse perform to prepare the client for the physical examination? a. Ensure that the client is lying down b. Ensure that the client's family is present c. Instruct the client to empty her bladder d. Instruct the client to keep taking deep breaths

c. Instruct the client to empty her bladder

A client has been following the conventional 28-day regimen for contraception. She is now considering switching to an extended OC regimen. She is seeking information about specific safety precautions. Which of the following is true for the extended OC regimen? a. It is not as effective as the conventional regimen b. It prevents pregnancy for 3 months at a time c. It carries the same safety profile as the 28-day regimen d. It does not ensure restoration of fertility if discontinued

c. It carries the same safety profile as the 28-day regimen

Which factor would most likely be responsible for a pregnant woman's failure to receive adequate prenatal care in the United States? a. Belief that it is not necessary in a normal pregnancy b. Use of denial to cope with pregnancy c. Lack of health insurance to cover expenses d. Inability to trust traditional medical practices

c. Lack of health insurance to cover expenses

Which of the following contraceptive methods offers protection against sexually transmitted infections (STIs)? a. Oral contraceptives b. Withdrawal c. Latex condom d. Intrauterine contraceptive (IUC)

c. Latex condom

The nurse is developing a teaching plan for a client undergoing a bilateral tubal ligation. Which of the following should be included in the plan? a. The surgical procedure is easily reversible. b. Menstruation usually ceases after the procedure. c. Libido should remain the same after the procedure. d. The incision will be made endocervically.

c. Libido should remain the same after the procedure.

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which of the following would the nurse include? a. Expanded stores of glucose and glycogen b. Thick skin with deep-lying blood vessels c. Limited voluntary muscle activity d. Enhanced shivering ability

c. Limited voluntary muscle activity

A pregnant client has a history of asthma. Which of the following agents would not be appropriate to help her control her asthma during her pregnancy? a. Albuterol b. Budesonide c. Misoprostol d. Salmeterol

c. Misoprostol

A nurse observes that a newborn has a 1-minute Apgar score of 5 points. What should the nurse conclude from the observed Apgar score? a. Severe distress in adjusting to extrauterine life b. Better condition of the newborn c. Moderate difficulty in adjusting to extrauterine life d. Abnormal central nervous system status

c. Moderate difficulty in adjusting to extrauterine life

The nurse is required to monitor a pregnant client with fallopian tube rupture. Which of the following interventions should a nurse perform to identify development of hypovolemic shock in this client? a. Monitor the client's beta-hCG level b. Monitor the mass with transvaginal ultrasound c. Monitor the client's vital signs, bleeding d. Monitor the fetal heart rate

c. Monitor the client's vital signs, bleeding

As the nurse working in labor and delivery, you understand that the client who is well prepared and has good labor support demonstrates all except which of the following? a. Less likely to need anesthesia b. Less likely to need analgesia c. Need someone to control the situation d. Unlikely to require cesarean birth

c. Need someone to control the situation

A woman is to undergo a colonoscopy at a freestanding outpatient surgery center. Which would the nurse identify as a major disadvantage associated with this community-based setting? a. Increased risk for infection b. Increased health care costs c. Need to be transferred if overnight stay is required d. Increased disruption of family functioning

c. Need to be transferred if overnight stay is required

The client is requesting information on the various pain medication management techniques that are available to decide which option she would like to choose for her impending delivery. While gathering together the information, which technique would you indicate that has become very popular and effective? a. Epidural analgesia b. Systemic analgesia c. Neuraxial analgesia/anesthesia d. Spinal analgesia

c. Neuraxial analgesia/anesthesia

The majorities of skin variations are transient and fade or disappear with time; however, parents with newborns with which of the following should be counseled to monitor this permanent variation that has been linked with potential childhood cancer? a. Mongolian spots b. Erythema toxicum c. Nevus flammeus d. Nevus vasculosus

c. Nevus flammeus

The nurse is teaching the new parents the best way to prevent hypothermia. She explains that the newborn's primary method of heat production is through which of the following methods? a. Shivering thermogenesis b. Thermoregulation c. Nonshivering thermogenesis d. Thermoconduction

c. Nonshivering thermogenesis

A pregnant client has been diagnosed with gestational diabetes. Which of the following are risk factors for developing gestational diabetes? (Select all that apply) a. Maternal age less than 18 years b. Genitourinary tract abnormalities c. Obesity d. Hypertension e. Previous large for gestational age (LGA) infant

c. Obesity d. Hypertension e. Previous large for gestational age (LGA) infant

Which of the following interventions should a nurse perform to promote thermal regulation in a preterm newborn? a. Assess the newborn's temperature every 5 hours until stable b. Set the temperature of the radiant warmer at a fixed level c. Observe for clinical signs of cold stress such as weak cry d. Check the blood pressure of the infant every 2 hours

c. Observe for clinical signs of cold stress such as weak cry

What is the first step in determining the couple's risk for a genetic disorder? a. Observing the client and family over time b. Conducting extensive psychological testing c. Obtaining a thorough family health history d. Completing an extensive exclusionary list

c. Obtaining a thorough family health history

As a nurse working at a community family clinic, you are aware that infant mortality is higher among newborns that are: a. Given soy-based formula b. With high birth weight c. Of low birth weight d. First-born

c. Of low birth weight

A client who has a breastfeeding newborn complains of sore nipples. Which of the following interventions can the nurse suggest to alleviate the client's condition? a. Recommend a moisturizing soap to clean the nipples b. Encourage use of breast pads with plastic liners c. Offer suggestions based on observation to correct positioning or latching d. Fasten nursing bra flaps immediately after feeding

c. Offer suggestions based on observation to correct positioning or latching

A nurse needs to check the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? a. After the newborn has been fed b. 24 hours after admission to the nursery c. On admission to the nursery d. 5 hours after admission to the nursery

c. On admission to the nursery

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

c. Pain assessment needs to be comprehensive and frequent

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

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

When assessing a postpartum woman, which of the following would lead the nurse to suspect postpartum blues? a. Panic attacks and suicidal thoughts b. Anger toward self and infant c. Periodic crying and insomnia d. Obsessive thoughts and hallucinations

c. Periodic crying and insomnia

A newborn has required resuscitation due to hypoxia. Which of the following would the nurse use as evidence of effective resuscitation? a. Retractions b. Weak cry c. Pink tongue d. Pulse rate of 60 beats per minute

c. Pink tongue

A nurse is required to obtain the temperature of a healthy newborn who is placed in an ordinary crib. Which of the following is the most appropriate method for measuring a newborn's temperature? a. Tape electronic thermistor probe to the abdominal skin b. Obtain temperature orally c. Place electronic temperature probe in the midaxillary area d. Obtain temperature rectally

c. Place electronic temperature probe in the midaxillary area

A nurse is assessing the temperature of a newborn using a skin temperature probe. Which point should the nurse keep in mind while taking the newborn's temperature? a. Ensure that the newborn is lying on it's abdomen b. Tape the temperature probe to the forehead c. Place the temperature probe over the liver d. Use the skin temperature probe only in open bassinets

c. Place the temperature probe over the liver

A nurse is required to assess the temperature of a newborn using a skin temperature probe. Which of the following points should the nurse keep in mind while taking the newborn's temperature? a. Ensure that the newborn is lying on its abdomen b. Place the temperature probe on the forehead c. Place the temperature probe over the liver d. Place the temperature probe on the buttocks

c. Place the temperature probe over the liver

The nurse is reviewing her client's records and notes one should be watched closely for a possible infection. Which of the following factors in the woman's history would lead the nurse to do so? a. Labor of 12 hours b. Multiparity c. Placenta removed via manual extraction d. Hemoglobin of 11.5 mg/dL

c. Placenta removed via manual extraction

Which activity would the nurse include in the teaching plan for parents with a newborn and an older child to reduce sibling rivalry when the newborn is brought home? a. Punishing the older child for bedwetting behavior b. Sending the sibling to the grandparents' house c. Planning a daily "special time" for the older sibling d. Allowing the sibling to share a room with the infant

c. Planning a daily "special time" for the older sibling

During the examination, the health care provider mentions the fetus has a good attitude. You explain to the parents that this means which of the following? a. The fetus is presenting head first. b. Posture of the fetus is with arms at its side and legs straight. c. Posture of the fetus with all joints flexed for delivery d. The fetus is cooperating with the labor.

c. Posture of the fetus with all joints flexed for delivery

A pregnant client is admitted with vaginal bleeding. The nurse performs a nitrazine test to confirm that the membranes have ruptured. The nitrazine tape remains yellow to olive green, with pH between 5 and 6. What does this indicate? a. Membranes have ruptured b. Presence of amniotic fluid c. Presence of vaginal fluid d. Presence of excess blood

c. Presence of vaginal fluid

The nurse cares for a newborn with a congenital cardiac anomaly. What component of nursing care is the priority for the newborn? a. Maintain oxygen saturation at 95% or above b. Accompany the newborn to all radiologic examinations c. Prevent pain as much as possible d. Teach the parents to take pulse and blood pressure measurements

c. Prevent pain as much as possible

The nurse is teaching a class about sexually transmitted infections to a middle school class. Which of the following is a misconception about condom use that needs to be clarified? a. Latex condoms protect best against disease b. Don't store condoms in your wallet c. Put the condom on just before orgasm d. Use water-based lubricant with latex condoms

c. Put the condom on just before orgasm

You have been asked to present information to a group of civic leaders concerning women's health issues. In preparing your information, you include what goals from Healthy People 2020? a. Ensure all couples receive preconceptional counseling b. Ensure prenatal care includes immunizations c. Reduce the rate of cesarean births among low-risk births d. Encourage women with previous cesareans to always have a cesarean

c. Reduce the rate of cesarean births among low-risk births

The nurse is developing a presentation for a group of young adult women about premenstrual syndrome. Which of the following would the nurse include as possible treatment options? Select all that apply. a. Antipsychotic medications b. Decrease in water intake c. Reduction of caffeine intake d. Vitamin and mineral supplements

c. Reduction of caffeine intake d. Vitamin and mineral supplements

A pregnant client arrives at the community clinic complaining of fever blisters and cold sores on the lips, eyes, and face. The primary health care provider has diagnosed it as the primary episode of genital herpes simplex, for which antiviral therapy is recommended. Which of the following information should the nurse offer the client when educating her about managing the infection? a. Antiviral drug therapy cures the infection completely b. Kissing during the primary episode does not transmit the virus c. Safety of antiviral therapy during pregnancy has not been established d. Recurrent HSV infection episodes are longer and more severe

c. Safety of antiviral therapy during pregnancy has not been established

A client in her third trimester of pregnancy wishes to use the method of feeding formula to her infant. Which of the following instructions should the nurse provide to assist the client in feeding her baby? a. Mix one scoop of powder with an ounce of water b. Feed the infant every 8 hours c. Serve the formula at room temperature d. Refrigerate any leftover formula

c. Serve the formula at room temperature

A young couple are anxious for the birth of their child. When discussing the options, you explain that elective induction of labor in nulliparous is associated with all of the following except: a. Neonatal resuscitation b. Postpartum hemorrhage c. Shorter hospitalizations d. Increased rates of cesarean sections

c. Shorter hospitalizations

Which of the following indicates meconium aspiration in a newborn? a. Bluish skin discoloration b. Listlessness or lethargy c. Stained umbilical cord d. Pink tongue

c. Stained umbilical cord

A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate? a. Continue to monitor contractions and fetal heart rate. b. Slow the oxytocin infusion to the initial rate. c. Stop the infusion immediately. d. Notify the birth attendant.

c. Stop the infusion immediately.

A pregnant woman has arrived to the office with the complaint of vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable abortion? a. Closed cervical os b. Slight vaginal bleeding c. Strong abdominal cramping d. No passage of fetal tissue

c. Strong abdominal cramping

A pregnant client complains of an increase in a thick, whitish vaginal discharge. Which of the following information should a nurse provide to this client? a. Refrain from any sexual activity b. Consult physician for fungal infection c. Such discharge is normal during pregnancy d. Use local antifungal agents regularly

c. Such discharge is normal during pregnancy

When managing a client's pain during labor, nurses should a. Make sure the agents given do not prolong labor b. Know that all pain relief measures are similar c. Support the client's decisions and requests d. Not recommend nonpharmacologic methods

c. Support the client's decisions and requests

A nurse is caring for a newborn with NEC, scheduled to undergo surgery for bowel resection. The infant's parents wish to know the implications of the surgery. What information should the nurse provide to the parents regarding this surgery? a. Surgically treated NEC is a short process b. Surgery will prevent long-term medical problems c. Surgery requires placement of a proximal enterostomy d. Surgery prevents the need for the use of long-term antibiotics

c. Surgery requires placement of a proximal enterostomy

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which of the following should alert the nurse to a potential infection in the client? a. Temperature of 38.5% C or higher after the first 36 hours after childbirth b. Temperature of 39% C or higher after the first 48 hours after childbirth c. Temperature of 38% C or higher after the first 24 hours after childbirth d. Temperature of 37.5% C or higher after the first 12 hours after childbirth

c. Temperature of 38% C or higher after the first 24 hours after childbirth

A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already delivered once and is pregnant a second time. What explanation should the nurse offer the client? a. Braxton Hicks contractions are not strong enough during first pregnancy b. Contractions are stronger during the first pregnancy than the second c. The cervix takes around 12 to 16 hours to dilate during first pregnancy d. Spontaneous rupture of membranes occurs during first pregnancy

c. The cervix takes around 12 to 16 hours to dilate during first pregnancy

A client who is sexually active is asking the nurse about Gardasil, one of the vaccines that is given to prevent human papillomavirus (HPV). Which of the following should be included in the counseling session? a. Gardasil is not recommended for women who are already sexually active. b. Gardasil protects recipients from all strains of the virus. c. The most common side effect from the vaccine is pain at the injection site. d. Anyone who is allergic to eggs is advised against receiving the vaccine.

c. The most common side effect from the vaccine is pain at the injection site.

What should the nurse expect for a full-term newborn's weight during the first few days of life?a. There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies.b. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only.c. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.d. A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%.

c. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

A client in the third stage of labor has experienced placental separation and expulsion. Why is it necessary for a nurse to massage the woman's uterus briefly until it is firm? a. To reduce boggy nature of the uterus b. To remove pieces left attached to uterine wall c. To constrict the uterine blood vessels d. To lessen the chances of conducting an episiotomy

c. To constrict the uterine blood vessels

As the nurse working with parents and their newborn, you encourage which of the following actions to assist the bonding and attachment between them? a. Feeding b. Talking c. Touching d. Looking

c. Touching

After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? a. Once a day b. Every other day c. Two or three times per week d. Once a week

c. Two or three times per week

A nurse is caring for an HIV-positive client who is on triple-combination highly active antiretroviral therapy (HAART). Which of the following should the nurse include in the teaching plan when educating the client about the treatment? Select all that apply. a. Exposure of fetus to antiretroviral agents is completely safe b. Successful antiretroviral therapy may prevent AIDS c. Unpleasant side effects such as nausea and diarrhea are common d. Provide written materials describing diet, exercise and medications e. Ensure that the client understands the dosing regimen and schedule

c. Unpleasant side effects such as nausea and diarrhea are common d. Provide written materials describing diet, exercise and medications e. Ensure that the client understands the dosing regimen and schedule

After teaching a group of students about fertilization the instructor determines that the teaching was successful when the group identifies which as the usual site of fertilization? a. Fundus of the uterus b. Endometrium of the uterus c. Upper portion of the fallopian tube d. Follicular tissue of the ovary

c. Upper portion of the fallopian tube

The nurse recognizes that any client may develop postpartum hemorrhage and frequent assessments are conducted to ensure this is not happening. Which of the following is the most common cause of postpartum hemorrhage? a. Distended bladder b. Placenta previa c. Uterine atony d. Uterine lacerations

c. Uterine atony

Which of the following would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis? a. PT b. Fibrinogen level c. aPTT d. INR

c. aPTT

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

c. conduction

Which factors in a maternal birth record are risks for fetal growth restriction?

congenital malformations, infections, or placental insufficiency Fetal growth restriction can result from aneuploidy, congenital malformations, infections, or uteroplacental insufficiency. Their size falls below the 10th percentile on growth charts. It is the pathological counterpart to a SGA. They are at risk for increased morbidity and mortality. The fetus is thought to have growth potential under normal circumstances. It is analogous to the failure to thrive in the infant. Newborns that experience nutritional deficiencies in utero and born with FGR are at risk of lifelong developmental deficits.

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

continuing to monitor maternal and fetal status Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus.

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction?

contractions most forceful in the middle of uterus rather than the fundus Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction. Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet.

A woman is admitted to the labor suite with contractions every five minutes lasting one minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth?

cord compression Oligohydramnios and meconium staining of the amniotic fluid are common complications of postterm pregnancy. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor.

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

d) "We'll take off the patches on his eyes when we're feeding him so he can look at us." The lights are to be positioned about 12 to 30 inches above the newborn. The newborn is turned every 2 hours while under the bilirubin lights. Eye patches are removed during feedings so that the newborn can interact with the caregiver. Evidence of effectiveness is indicated by loose, green stools indicating that the bilirubin is being broken down.

A male newborn is born with hypospadias. The nurse doing the newborn physical assessment notes that the penis is also curved downward. What information would the nurse provide the parents for this infant? a) The parents will be taught maneuvers to perform on the penis to help straighten it out prior to repairing the urethral opening. b) The infant's penis will not require surgery but may never be completely straight. c) The circumcision may have to be revised when he is older. d) His ability to void and have an erection in adulthood may be impaired and surgery is needed.

d) His ability to void and have an erection in adulthood may be impaired and surgery is needed. Hypospadias is a relatively common malformation of the male genital organ. It is an abnormal positioning of the urinary meatus on the underside of the penis. It is often accompanied by a downward bowing of the penis (chordee), which can lead to urination and erection problems in adulthood. There are no maneuvers that will improve the penis curvature, surgery is definitely warranted and needed, and infants with hypospadius are never circumcised because the foreskin may be needed for later repairs

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? a) Gaze aversion b) Yawning c) Hiccups d) Quiet, alert state

d) Quiet, alert state When caring for neonates experiencing drug withdrawal, the nurse must be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet, alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate can't handle stimuli at that time

After teaching the pregnant woman about ways to minimize flatulence and bloating during pregnancy, which statement indicates the need for additional teaching? a. "I'll stay away from foods like cabbage and brussels sprouts." b. "I'll increase my time spent on walking each day." c. "I'll try to drink more fluids to help move things along." d. "I'll switch to chewing gum instead of using mints."

d. "I'll switch to chewing gum instead of using mints."

A preterm newborn is to be discharged home on oxygen therapy and tube feedings. Which statement by the parents would indicate that they need additional teaching and preparation for this transition? a. "We know how to check to make sure the feeding tube isn't clogged." b. "Our parents are going to take turns helping out at night so that we can get some sleep." c. "We'll make sure that we have enough feeding solution to get through the weekend." d. "Our insurance company will pay for all the equipment that we need for the treatments."

d. "Our insurance company will pay for all the equipment that we need for the treatments."

The nurse is caring for a client at the prenatal care clinic. The client reports to the nurse that she heard her baby referred to as an embryo. The client questions what this means. What statement by the nurse is most appropriate? a. "The embryo is the name given to the baby when the lungs are still immature to survive outside of the womb" b. "The embryonic period is that time from conception till approximately 4 weeks of gestation" c. "The embryo refers to the products of conception until the placenta begins to fully function" d. "The products of conception become an embryo around 2 weeks after conception and until it becomes a fetus"

d. "The products of conception become an embryo around 2 weeks after conception and until it becomes a fetus"

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

d. "We'll take off the patches on his eyes when we're feeding him so he can look at us."

New parents are getting ready to go home and have received information to help them adjust to and learn how best to care for the new infant. Which of the following statements indicates that they understand how to soothe their newborn if he becomes upset? a. "We'll hold off on feeding him for a while because he might be too full." b. "We'll vigorously rub his back as we play some music." c. "We'll place him on his belly on a blanket on the floor." d. "We'll turn the mobile on that's hanging above his head in his crib."

d. "We'll turn the mobile on that's hanging above his head in his crib."

A client is getting divorced and wants to be sure that her soon-to-be ex-husband cannot have access to her medical information. Which would be the best instruction for the nurse to give the client? a. "Don't worry about things like that, you have too much else to worry about right now." b. "Husbands always have access to their wife's health records." c. "We have to give him access to your records in case they impact your divorce proceedings" d. "You have the right to say who can see your health records and who cannot"

d. "You have the right to say who can see your health records and who cannot"

The nurse plays a major role in assessing the progress of labor. Which of the following is a simple rule that the nurse will use to monitor the progress? a. 1 cm per hour for fetal descent b. 2 cm per hour for fetal descent c. 2 cm per hour for cervical dilation d. 1 cm per hour for cervical dilation

d. 1 cm per hour for cervical dilation

A pregnant woman comes to the clinic for a visit. This is her third pregnancy. She had a miscarriage at 12 weeks and gave birth to a son, now 3 years old, at 32 weeks. Using the GTPAL system, the nurse would document this woman's obstetric history as: a. 20111 b. 21212 c. 31021 d. 30111

d. 30111

The new mother has decided to feed her infant formula. When teaching her about the different types, the nurse should stress the infant should receive how many calories each day? a. 950 calories b. 800 calories c. 500 calories d. 650 calories

d. 650 calories

The nurse emphasizes the importance of regular Pap smears and routine physical examinations due to the fact that _______ of women are asymptomatic when infected with chlamydia. a. 50% b. 90% c. 30% d. 70%

d. 70%

Before becoming pregnant, a woman's heart rate averaged 72 beats per minute. The woman is now 15 weeks pregnant. The nurse would expect this woman's heart rate to be approximately: a. 100 beats per minute b. 95 beats per minute c. 90 beats per minute d. 85 beats per minute

d. 85 beats per minute

A nurse is assessing pregnant clients for the risk of placenta previa. Which of the following clients faces the greatest risk for this condition? a. A 23-year-old client b. A client with a history of alcohol ingestion c. A client with a structurally defective cervix d. A client who had undergone a myomectomy to remove fibroids

d. A client who had undergone a myomectomy to remove fibroids

A pregnant client is diagnosed with AIDS. Which of the following interventions should the nurse undertake to minimize the risk of transmission of AIDS to the infant? a. Ensure that the baby is delivered via cesarean b. Begin triple-combination HAART for the newborn c. Ensure that the baby is breastfed instead of being given formula d. Administer antiretroviral syrup to the infant within 12 hours of birth

d. Administer antiretroviral syrup to the infant within 12 hours of birth

A nurse at the college health care clinic is developing a campaign to educate the students about HPV. She would emphasize that the primary prevention for HPV includes which of the following? a. Teaching about HPV testing in women over age 30 b. Educating about the importance of regular Pap smears c. Recommending treatment of genital warts d. Administering HPV vaccine

d. Administering HPV vaccine

During an assessment, the nurse finds that a young mother has several risk factors for delivering an infant with a neural tube defect. Which of the following laboratory tests can be used to monitor the fetus for this birth defect? a. Cultures for infections b. Folic acid levels c. Genetic studies d. Alpha-fetoprotein levels

d. Alpha-fetoprotein levels

A client in the third trimester of pregnancy has to travel a long distance by car. The client is anxious about the effect the travel may have on her pregnancy. Which of the following instructions should the nurse provide to promote easy and safe travel for the client? a. Activate the airbag in the car b. Use a lap belt that crosses over the uterus c. Apply a padded shoulder strap properly d. Always wear a three-point seat belt

d. Always wear a three-point seat belt

A 28-year-old client in her first trimester of pregnancy complains of conflicting feelings. She expresses feeling proud and excited about her pregnancy while at the same time feeling fearful and anxious of its implications. Which of the following maternal emotional responses is the client experiencing? a. Introversion b. Mood swings c. Acceptance d. Ambivalence

d. Ambivalence

During a routine antepartum visit, a pregnant woman reports a white, thick, vaginal discharge. Which of the following would the nurse do next? a. Advise the woman about the need to culture the discharge. b. Tell the woman that this is entirely normal. c. Check the discharge for evidence of ruptured membranes. d. Ask the woman if she is having any itching or irritation.

d. Ask the woman if she is having any itching or irritation.

A nurse is caring for a pregnant client with heart disease in a labor unit. Which of the following is the most important intervention for this client in the first 48 hours postpartum? a. Limiting sodium intake b. Inspecting the extremities for edema c. Ensuring that the client consumes a high-fiber diet d. Assessing for cardiac decompensation

d. Assessing for cardiac decompensation

The nurse is required to assess a pregnant client who is complaining of vaginal bleeding. Which of the following assessments should be considered as a priority by the nurse? a. Monitoring uterine contractility b. Assessing signs of shock c. Determining the amount of funneling d. Assessing the amount and color of the bleeding

d. Assessing the amount and color of the bleeding

During the newborn's assessment, which of the following would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? a. Seizures b. Feeble sucking c. Temperature instability d. Asymmetrical movement

d. Asymmetrical movement

A pregnant client in her 12th week of gestation has come to a health care center for a physical examination of her abdomen. Where should the nurse palpate for the fundus in this client? a. At the umbilicus b. Below the ensiform cartilage c. Midway between the symphysis and umbilicus d. At the symphysis pubis

d. At the symphysis pubis

A woman is 20 weeks pregnant. The nurse would expect to palpate the fundus at which of the following locations? a. Symphysis pubis b. Just below the ensiform cartilage c. Between the symphysis and umbilicus d. At the umbilicus

d. At the umbilicus

Which finding would the nurse expect to assess in an infant with developmental dysplasia of the hip? a. Symmetrical thigh folds b. Even knee height c. Full abduction of the hip d. Audible clunk on hip abduction

d. Audible clunk on hip abduction

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?a. Respiratory Rateb. Heart Ratec. Temperatured. Blood Pressure

d. Blood Pressure

The nurse is explaining to a client that there are several laboratory and diagnostic tests that can be conducted to evaluate her preterm labor risk. The nurse will mention all except which of the following as a potential test the physician may use? a. Fetal fibronectin testing b. Salivary estriol levels c. Transvaginal ultrasound d. Blood chemistry levels

d. Blood chemistry levels

Methergine has been ordered for a postpartum woman because of excessive bleeding. The nurse should question this order if which of the following is present? a. Mild abdominal cramping b. Tender inflamed breasts c. Pulse rate of 68 beats per minute d. Blood pressure of 158/69 mm Hg

d. Blood pressure of 158/69 mm Hg

During a clinic visit, a pregnant client at 30 weeks' gestation tells the nurse, "I've had some mild cramps that are pretty irregular. What does this mean?" The cramps are probably: a. The beginning of labor in the very early stages b. An ominous finding indicating that the client is about to have a miscarriage c. Related to overhydration of the woman d. Braxton Hicks contractions, which occur throughout pregnancy

d. Braxton Hicks contractions, which occur throughout pregnancy

A nurse is assigned to care for a 38-year-old overweight client scheduled to undergo a cesarean section. The client is at an increased risk of thromboembolic complications. During assessment, what factor will help the nurse in the diagnosis of deep vein thrombosis of the leg? a. Sudden chest pain b. Dyspnea c. Tachypnea d. Calf tenderness

d. Calf tenderness

When monitoring a woman in labor, which of the following is not expected to occur? a. Respiratory rate to increase b. Heart rate increase by 10 to 20 beats per minute c. Blood pressure to increase up to 35 mmHg d. Cardiac output increase by 50% during the first stage

d. Cardiac output increase by 50% during the first stage

A client is admitted to the health care facility with a gestational age of 42 weeks. The client is to undergo a cesarean section. Which of the following would be the fetal risk associated with postterm pregnancy? a. Underdeveloped suck reflex b. Congenital heart defects c. Intraventricular hemorrhage d. Cephalopelvic disproportion

d. Cephalopelvic disproportion

When providing nutritional counseling to a pregnant woman with diabetes, the nurse would urge the client to obtain most of her calories from which of the following? a. Saturated fats b. Unsaturated fats c. Protein sources d. Complex carbohydrates

d. Complex carbohydrates

A nurse, while examining a newborn, observes salmon patches on the nape and on the eyelids. Which of the following is the most likely cause of the salmon patches? a. Concentration of pigmented cells b. Eosinophils reacting to environment c. Immature autoregulation of blood flow d. Concentration of immature blood vessels

d. Concentration of immature blood vessels

A postpartum client has decided to use Depo-Provera (medroxyprogesterone acetate) as her contraceptive method. What should the nurse advise the client regarding this medication? a. Take the pill at the same time each day. b. Refrain from breastfeeding while using the method. c. Expect to have no periods as long as she takes the medicine. d. Consider switching to another birth control method in a year or so.

d. Consider switching to another birth control method in a year or so.

A pregnant woman comes to the emergency department because she thinks she is in labor. The nurse determines that the client is in true labor when assessment of contractions reveals which of the following? a. Contractions occur in an irregular pattern. b. Contractions last about 20 to 30 seconds. c. Contractions slow when the woman changes position. d. Contractions radiate to the front of the abdomen from the back.

d. Contractions radiate to the front of the abdomen from the back.

A client has been admitted to the unit for tocolytic therapy. The nurse recognizes all except which of the following tocolytics may be used in this woman's care plan? a. Magnesium sulfate b. Terbutaline c. Indomethacin d. Corticosteroids

d. Corticosteroids

The nurse is caring for a client at the ambulatory care clinic who questions the nurse for information about contraception. The client reports that she is not comfortable about using any barrier methods and would like the option of regaining fertility after a couple of years. Which of the following methods should the nurse suggest to this client? a. BBT b. Coitus interruptus c. Lactational amenorrhea method d. Cycle Beads or Depo-Provera

d. Cycle Beads or Depo-Provera

A nurse is caring for a client in labor who is delivering. Which of the following fetal responses should the nurse monitor for in the client's baby? a. Decrease in arterial carbon dioxide pressure b. Increase in fetal breathing movements c. Increase in fetal oxygen pressure d. Decrease in circulation and perfusion to the fetus

d. Decrease in circulation and perfusion to the fetus

All except which of the following might indicate pain in the newborn? a. Fussiness b. Sudden high-pitched cry c. Increased muscle tone d. Decreased body posturing

d. Decreased body posturing

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which of the following complications? a. Postpartum hemorrhage b. Uterine atony c. Metritis d. Deep Vein Thrombosis

d. Deep Vein Thrombosis

A nurse working in the newborn nursery hears a murmur on auscultation of a 24-hour-old infant's chest. It is recognized that this murmur is usually due to: a. Congenital defect b. Dysfunctional foramen ovale c. Attached umbilical cord stump d. Delayed fetal shunt closure

d. Delayed fetal shunt closure

During a routine assessment the nurse notes the client is tachycardic. Which of the following should be ruled out as the cause? a. Uterine atony b. Bladder distention c. Extreme diaphoresis d. Delayed hemorrhage

d. Delayed hemorrhage

A couple is being assessed for infertility. The male partner is required to collect a semen sample for analysis. What instruction should the nurse give him? a. Abstain from sexual activity for 10 hours before collecting the sample b. Avoid strenuous activity for 24 hours before collecting the sample c. Collect a specimen by ejaculatng into a condom or plastic bag d. Deliver sample for analysis within 1 to 2 hours after ejaculation

d. Deliver sample for analysis within 1 to 2 hours after ejaculation

A nurse is assessing a pregnant client with preeclampsia for suspected dependent edema. Which of the following is the most accurate description of dependent edema? a. Dependent edema leaves a small depression or pit after finger pressure is applied to a swollen area b. Dependent edema occurs only in clients on bed rest c. Dependent edema can be measured when pressure is applied d. Dependent edema may be seen in the sacral area if the client is on bed rest

d. Dependent edema may be seen in the sacral area if the client is on bed rest

A nurse is caring for a pregnant client in labor in a health care facility. The nurse knows that which of the following marks the termination of the first stage of labor in the client? a. Diffuse abdominal cramping b. Rupturing of fetal membranes c. Start of regular contractions d. Dilation of cervix diameter to 10 cm

d. Dilation of cervix diameter to 10 cm

Which of the following would the nurse identify as a normal physiologic change in the renal system due to pregnancy? a. Reduction in kidney size b. Shortening of the ureters c. Decrease in glomerular filtration rate d. Dilation of the renal pelvis

d. Dilation of the renal pelvis

Which of the following measures helps prevent osteoporosis? a. Supplementing with iron b. Sleeping 8 hours nightly c. Eating lean meats only d. Doing weight-bearing exercises

d. Doing weight-bearing exercises

A newborn with tracheoesophageal fistula is likely to present with which assessment finding? a. Subnormal temperature b. Absent Moro reflex c. Inability to swallow d. Drooling from mouth

d. Drooling from mouth

The nurse recognizes that the postpartum period is a time of rapid changes for each client. Which of the following is believed to be the cause of postpartum affective disorders? a. Preexisting conditions in the client b. Medications used during labor and delivery c. Lack of social support from family or friends d. Drop in estrogen and progesterone levels after birth

d. Drop in estrogen and progesterone levels after birth

After teaching a group of nursing students about thermoregulation and appropriate measures to prevent heat loss by evaporation, which of the following student behaviors would indicate successful teaching? a. Transporting the newborn in an isolette b. Maintaining a warm room temperature c. Placing the newborn on a warmed surface d. Drying the newborn immediately after birth

d. Drying the newborn immediately after birth

The nurse's discharge teaching plan for woman with pelvic inflammatory disease (PID) should reinforce which of the following potentially life-threatening complications? a. Involuntary infertility b. Chronic pelvic pain c. Depression d. Ectopic pregnancy

d. Ectopic pregnancy

Which of these activities would best help the postpartum nurse to provide culturally sensitive care for the childbearing family? a. Take a transcultural course b. Caring for only families of his or her cultural reign c. Teaching Western beliefs to culturally diverse families d. Educating himself or herself about diverse cultural practices

d. Educating himself or herself about diverse cultural practices

A pregnant woman is being evaluated for HELLP. The nurse will review all except which of the following laboratory results to confirm this diagnosis? a. Elevated AST b. Elevated BUN c. Elevated LDH d. Elevated glucose

d. Elevated glucose

The nurse assessing a newborn suspects meconium aspiration syndrome. What sign or symptom would alert the nurse to this condition? a. High-pitched cry b. Bile-stained emesis c. Increased intracranial pressure d. End-expiratory grunting

d. End-expiratory grunting

A client has been admitted to the hospital with a diagnosis of bulimia. Which of the following physical findings would the nurse expect to see? a. Mastoiditis. b. Hirsutism. c. Gynecomastia. d. Esophagitis.

d. Esophagitis.

During the first hour of the fourth stage of labor, the nurse would assess the woman's fundus how often? a. Every 20 minutes b. Every 10 minutes c. Every 5 minutes d. Every 15 minutes

d. Every 15 minutes

The nurse is reviewing the family history information in a newly admitted client's chart. The nurse notes that the client lives with his parents and grandparents. Which term best describes the client's family structure? a. Blended family b. Communal family c. Binuclear family d. Extended family

d. Extended family

The nurse is assessing a client for amenorrhea. Which of the following should the nurse document as evidence of androgen excess secondary to a tumor? a. Reduced subcutaneous fat b. Hypothermia c. Irregular heart rate and pulse d. Facial hair and acne

d. Facial hair and acne

The nurse is working with a young couple who are expecting their first child but do not have family living in the area. The nursing support can involve all of the following, except: a. Instrumental support b. Appraisal support c. Emotional support d. Familial support

d. Familial support

The nurse is assisting a client in completing the Postpartum Depression Screening Scale tool to assess for postpartum depression. Which of the following is least likely to be screened with this tool? a. Guilt b. Emotional liability c. Cognitive impairment d. Family and social support system

d. Family and social support system

When reviewing the medical record of a client, the nurse notes that the woman has a condition in which the fetus cannot physically pass through the maternal pelvis. The nurse interprets this as: a. Cervical insufficiency b. Contracted pelvis c. Maternal disproportion d. Fetopelvic disproportion

d. Fetopelvic disproportion

A nurse is questioning the family members of a pregnant client to obtain a genetic history. While asking questions, which of the following should the nurse keep in mind? a. Inquire about the socioeconomic status of the family members b. Avoid questions about race or ethnic background c. Ask questions regarding physical characteristics of family members d. Find out if couples are related to each other or have blood ties

d. Find out if couples are related to each other or have blood ties

Which of the following complications should a nurse keep in mind while administering IV therapy to a newborn? a. Heart rate increase b. Lower blood pressure c. Decrease in alertness d. Fluid overload

d. Fluid overload

When preparing a lecture for a group of students about fetal circulation, which structure would the nurse explain as being primarily responsible for ensuring that highly oxygenated blood reaches the fetal brain? a. Ductus arteriosus b. Ductus venosus c. Umbilical vein d. Foramen ovale

d. Foramen ovale

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. Which of the following classifications will the nurse use to describe the laceration? a. First-degree laceration b. Second-degree laceration c. Third-degree laceration d. Fourth-degree laceration

d. Fourth-degree laceration

A 41-year-old pregnant woman and her husband are anxiously awaiting the results of various blood tests to evaluate the fetus for potential Down syndrome, neural tube defects, and spina bifida. Client education should include which of the following? a. A second set of screening tests can be obtained to confirm results. b. Treatment can be started once the test results are back. c. The blood tests are definitive. d. Further testing will be required to confirm any diagnosis.

d. Further testing will be required to confirm any diagnosis.

A nurse needs to assess a female client for primary stage herpes simplex virus (HSV) infection. Which of the following symptoms related to this condition should the nurse assess for? a. Rashes on the face b. Yellow-green vaginal discharge c. Loss of hair or alopecia d. Genital vesicular lesions

d. Genital vesicular lesions

A nurse is assigned to care for a client who has been diagnosed with placental abruption. The nurse knows that which of the following could have led to placental abruption in the client? a. Obesity or excess weight gain b. CVD c. Gestational diabetes d. Gestational hypertension

d. Gestational hypertension

A nurse has placed an infant with asphyxia on a radiant warmer. Which of the following signs indicate that the resuscitation methods have been successful? a. Heart rate of 80 bpm b. Tremors c. Bluish tongue d. Good cry

d. Good cry

One of the nurse's responsibilities is to educate new parents on the best method to prevent infections in the newborn environment. Which of the following is one of the best methods to control infection? a. Using antimicrobial soaps b. Instruct visitors to wear face masks, if ill c. Keeping the infant isolated from others d. Handwashing

d. Handwashing

A client has arrived to the birthing center in labor, requesting a VBAC. The nurse knows that she would be a good candidate after reading her previous history due to which of the following? a. Had prior classic uterine incision b. Had prior transfundal uterine surgery c. Has contracted pelvis d. Has previous lower abdominal incision

d. Has previous lower abdominal incision

In assessing a preterm newborn, which of the following findings would be of greatest concern? a. Milia over the bridge of the nose b. Thin transparent skin c. Poor muscle tone d. Heart murmur

d. Heart murmur

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which of the following medications would be contraindicated in her case? a. Pitocin b. Cytotec c. Methergine d. Hemabate

d. Hemabate

Which one of the following immunizations is most commonly received by newborns before hospital discharge? a. Pneumococcus b. Varicella c. Hepatitis A d. Hepatitis B

d. Hepatitis B

When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing? a. Hold your breath and push through entire contraction b. Use chest-breathing with the contraction c. Pant and blow during each contraction d. Instruct her to wait until she feels the urge to push

d. Instruct her to wait until she feels the urge to push

Which of the following would the nurse expect a woman with dysmenorrhea to report? a. Abnormally long, heavy menstrual periods b. Dysphoria c. Chronic pelvic pain d. Intermittent sharp suprapubic pain

d. Intermittent sharp suprapubic pain

During the assessment, the nurse explains that certain landmarks are used to determine the progress of the delivery. What are these landmarks? a. Pubic symphysis b. Cervical os c. Ischial tuberosity d. Ischial spine

d. Ischial spine

A pregnant client is admitted to a maternity clinic for childbirth. The client wishes to adopt the kneeling position during labor. The nurse knows that which of the following is the advantage of adopting a kneeling position during labor? a. It helps the woman in labor to save energy b. It facilitates vaginal examinations c. It facilitates external belt adjustment d. It helps to rotate fetus in a posterior position

d. It helps to rotate fetus in a posterior position

Which of the following exercises should a nurse suggest to the client during the first day of postpartum? a. Abdominal exercises b. Buttock exercises c. Thigh-toning exercises d. Kegel exercises

d. Kegel exercises

A nurse is caring for a pregnant adolescent client, who is in her first trimester, during a visit to the maternal child clinic. Which of the following is an important area that the nurse should address during assessment of the client? a. Sexual development of the client b. Whether sex was consensual c. Options for birth control in the future d. Knowledge of child development

d. Knowledge of child development

Which of the following would the nurse include in the plan of care for a woman with premature rupture of membranes if her fetus's lungs are mature? a. Reduction in physical activity level b. Administration of corticosteroids c. Observation for signs of infection d. Labor induction

d. Labor induction

As a nurse in the emergency department, you have witnessed women arriving in labor with complications. You recognize a major factor that contributes to a poor outcome for many of these clients is: a. Lack of adequate nutrition b. Lack of education c. Lack of employment d. Lack of care

d. Lack of care

The nurse is educating a group of adolescent women regarding sexually transmitted infections (STIs). The nurse knows that learning was achieved when a group member states that the most common sign/symptom of sexually transmitted infections is which of the following? a. Menstrual cramping. b. Heavy menstrual periods. c. Flu-like symptoms. d. Lack of signs or symptoms.

d. Lack of signs or symptoms.

A client is to be examined for the presence and extent of endometriosis. Which of the following tests should the nurse prepare the client for? a. Tissue biopsy b. Hysterosalpingogram c. Clomiphene citrate challenge test d. Laparoscopy

d. Laparoscopy

A nurse finds that a client is bleeding excessively after a vaginal delivery. Which assessment findings would indicate retained placental fragments as a cause of bleeding? a. Soft and boggy uterus that deviates from the midline b. Firm uterus with trickle of bright-red blood in perineum c. Firm uterus with a steady stream of bright-red blood d. Large uterus with painless dark-red blood mixed with clots

d. Large uterus with painless dark-red blood mixed with clots

Upon reviewing the mother's record, the nurse notes the client has diabetes mellitus. The nurse anticipates that her newborn will probably be which of the following? a. Small-for-gestational-age b. Appropriate-for-gestational-age c. Very-large-for-gestational-age d. Large-for-gestational-age

d. Large-for-gestational-age

A physician orders oral tocolytic therapy for a woman with preterm labor. Which agent would the nurse be least likely to administer? a. Terbutaline b. Indomethacin c. Nifedipine d. Magnesium sulfate

d. Magnesium sulfate

A nurse is caring for a client who wishes to undergo an abortion. The nurse has concerns because abortion is against her personal convictions, and this is interfering with her professional duty. Which of the following should the nurse do to follow American Nurses Association's (ANA) code of ethics for nurses? a. Provide emotional support to the client while caring for her b. Not allow her personal convictions to interfere with her profession c. Involve the client's family in convincing the client against an abortion d. Make arrangements for alternate care providers

d. Make arrangements for alternate care providers

A pregnant client's last normal menstrual period was on August 10. Using Nagele's rule, the nurse calculates that her estimated date of birth (EDB) will be which of the following? a. June 23 b. July 10 c. July 30 d. May 17

d. May 17

A preterm newborn is in the NICU receiving supplemental oxygen. The nurse is aware that to help reduce the severity of retinopathy of prematurity, the oxygen saturation target ranges are which of the following? a. Upper mid-80s to mid-90s b. Lower mid-90s to upper mid-90s c. Mid-80s to mid-90s d. Mid-80s to lower mid-90s

d. Mid-80s to lower mid-90s

A nurse is aware that the newborn's neuromuscular maturity is typically completed within 24 hours after birth. Which of the following would the nurse be less likely to conduct to determine the newborn's degree of maturity? a. Popliteal angle b. Square window c. Scarf sign d. Moro reflex

d. Moro reflex

What is the most precise term used to describe a herniation through the skin of the back of a newborn when both the spinal cord and nerve roots are involved? a. Meningocele b. Spina bifida occulta c. Spina bifida cystica d. Myelomeningocele

d. Myelomeningocele

Which finding would lead the nurse to suspect that a newborn is experiencing respiratory distress syndrome? a. Abdominal distention b. Acrocyanosis c. Depressed fontanels d. Nasal flaring

d. Nasal flaring

A diabetic woman presented to the emergency department in active labor. Assessment confirms placenta previa. She was given oxytocin to stimulate the labor. The nurse should anticipate that the newborn will require monitoring for which of the following? a. Transient tachypnea b. Respiratory distress syndrome c. Acidosis d. Neonatal asphyxia

d. Neonatal asphyxia

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

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

A nurse is caring for an infant born after a prolonged and difficult maternal labor. What are the nursing interventions involved when assessing for trauma and birth injuries in the newborn? a. Examine the newborn's skin for cyanosis b. Be alert for signs of apathy and listlessness c. Assess the baby for any temperature instability d. Note any absence of or decrease in deep tendon reflexes

d. Note any absence of or decrease in deep tendon reflexes

During a prenatal visit, a client in her second trimester of pregnancy verbalizes positive feelings about the pregnancy and conceptualizes the fetus. Which of the following is the most appropriate nursing intervention when the client expresses such feelings? a. Encourage the client to focus on herself, not on the fetus b. Inform the primary health care provider about the client's feelings c. Inform the client that it is too early to conceptualize the fetus d. Offer support and validation about the client's feelings

d. Offer support and validation about the client's feelings

In preparing for a prenatal class to discuss the hormonal changes during pregnancy, it is important to include which of the following? a. Taking hormonal replacement therapy can improve the discomfort of the changes. b. Most of the hormonal changes are permanent after the pregnancy is completed. c. Using herbs will help ease the discomfort. d. Over-the-counter antacids can be used to treat acid reflux with the health care provider's knowledge.

d. Over-the-counter antacids can be used to treat acid reflux with the health care provider's knowledge.

A client with full-term pregnancy who is not in active labor has been ordered oxytocin intravenously. Which of the following is a contraindication for oxytocin administration a. Dysfunctional labor pattern b. Postterm status c. Prolonged ruptured membranes d. Overdistended uterus

d. Overdistended uterus

The nurse is explaining phototherapy to the parents of a newborn. The nurse would include which of the following as the purpose? a. Increase surfactant levels b. Stabilize the newborn's temperature c. Destroy Rh-negative antibodies d. Oxidize bilirubin on the skin

d. Oxidize bilirubin on the skin

A female client who has just given birth arrives in a health care facility wanting to know of ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse provide? a. Drape the infant in warm clothes b. Feed a mixture of salts, sugar and water c. Provide very soft bedding d. Place the infant on his or her back to sleep

d. Place the infant on his or her back to sleep

A nurse is caring for a 5-hour-old newborn. The physician has asked the nurse to maintain the newborn's temperature between 97.7 and 99.5F (between 36.5 and 37.5 C). What nursing intervention should the nurse perform to maintain the temperature within the recommended range? a. Avoid measuring the weight of the infant, as scales may be cold b. Use the stethoscope over the baby's garment c. Place the newborn close to the outer wall in the room d. Place the newborn skin-to-skin with the mother

d. Place the newborn skin-to-skin with the mother

A nurse is caring for a 5-hour-old newborn. The physician has asked the nurse to maintain the newborn's temperature between 97.7℉ and 99.5℉ (36.5°C and 37.5°C). Which nursing intervention would be the best approach to maintaining the temperature within the recommended range? a. Delay weighing the infant, as the scales may be cold b. Use the stethoscope over the newborn's garment c. Place the newborn's crib close to the outer wall in the room d. Place the newborn skin-to-skin with the mother

d. Place the newborn skin-to-skin with the mother

When preparing to resuscitate a preterm newborn, which of the following would the nurse do first? a. Hyperextend the newborn's neck. b. Administer epinephrine. c. Use positive-pressure ventilation. d. Place the newborn's head in a neutral position.

d. Place the newborn's head in a neutral position.

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

d. Postpartum hemorrhage

In an effort to decrease rising health care costs, more nursing care is moving to the home setting. Nurses in the home care setting are responsible for all of the following, except: a. Direct care provider b. Client advocate c. Education d. Prescribing needed medications

d. Prescribing needed medications

Which of the following hormones would the nurse expect to cause the pelvic connective tissue to become more relaxed and elastic in preparation for labor? a. Oxytocin b. Prolactin c. Progesterone d. Relaxin

d. Relaxin

A nurse caring for a client in labor has asked her to perform Lamaze breathing techniques to avoid pain. Which of the following should the nurse keep in mind to promote effective Lamaze-method breathing? a. Ensure deep abdominopelvic breathing b. Ensure abdominal breathing during contractions c. Ensure client's concentration on pleasurable sensations d. Remain quiet during client's period of imagery

d. Remain quiet during client's period of imagery

The parents of an infant with congenital clubfoot ask the nurse what the treatment will consist of. What is the initial treatment for an infant born with a congenital club foot? a. Surgery b. Braces c. Physical therapy d. Serial casting

d. Serial casting

When describing the methods of transmission for herpes simplex virus to a group of college students, which method would be least likely? a. Kissing b. Vaginal birth c. Sexual contact d. Sharing contaminated needles

d. Sharing contaminated needles

Parents tell the nurse that they have been told to keep their newborn away from windows and be sure to cover the baby with a light blanket. They do not understand why this is necessary. What rationale would the nurse provide for this care?a. Newborns have very thin skin, which allows radiant heat loss.b. Newborns weighing below 8 pounds lack enough brown fat to produce heat.c. Windows can be drafty and placing the newborn by one can result in evaporative heat loss.d. Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.

d. Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.

A young mother is suspected of abusing heroin. Which of the following would the nurse expect to find in her newborn? a. Hypotonicity b. Easy consolability c. Vigorous sucking d. Sneezing

d. Sneezing

Circumcision is a very personal decision for parents and the nurse's major responsibility is to inform the parents of the risks and benefits of the procedure. The nurse needs to recognize that this decision is mainly which of the following? a. Family decision b. Difficult decision c. Legal decision d. Social decision

d. Social decision

The rationale for using a prostaglandin gel for a client prior to the induction of labor is to: a. Stimulate uterine contractions b. Numb cervical pain receptors c. Prevent cervical lacerations d. Soften and efface the cervix

d. Soften and efface the cervix

A client has delivered an infant with Patau syndrome, or trisomy 13. As the nurse, you counsel this couple that the care of this infant is: a. Long-term b. Complicated c. Therapeutic d. Supportive

d. Supportive

Which of the following would lead the nurse to suspect that a postpartum woman was developing a complication? a. Fatigue and irritability b. Perineal discomfort and pink discharge c. Pulse rate of 60 bpm d. Swollen, tender, hot area on breast

d. Swollen, tender, hot area on breast

After teaching a class about autosomal dominant and recessive inheritance patterns, the nurse determines that the class needs additional teaching when they identify which condition as an example of an autosomal dominant disorder? a. Neurofibromatosis b. Huntington disease c. Achondroplasia d. Tay-Sachs disease

d. Tay-Sachs disease

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's uterine fundus, the nurse would expect to find it at: a. Between the umbilicus and symphysis pubis b. 2 cm below the umbilicus c. 1 cm below the umbilicus d. The level of the umbilicus

d. The level of the umbilicus

A nurse is caring for a pregnant client who is HIV-positive. What is a priority issue that the nurse should discuss with the client? a. The client's relationship with the spouse b. The amount of physical contact that should occur with the infant c. The client's plan for future pregnancies d. The need for the client to avoid breastfeeding

d. The need for the client to avoid breastfeeding

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this as which of the following? a. First-degree laceration b. Second-degree laceration c. Fourth-degree laceration d. Third-degree laceration

d. Third-degree laceration

The client, who has just been walking around her room, sits down and complains of leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes this could be which of the following? a. Infection b. Normal response to the body converting back to prepregnancy state c. Hormonal shifting of relaxin and estrogen d. Thromboembolic disorder of the lower extremities

d. Thromboembolic disorder of the lower extremities

A pregnant woman in her second trimester comes to the prenatal clinic for a routine visit. She reports that she has a new kitten. The nurse would have the woman evaluated for which infection? a. Herpes simplex virus b. Parvovirus B19 c. Cytomegalovirus d. Toxoplasmosis

d. Toxoplasmosis

When caring for an adolescent, in which instance must the nurse share information with the parents, no matter which state care is provided in? a. Pregnancy counseling b. Depression c. Contraception d. Tuberculosis

d. Tuberculosis

When developing a plan of care for a pregnant woman who is HIV-positive, which of the following is essential to be included? a. Preparing the woman for cesarean birth b. Helping her choose a newborn feeding method c. Educating her about family planning d. Using standard precautions

d. Using standard precautions

A female client asks the nurse about treatment for human papilloma viral warts. The nurse's response should be based on which of the following? a. An antiviral injection cures approximately fifty percent of cases. b. Aggressive treatment is required to cure warts. c. Warts often spread when an attempt is made to remove them surgically. d. Warts often recur a few months after a client is treated.

d. Warts often recur a few months after a client is treated.

The hormone that ensures implantation of the embryo at the beginning of conception is: a. Estrogen b. Progesterone c. LH d. hCG

d. hCG

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

d. orientation

A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function?a. voluntary movementsb. crying responsec. orientation to surroundingsd. reflex

d. reflex

All the options are signs of respiratory distress in the newborn except:a. grunting.b. coughing.c. central cyanosis.d. respiratory rate >50 breaths/minute.e. chest retractions.f. nasal flaring.

d. respiratory rate >50 breaths/minute.

The nurse providing care for a woman with preterm labor on magnesium sulfate would include which assessment for safe administration of the drug?

deep tendon reflexes (DTR)s Assessing deep tendon reflexes hourly in a client receiving magnesium sulfate is appropriate as depressed DTRs are a sign of magnesium toxicity. Elevated blood glucose is a fetal side effect but not noted to assess with the mother. Assessing for depressed respiration and hypotension not tachypnea or tachycardia would be appropriate assessments needed for the safe administration of magnesium sulfate.

Periventricular-Intraventricular Hemorrhage

defined as bleeding that usually originates in the subependymal germinal matrix region of the brain, often extending into the ventricular system *IVH occurs in up to 50% of infants with birthweight less than 1,500 g and/or born at less than 35 weeks' gestation. It is uncommon in term neonates but may occur with birth trauma or asphyxia

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

Necrotizing Enterocolitis

disease of the bowel which can cause ischemic and necrotic injury in the gastrointestinal tract. * preterm * breast milk!

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. Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

Hemolytic disease of the newborn typically shows within 24 hours after birth due to ______________

due to the different types of blood between mother and newborn.

A nurse is assessing a pregnant woman who has come to the clinic. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply.

dull low backache malodorous vaginal discharge dysuria Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and heaviness or aching in the thighs. Constipation is not known to be a sign of preterm labor. Preterm labor is assessed when there are more than six contractions per hour.

What is a classic sign of neonatal respiratory distress syndrome? Select all that apply.

expiratory grunting nasal flaring retractions tachypnea

A common symptom that would alert you that a preterm infant is developing respiratory distress syndrome is a) inspiratory "crowing." b) inspiratory stridor. c) expiratory grunting. d) expiratory wheezing.

expiratory grunting.

A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?

external cephalic version External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilatation of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called?

external version External version is the process of manipulating the position of the fetus in order to try to turn the fetus to a cephalic presentation.

The client is 35 weeks of gestation and is being admitted for vaginal bleeding. She is stable at the time of admission. The priority nursing assessment for the client is for:

fetal heart tones. When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. The other options are not a higher priority than fetal heart tones.

A nurse is conducting an in-service presentation for a group of neonatal nurses. After teaching the group about the effects of prematurity on various body systems, the nurse determines that the class was successful when the group identifies which condition as an effect of prematurity?

fragile cerebral blood vessels Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate.

A newborn that has a surfactant deficiency will have which assessment noted on a physical exam?

grunting Infants that are deficient in lung surfactant will show signs of respiratory distress: grunting, retracting, tachypnea, cyanosis, poor perfusion, hypotension, and skin mottling.

A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess?

head larger than body

A small-for-gestational age neonate is admitted to the observational nursery for blood work. Which result would require further assessment?

hematocrit: 80%

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what does the nurse prepare her?

hospitalization, tocolytic therapy, and IM corticosteroids At 31 weeks gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allow for monitoring and a safe place if the woman continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the woman home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal kick counts is typically done with a postterm pregnancy.

An infant has a grade 3 intraventricular hemorrhage (IVH). The nurse monitors the infant for which complication?

hydrocephalus A grade 3 bleed causes enlargement of the ventricles. A long-term effect of hemorrhage may be the development of hydrocephalus. Encephalitis and meningitis are not complications of IVH. Intraparenchymal hemorrhage is seen in a grade 4 bleed.

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

hypoglycemia LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes which was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.

A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that the child is at risk for which complication?

hypoglycemia Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus through the placenta. The neonate's liver cannot initially adjust to the changing glucose levels after birth. This inability may result in an overabundance of insulin in the neonate, causing hypoglycemia. Neonates of mothers with diabetes are not at increased risk for anemia, nitrogen loss, or thrombosis.

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

increased amounts of vernix

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

intercostal and substernal retractions

human breast milk provides a passive mechanism to protect the newborn against the dangers of a deficient _______ defense system

intestinal

A nurse is reading a journal article about cesarean births and the indications for them. Place the indications for cesarean birth below in the proper sequence from most frequent to least frequent. All options must be used.

labor dystocia abnormal fetal heart rate tracing fetal malpresentation multiple gestation suspected macrosomia The most common indications for primary cesarean births include, in order of frequency, labor dystocia, abnormal fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected macrosomia.

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

The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn? Select all that apply.

maternal smoking during pregnancy asthma exacerbations during pregnancy drug abuse

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

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 Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.

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

meconium stained fluids followed by tachypnea Meconium stained cord and skin indicates a potential of meconium aspiration, and the nurse should inform the primary care provider. But if the infant actually experiences respiratory distress following a birth with meconium stained fluids, the likelihood of meconium aspiration is greatly increased. Listlessness or lethargy by themselves does not indicate meconium aspiration. Bluish skin discoloration is normal in infants shortly after birth until the infant's respiratory system clears out all the amniotic fluid.

The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails Postterm newborns typically exhibit the following characteristics: dry, cracked, peeling, wrinkled skin; vernix caseosa and lanugo are absent; long, thin extremities; creases that cover the entire soles of the feet; abundant hair on scalp; thin umbilical cord; long fingernails; limited vernix and lanug; and meconium-stained skin and fingernails.

Pregnant women dependent on opioids are maintained on as the current standard of care, which provides multiple benefits including improved prenatal care, reduced fetal mortality, and improved fetal growth

methadone

After a gavage feeding of a preterm neonate, the nurse aspirates 4 mL of undigested formula. This finding may indicate the development of which complication?

necrotizing enterocolitis

After a gavage feeding of a preterm neonate, the nurse aspirates 4 mL of undigested formula. This finding may indicate the development of which complication?

necrotizing enterocolitis An inability to digest enteral feeding is a sign that necrotizing enterocolitis (NEC), a destructive intestinal disorder that often occurs in preterm babies, may be developing. Dumping syndrome and malabsorption may be consequences of NEC. Neonates rarely develop acute gastroenteritis.

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 nursing student correctly identifies the most desirable position to promote an easy birth as which position?

occiput anterior Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm. dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?

occiput posterior position A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor."

Losing a newborn is perhaps one of the most difficult situations for a family. Which action by the nurse would be the most appropriate if a newborn dies?

offering mementos to the family of the newborn

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

on the back with the head slightly extended.

Afterpains are usually stronger during breast-feeding because ___________ released by the sucking reflex strengthens the contractions. Mild analgesics can reduce this discomfort.

oxytocin

A nurse is conducting a class for a group of expectant couples on fetal growth and development. The nurse determines that additional teaching is needed when the class identifies which factor as playing an important role in fetal growth and development?

paternal factors

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

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 Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.

A client is at 23 weeks' gestation and was admitted for induction and birth after noting the infant was an intrauterine fetal death. The client had fallen 3 days prior to the diagnosis and landed on her side. What is the most likely attributable cause to the fetal death?

placental abruption The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. The scenario does not indicate that there has been a premature rupture of membranes or the possibility of preeclamsia.

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant?

placental factors Assessment of the SGA infant begins by reviewing the maternal history to identify risk factors such as placental factors with abnormal umbilical cord insertion, chronic placental abruption, malformed and smaller placentas, with placental previa or placental insufficiency being the main placental causes. Blood group incompatibility, having many pregnancies, and being over the age of 30 will not cause an SGA infant.

A preterm infant receives surfactant by lung lavage. What intervention should the nurse perform immediately? Select all that apply.

placing the infant in an upright position not suctioning the airway

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

polycythemia

The small-for-gestational-age neonate is at increased risk for which complication during the transitional period?

polycythemia, probably due to chronic fetal hypoxia

Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of ______________________

postpartum hemorrhage.

The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which term?

precipitous labor When the expulsive forces of the uterus become dysfunctional, the uterus may either never fully relax (hypertonic contractions) placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions. Another dysfunction can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place (precipitous labor).

Heat loss mechanisms

radiation, conduction, convection, evaporation

Sternal retractions are a sign of ______________ requiring immediate intervention, such as mechanical ventilation and other monitoring devices.

respiratory distress

Which sign would indicate dehydration in a newborn?

sunken fontanels Sunken fontanels in a newborn are a sign of dehydration. Other signs are sunken eyeballs, decreased urine output, lethargy, decreased skin turgor, decreased body weight, and irritability.

Management of TTN is ___________. As the retained lung fluid is absorbed by the infant's lymphatic system, the pulmonary status improves.

supportive

A nurse is caring for a newborn with tecrotizing enterocolitis (NEC) who is schedule to undergo surgery for a bowel resection. The infant's parents wish to know the implications of the surgery. What information should the nurse provide?

surgery requires placement of a proximal enterostomy

A newborn with persistent pulmonary hypertension demonstrates _______ within 12 hours after birth

tachypnea, cyanosis, grunting, respiratory distress with tachypnea, and retractions.

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

tea-colored urine

A woman gives birth to a newborn at 39 weeks' gestation. The nurse classifies this newborn as:

term

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 Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small for gestational age (SGA). Those who fall above the 90th percentile in weight are considered large for gestational age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLB). Those born weighing 500 to 1000 g are considered extremely very-low-birth-weight infants (EVLB).

yellowish-green staining of the umbilical cord and nails and skin indicates that

that meconium has been present for some time.

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

Failure to maintain and restore perineal muscular tone leads to ___________________ later in life for many women.

urinary incontinence

While in labor a woman with a prior history of cesarean birth reports light-headedness and dizziness. The nurse assesses the client and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms?

uterine rupture The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of:

very low birth weight.

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

A client just delivered a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Estimate the urinary flow by weighing the diaper. b) Dress the baby in a stockinette cap. c) Dress the baby to keep the body warm. d) Place the baby under isolette care. e) Carry and handle the baby frequently.

• Dress the baby in a stockinette cap. • Place the baby under isolette care. • Estimate the urinary flow by weighing the diaper. Explanation: The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature often. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the child. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing.

The nurse in the NICU is caring for preterm newborns. Which of the following are recommended guidelines for care of these newborns? Select all that apply. a) Take the newborn's temperature often. b) Discourage contact with parents to maintain asepsis. c) Dress the newborn in ways to preserve warmth. d) Supply oxygen for the newborn, if necessary. e) Handle the newborn as much as possible. f) Give the newborn a warm bath immediately.

• Dress the newborn in ways to preserve warmth. • Take the newborn's temperature often. • Supply oxygen for the newborn, if necessary. Explanation: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.

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

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

The nurse caring for newborns on an obstetrical ward assesses a SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) Tight and moist skin b) Diminished muscle tissue c) Narrow skull sutures d) Poor skin turgor e) Increased fatty tissue f) Sparse or absent hair

• Poor skin turgor • Sparse or absent hair • Diminished muscle tissue

The nurse caring for newborns on an obstetrical ward assesses a SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) Diminished muscle tissue b) Tight and moist skin c) Sparse or absent hair d) Narrow skull sutures e) Poor skin turgor f) Increased fatty tissue

• Poor skin turgor • Sparse or absent hair • Diminished muscle tissue Explanation: Characteristics of the SGA newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts.

Which of the following would the nurse expect to find in a newborn who is considered small for gestational age? Select all that apply. a) Dry or thin umbilical cord b) Sunken abdomen c) Narrow skull sutures d) Poor muscle tone over buttocks e) Increased subcutaneous fat stores

• Sunken abdomen • Poor muscle tone over buttocks • Dry or thin umbilical cord Explanation: A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.

Which of the following would be most effective in reducing pain in the preterm newborn? Select all that apply. a) Removing tape quickly from the skin b) Swaddling the newborn closely c) Offering a pacifier prior to a procedure d) Encouraging kangaroo care during procedures e) Increasing the volume on device alarms f) Using cool blankets to soothe the newborn

• Swaddling the newborn closely • Encouraging kangaroo care during procedures • Offering a pacifier prior to a procedure Explanation: Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation.

The nurse in the NICU is caring for preterm newborns. Which of the following are recommended guidelines for care of these newborns? Select all that apply. a) Give the newborn a warm bath immediately. b) Discourage contact with parents to maintain asepsis. c) Take the newborn's temperature often. d) Dress the newborn in ways to preserve warmth. e) Supply oxygen for the newborn, if necessary. f) Handle the newborn as much as possible.

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

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply. a) Avoid using disposable equipment b) Use sterile gloves for an invasive procedure c) Avoid coming to work when ill d) Cover jewelry while washing hands e) Initiate universal precautions when caring for the infant

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

The procedure for newborn resuscitation is easily remembered by the

"ABCDs" - airway, breathing, circulation, and drugs

An infant born 10 minutes prior was brought into the nursery for its exam. The nurse notices the infant's lip and palate are malformed. The father comes up to door and asks if the baby seems okay. What is the appropriate response by the nurse?

"Come on over and I will explain your infant's exam and findings." The nurse should include the parents and notify them of any visible anomalies right away. An in-depth discussion can take place later when the diagnosis is more definitive. Although the family may be in shock or denial, the nurse should give a realistic appraisal of the condition of their baby. Keeping communication lines open will lessen the family's feelings of helplessness and support their parental role.

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."

A premature newborn has repeated blood work drawn by heel prick. The mother asks the nurse, "Does my baby feel the pain from all these procedures?" What is the nurse's best response?

"Your baby is more sensitive to the pain than adults are."

A client who delivered a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid."

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. To minimize the risk of infections, the nurse should avoid coming to work when ill, use sterile gloves for an invasive procedure, and initiate universal precautions. The nurse should remove all jewelry before washing hands, not cover the jewelry. The nurse should use disposable equipment rather than avoid it.

how to asses Apgar score?

- Determine the Apgar score at 1 and 5 minutes - if less than 7 at 5 minutes, repeat the assessment at 10 minutes of age. - If the initial assessment is poor, begin resuscitation measures until the Apgar score is above 7.

uterine involution

- During the first few days after birth, the uterus typically descends from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day. - By 3 days, the fundus lies 2 to 3 fingerbreadths below the umbilicus (or slightly higher in multiparous women). - By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

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 Diabetes mellitus, postdates gestation, and prepregnancy obesity are the maternal factors the nurse should consider that could lead to a newborn being large for gestational age. Renal condition and maternal alcohol use are not factors associated with a newborn's being large for gestational age.

Persistent Pulmonary Hypertension of the Newborn

- previously referred to as persistent fetal circulation - is a cardiopulmonary disorder characterized by marked pulmonary hypertension that causes right-to-left extrapulmonary shunting of blood and hypoxemia - It occurs when the newborn's circulatory system does not have normal transition after birth.

Diagnosis of fetal alcohol syndrome requires the presence of three findings:

1. Documentation of all three facial abnormalities 2. Documentation of growth deficits (height, weight, or both <10th percentile) 3. Documentation of CNS abnormalities (structural, neurologic, or functional)

laceration degrees

1st degree - skin only 2nd degree - muscle also 3rd degree - anal sphincter also 4th degree - rectal mucosa also

A client complains to the nurse of pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints?

Maintain correct posture and positioning.

Assessment of a newborn at 40 weeks' gestation reveals that he is a low birth weight newborn. Which of the following weights would the nurse identify as being low birth weight? a) 2400 g b) 3400 g c) 4400 g d) 1400 g

2400 g

Assessment of a newborn at 40 weeks' gestation reveals that he is a low birth weight newborn. Which of the following weights would the nurse identify as being low birth weight? a) 4400 g b) 1400 g c) 2400 g d) 3400 g

2400 g Correct Explanation: A birth weight of less than 2500 g is categorized as a low birth weight in infants. The normal birth weight of term infants ranges from 3000-4000 g. Hence infants with a birth weight of 3500 g or 4500 g will not be categorized as low birth weight infants. Infants having birth weights lower than 1500g are termed as very low birth weight infants, and not merely low birth weight.

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

40 mg/100 mL whole blood Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 mL whole blood is considered hypoglycemia.

A nurse is counseling a mother about the immunologic properties of breast milk. The nurse integrates knowledge of immunoglobulins, emphasizing that breast milk is a major source of which immunoglobulin? A) IgA B) IgG C) IgM D) IgE

A A major source of IgA is human breast milk. IgG, found in serum and interstitial fluid, crosses the placenta beginning at approximately 20 to 22 weeks' gestation. IgM is found in blood and lymph fluid and levels are generally low at birth unless there is a congenital intrauterine infection. IgE is not found in breast milk and does not play a major role in defense in the newborn.

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which of the following would the nurse identify as being least significant to this condition? A) Early ambulation B) Prolonged labor C) Large fetus D) Use of anesthetics

A Factors that inhibit involution include prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion of amniotic membranes and placenta at birth, complication-free labor and birth process, breast-feeding, and early ambulation.

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following? A) Normal progression of behavior B) Probable hypoglycemia C) Physiological abnormality D) Inadequate oxygenation

A From 30 to 120 minutes of age, the newborn enters the second stage of transition, that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.

Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A) How many hours old is this newborn? B) How long ago did this newborn eat? C) What was the newborn's birthweight? D) Is acrocyanosis present?

A The typical heart rate of a newborn ranges from 120 to 160 beats per minute with wide fluctuation during activity and sleep. Typically heart rate is assessed every 30 minutes until stable for 2 hours after birth. The time of the newborn's last feeding and his birthweight would have no effect on his heart rate. Acrocyanosis is a common normal finding in newborns.

A pregnant client asks why ultrasound is used so frequently during pregnancy. The nurse's response is based on her knowledge that the advantages of ultrasound include which of the following? Select all that apply. a)"It is noninvasive and painless." b)"It can be used to estimate gestational age." c)"Results are immediate." d)"The ultrasound is the only test to determine gender."

A, B, C The ability to establish fetal age accurately by ultrasound is lost in the third trimester because fetal growth is not as uniform as it is in the first two trimesters; however, ultrasound can be used to approximate gestational age within 1-3 weeks' accuracy during the third trimester. A comprehensive ultrasound is used to detect anatomical defects, not gestational age. Ultrasound is not used to determine gender.

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?

Administer 0.5 ml/kg/hr of breast milk enterally. The nurse should administer 0.5 to 1 ml/kg/hr of breast milk enterally to induce surges in gut hormones that enhance maturation of the intestine. Administering vitamin D supplements, iron supplements, or intravenous dextrose will not significantly help the preterm newborn's gut overcome feeding difficulties.

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?

Administer dextrose intravenously.

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? a) An infant whose labor began with ruptured membranes b) An infant whose mother craved chocolate during pregnancy c) An infant who had difficulty establishing respirations at birth d) An infant who has marked acrocyanosis of his hands and feet

An infant who had difficulty establishing respirations at birth

When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure? A) Early parent-infant contact following birth B) Expert medical care for the labor and birth C) Good nutrition and prenatal care during pregnancy D) Grandparent involvement in infant care after birth

Ans: A Optimal bonding requires a period of close contact between the parents and newborn within the first few minutes to a few hours after birth. Expert medical care, nutrition and prenatal care, and grandparent involvement are not associated with the promotion of bonding.

After reviewing information about postpartum blues, a group of students demonstrate understanding when they state which of the following about this condition? A) "Postpartum blues is a long-term emotional disturbance." B) "Sleep usually helps to resolve the blues." C) "The mother loses contact with reality." D) "Extended psychotherapy is needed for treatment."

Ans: A Postpartum blues are transient emotional disturbances beginning in the first week after childbirth and are characterized by anxiety, irritability, insomnia, crying, loss of appetite, and sadness (Hanley, 2010). These symptoms typically begin 3 to 4 days after childbirth and resolve by day 8 (Mattson & Smith, 2011). These mood swings may be confusing to new mothers but usually are self-limiting. The blues typically resolves with restorative sleep. Postpartum blues are thought to affect up to 75% of all new mothers; this condition is the mildest form of emotional disturbance associated with childbearing (March of Dimes, 2011). The mother maintains contact with reality consistently and symptoms tend to resolve spontaneously without therapy within 1 to 2 weeks.

A nurse suspects that a preterm newborn is having problems with thermal regulation. Which of the following would support the nurse's suspicion? (Select all that apply.) A) Shallow, slow respirations B) Cyanotic hands and feet C) Irritability D) Hypertonicity E) Feeble cry

Ans: A, B, E Feedback: Typically, a preterm newborn that is having problems with thermal regulation is cool to cold to the touch. The hands, feet, and tongue may appear cyanotic. Respirations are shallow or slow, or signs of respiratory distress are present. The newborn is lethargic and hypotonic, feeds poorly, and has a feeble cry. Blood glucose levels are probably low, leading to hypoglycemia, due to the energy expended to keep warm.

A nurse is developing a plan of care for a preterm newborn to address the nursing diagnosis of risk for delayed development. Which of the following would the nurse include? (Select all that apply.) A) Clustering care to promote rest B) Positioning newborn in extension C) Using kangaroo care D) Loosely covering the newborn with blankets E) Providing nonnutritive sucking

Ans: A, C, E Feedback: The nurse would focus the plan of care on developmental care, which includes clustering care to promote rest and conserve energy, using flexed positioning to simulate in utero positioning, using kangaroo care to promote skin to skin sensations, swaddling with a blanket to maintain the flexed position, and providing nonnutritive sucking.

A nurse is assessing a newborn who has been classified as small for gestational age. Which of the following would the nurse expect to find? (Select all that apply.) A) Wasted extremity appearance B) Increased amount of breast tissue C) Sunken abdomen D) Adequate muscle tone over buttocks E) Narrow skull sutures

Ans: A, C, E Feedback: Typical characteristics of SGA newborns include a head that is disproportionately large compared to the rest of the body, wasted appearance of the extremities, reduced subcutaneous fat stores, decreased amount of breast tissue, scaphoid abdomen, wide skull sutures, poor muscle tone over buttocks and cheeks, loose and dry skin appearing oversized, and a thin umbilical cord.

The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which of the following would the nurse correlate with this gestational age variation? A) Strong, brisk motor skills B) Difficulty in arousing to a quiet alert state C) Birth weight of 7 lb 14 oz D) Wasted appearance of extremities

Ans: B Feedback: LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb 13 oz at term.

When planning the care of a newborn addicted to cocaine who is experiencing withdrawal, which of the following would be least appropriate to include? A) Wrapping the newborn snugly in a blanket B) Waking the newborn every hour C) Checking the newborn's fontanels D) Offering a pacifier

Ans: B Feedback: Stimuli need to be decreased. Waking the newborn every hour would most likely be too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive sucking. Checking the fontanels provides evidence of hydration.

Which of the following would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A) Avoid using the terms "death" or "dying." B) Provide opportunities for them to hold the newborn. C) Refrain from initiating conversations with the parents. D) Quickly refocus the parents to a more pleasant topic.

Ans: B Feedback: When dealing with grieving parents, nurses should provide them with opportunities to hold the newborn if they desire. In addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn. These interventions help to validate the parents' sense of loss, relive the experience, and attach significance to the meaning of loss. The nurse should use appropriate terminology, such as "dying," "died," and "death," to help the parents accept the reality of the death. Nurses need to demonstrate empathy and to respect the parents' feelings, responding to them in helpful and supportive ways. Active listening and allowing the parents to vent their frustrations and anger help validate the parents' feelings and facilitate the grieving process.

A postpartum woman is having difficulty voiding for the first time after giving birth. Which of the following would be least effective in helping to stimulate voiding? A) Pouring warm water over her perineal area B) Having her hear the sound of water running nearby C) Placing her hand in a basin of cool water D) Standing her in the shower with the warm water on

Ans: C Helpful measures to stimulate voiding include placing her hand in a basin of warm water, pouring warm water over her perineal area, hearing the sound of running water nearby, blowing bubbles through a straw, standing in the shower with the warm water turned on, and drinking fluids.

After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify the development of a close emotional attraction to a newborn by parents during the first 30 to 60 minutes after birth as which of the following? A) Reciprocity B) Engrossment C) Bonding D) Attachment

Ans: C The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.

The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which of the following? A) Inability to clear fluids B) Immature respiratory control center C) Deficiency of surfactant D) Smaller respiratory passages

Ans: C Feedback: A preterm newborn is at increased risk for respiratory distress syndrome (RDS) most commonly because of a surfactant deficiency. Surfactant helps to keep the alveoli open and maintain lung expansion. With a deficiency, the alveoli collapse, predisposing the newborn to RDS. An inability to clear fluids can lead to transient tachypnea. Immature respiratory control centers lead to an increased risk for apnea. Smaller respiratory passages lead to an increased risk for obstruction.

Assessment of newborn reveals a large protruding tongue, slow reflexes, distended abdomen, poor feeding, hoarse cry, goiter and dry skin. Which of the following would the nurse suspect? A) Phenylketonuria B) Galactosemia C) Congenital hypothyroidism D) Maple syrup urine disease

Ans: C Feedback: The manifestations listed correlate with congenital hypothyroidism. With phenylketonuria, the infant appears normal at birth but by 6 months of age, signs of slow mental development are evident. Vomiting, poor feeding, failure to thrive, overactivity and musty-smelling urine are additional signs. With maple syrup urine disease, signs and symptoms include lethargy, poor feeding, vomiting, weight loss, seizures, shrill cry, shallow respirations, loss of reflexes, and a sweet maple syrup odor to the urine. With galactosemia, manifestations include vomiting, hypoglycemia, hyperbilirubinemia, poor weight gain, cataracts, and frequent infections.

A nurse is assisting the anxious parents of a preterm newborn to cope with the situation. Which statement by the nurse would be least appropriate? A) "I'll be here to help you all along the way." B) "What has helped you to deal with stressful situations in the past?" C) "Let me tell you about what you will see when you visit your baby." D) "Forget about what's happened in the past and focus on the now."

Ans: D Feedback: Instead of telling the parents to forget about what's happened, the nurse should review with them the events that have occurred since birth to help them understand and clarify any misconceptions they might have. Other helpful interventions would include telling the parents that the nurse will be with them because this provides them with a physical presence and support; asking about previous coping strategies that worked so that they can use them now; and explaining what is happening and all the equipment being used so they can understand the situation.

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Tachycardia b) Apnea c) Sleepiness d) Crying

Apnea

A newborn with high serum bilirubin is receiving phototherapy. Which of the following is the most appropriate nursing intervention for this client? a) Gentle shaking of the baby b) Delay of feeding until bilirubin levels are normal c) Placing light 6 inches above the newborn's bassinet d) Application of eye dressings to the infant

Application of eye dressings to the infant

Which of the following would lead the nurse to suspect that a postpartum woman is experiencing a problem? A) Elevated white blood cell count B) Acute decrease in hematocrit C) Increased levels of clotting factors D) Pulse rate of 60 beats/minute

B Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding. The WBC count remains elevated for the first 4 to 6 days and clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for the first two weeks reflects the decrease in cardiac output.

The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which of the following would the nurse correlate with this gestational age variation? A) Strong, brisk motor skills B) Difficulty in arousing to a quiet alert state C) Birthweight of 7 lb 14 oz D) Wasted appearance of extremities

B LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb 13 oz at term.

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate? A) "You must have an infection, so let me get a urine specimen." B) "Your body is undergoing many changes that cause your bladder to fill quickly." C) "Your uterus is not contracting as quickly as it should." D) "The anesthesia that you received is wearing off and your bladder is working again."

B Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines, the buildup and retention of extra fluids during pregnancy, and a decreasing production of aldosterone—the hormone that decreases sodium retention and increases urine production. All these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum. Rapid bladder filling, possible infection, or effects of anesthesia are not involved.

A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate? A) "You probably took iron during your pregnancy." B) "This is meconium stool, normal for a newborn." C) "I'll take a sample and check it for possible bleeding." D) "This is unusual and I need to report this."

B The mother is describing meconium. Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.

After teaching a group of nursing students about a neutral thermal environment, the instructor determines that the teaching was successful when the students identify which of the following as the newborn's primary method of heat production? A) Convection B) Nonshivering thermogenesis C) Cold stress D) Bilirubin conjugation

B The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. Convection is a mechanism of heat loss. Cold stress results with excessive heat loss that requires the newborn to use compensatory mechanisms to maintain core body temperature. Bilirubin conjugation is a mechanism by which bilirubin in the blood is eliminated.

Which of the following suggestions would be most appropriate to include in the teaching plan for a postpartum woman who needs to lose weight? a. Increase fluid intake and acid-producing foods in her diet. b. Avoid empty-calorie foods, breast-feed, increase exercise. c. Start a high-protein, low carbohydrate diet and restrict fluids. d. Eat no snacks or carbohydrates after dinner.

B. Because weight loss is based on the principle of intake of calories and output of energy, instructing this woman to avoid high-calorie foods that yield no nutritive value and expending more energy through active exercise would result in weight loss for her.

The newborn nursery nurse has admitted a large-for-gestational age infant, one hour old for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action?

Begin supervised feedings for the newborn.

A mother of a 32-week-gestation neonate is encouraged to perform kangaroo care in the neonatal intensive care unit. What would best correlate with this suggestion?

Breastfeeding attempts will be enhanced.

A 28-week-gestation newborn experienced birth asphyxia at the time of delivery. What is a long-term complication of birth asphyxia? a)Necrotizing enterocolitis b)Retinopathy of prematurity c)Intraventricular hemorrhage d)Anemia of prematurity

C Birth asphyxia will cause an insult to the brain, and more often than not will cause a bleed or intraventricular hemorrhage. Birth asphyxia is not directly correlated with NEC, retinopathy of prematurity, or anemia of prematurity. These are common for the premature infant, but not necessarily birth asphyxia.

A client states that she had a spontaneous abortion 12 months ago. The client asks if her hormones may have contributed to the loss of the pregnancy. The nurse's response is based upon her knowledge of which of the following facts? a) Implantation occurs when progesterone levels are low. b) hCG reaches a maximum level at 4 weeks gestation. c) Progesterone decreases the contractility of the uterus. d) Progesterone is only produced by the corpus luteum during pregnancy.

C Progesterone decreases the contractility of the uterus, thus preventing uterine contractions that might cause spontaneous abortion. Progesterone must be present in high levels for implantation to occur. After 10 weeks, the placenta takes over the production of progesterone. hCG reaches its maximum level at 50-70 days gestation.

The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which of the following? A) Inability to clear fluids B) Immature respiratory control center C) Deficiency of surfactant D) Smaller respiratory passages

C A preterm newborn is at increased risk for respiratory distress syndrome (RDS) because of a surfactant deficiency. Surfactant helps to keep the alveoli open and maintain lung expansion. With a deficiency, the alveoli collapse, predisposing the newborn to RDS. An inability to clear fluids can lead to transient tachypnea. Immature respiratory control centers lead to an increased risk for apnea. Smaller respiratory passages led to an increased risk for obstruction.

A group of nursing students are reviewing the changes in the newborn's lungs that must occur to maintain respiratory function. The students demonstrate understanding of this information when they identify which of the following as the first event? A) Expansion of the lungs B) Increased pulmonary blood flow C) Initiation of respiratory movement D) Redistribution of cardiac output

C Before the newborn's lungs can maintain respiratory function, the following events must occur: respiratory movement must be initiated; lungs must expand, functional residual capacity must be established, pulmonary blood flow must increase, and cardiac output must be redistributed.

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? A) Deep red, fleshy-smelling lochia B) Voiding of 350 cc C) Heart rate of 120 beats/minute D) Profuse sweating

C Tachycardia in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period.

A client at 28 weeks gestation is admitted to the labor and birth unit. Which test would most likely be used to assess the client's comprehensive fetal status? a) Ultrasound for physical structure b) Nonstress test (NST) c) Biophysical profile (BPP) d) Amniocentesis

C. Biophysical profile is a comprehensive test that would be used to assess the client's fetal status at 28 weeks gestation. Ultrasound for physical structure is limited to identifying the growth and development of the fetus, and does not assess for other parameters of fetal well-being. Women with a high-risk factor will probably begin having NSTs at 30-32 weeks gestation and at frequent intervals for the remainder of the pregnancy. Amniocentesis late in pregnancy is used to test for lung maturity, not overall fetal status in labor, and when performed earlier it is used to test for specific disorders.

The nurse is assessing Ms. Smith, who gave birth to her first child 5 days ago. What findings by the nurse would be expected? A. Cream-colored lochia; uterus above the umbilicus B. Bright-red lochia with clots; uterus 2 fingerbreadths below umbilicus C. Light pink or brown lochia; uterus 4 to 5 fingerbreadths below umbilicus D. Yellow, mucousy lochia; uterus at the level of the umbilicus

C. The nurse would expect light pink or brown lochia, and the uterus should be four to five fingerbreadths below the umbilicus.

Which of the following is an example of developmental care in the NICU? a) Giving a bath b) Cluster care and activities c) Giving medications d) Holding the infant

Cluster care and activities

What are the factors that facilitate uterine involution?

Complete expulsion of amniotic membranes and placenta at birth; complication-free labor & birth process; breastfeeding; ambulation

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? a) Evaporation b) Conduction c) Radiation d) Convection

Conduction

transfer of heat from one object to another when the two objects are in direct contact with each other

Conduction

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? a) Conduction b) Convection c) Evaporation d) Radiation

Conduction Correct Explanation: A conduction heat loss results from direct contact with an object that is cooler.

The nurse is taking an initial history of a prenatal client. Which of the following, if detected by the nurse practitioner, would indicate a positive, or diagnostic sign of pregnancy? a) Positive pregnancy test b) Goodell's sign c) Uterine enlargement and amenorrhea d) Fetal heartbeat with at Doppler at 11 weeks gestation

D The positive signs of pregnancy are completely objective, cannot be confused with a pathologic state, and offer conclusive proof of pregnancy. The fetal heartbeat can be detected with an electronic Doppler device as early as weeks 10-12 of pregnancy. Pregnancy tests detect the presence of hCG in the maternal blood or urine. These are not considered a positive sign of pregnancy because other conditions can cause elevated hCG levels. Physical changes, like Godell's sign and uterine enlargement, can also have other causes and do not confirm pregnancy. The subjective changes of pregnancy, like amenorrhea, are the symptoms the woman experiences and reports. Because they can be caused by other conditions, they cannot be considered proof of pregnancy.

After teaching a group of nursing students about the process of involution, the instructor determines that additional teaching is needed when the students identify which of the following as being involved? A) Catabolism B) Muscle fiber contraction C) Epithelial regeneration D) Vasodilation

D Involution involves three retrogressive Process: contraction of muscle fibers to reduce those previously stretched during pregnancy; catabolism, which reduces enlarged myometrial cells; and regeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed during lochial discharge. Vasodilation is not involved.

The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal? A) Prevent cold stress B) Increase surfactant levels in the lungs C) Promote respiratory stability D) Decrease the serum bilirubin level

D Jaundice reflects elevated serum bilirubin levels; phototherapy helps to break down the bilirubin for excretion. Phototherapy has no effect on body temperature, surfactant levels, or respiratory stability.

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: A) Have a smaller body surface compared to body mass B) Lose more body heat when they sweat than adults C) Have an abundant amount of subcutaneous fat all over D) Are unable to shiver effectively to increase heat production

D Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.

Which of the following would alert the nurse to the possibility of respiratory distress in a newborn? A) Symmetrical chest movements B) Periodic breathing C) Respirations of 40 breaths/minute D) Sternal retractions

D Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life.

Which of the following would alert the nurse to the possibility of respiratory distress in a newborn? A) Symmetrical chest movements B) Periodic breathing C) Respirations of 40 breaths/minute D) Sternal retractions

D Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life.

What is the correct sequence of events in a neonatal resuscitation?

Dry the infant, establish an airway, expand the lungs, and initiate ventilation.

the loss of heat when a liquid is converted to a vapor

Evaporation

After teaching a group of students about the effects of prematurity on various body systems, the instructor determines that the class was successful when the students identify which of the following as an effect of prematurity? a) Rapid glomerular filtration rate b) Enhanced ability to digest proteins c) Enlarged respiratory passages d) Fragile cerebral blood vessels

Fragile cerebral blood vessels

A client has delivered a small for gestation age (SGA) newborn. Which of the following would the nurse expect to assess? a) Protuberant abdomen b) Brown lanugo body hair c) Round flushed face d) Head larger than body

Head larger than body

A client asks the nurse what surfactant is. Which explanation would the nurse give as the main role of surfactant in the neonate? a) Helps the lungs remain expanded after the initiation of breathing b) Assists with ciliary body maturation in the upper airways c) Helps maintain a rhythmic breathing pattern d) Promotes clearing of mucus from the respiratory tract

Helps the lungs remain expanded after the initiation of breathing

The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which of the following? a) Hypoglycemia b) Polycythemia c) Asphyxia d) Meconium aspiration

Hypoglycemia

A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that he's at risk for which complication? a) Anemia b) Hypoglycemia c) Nitrogen loss d) Thrombosis

Hypoglycemia Correct Explanation: Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus through the placenta. The neonate's liver can't initially adjust to the changing glucose levels after birth. This inability may result in an overabundance of insulin in the neonate, causing hypoglycemia. Neonates of mothers with diabetes aren't at increased risk for anemia, nitrogen loss, or thrombosis.

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings does not confirm that this newborn is 12 days postmature? a) Hypoglycemia. b) Meconium aspiration. c) Absence of lanugo. d) Increased amounts of vernix.

Increased amounts of vernix.

A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) Less than 1,000 g b) Less than 1,500 g c) More than 4,000 g d) Approximately 2,500 g

Less than 1,500 g

The nurse in a newborn nursery is observing for developmentally appropriate care. Which of the following is an example of self-regulation? a) Infant is kicking feet b) Infant has hand in mouth c) Infant is quiet d) Infant is crying

Infant has hand in mouth

At the birth of a high-risk newborn, what is the nurse's priority action to prevent cerebral hypoxia?

Maintain adequate respirations.

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? a) Hyperalert state b) Jitteriness c) Loud and forceful crying d) Serum glucose level of 60 mg/dl

Jitteriness

An infant is suffering from neonatal abstinence syndrome. The nurse provides appropriate care and support for the infant during the infant's time on the unit. Besides nursing and medical care, what other step would the nurse take to support the infant?

Link the family with community sources for aid. Besides nursing care, the nurse would make sure that interdisciplinary members of team were involved such as the doctor, nutritionist, community worker or resources, and provide a supportive environment for the family and the client. The chaplain may not be support for infant or family may not be present. The bright room is overly stimulating to the withdrawing infant, and feeding is basic care.

Upon assessment, a nurse notes the client has a pulse of 90 bpm, moderate lochia, and a boggy uterus. What should the nurse do next?

Massage the client's fundus. Tachycardia and a boggy fundus in the postpartum woman indicate excessive blood loss. The nurse would massage the fundus to promote uterine involution. It is not priority to notify the healthcare provider, assess blood pressure, or change the peri-pad at this time.

The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn?

Maternal Smoking during pregnancy Asthma exacerbations during pregnancy Drug abuse

Which of the following data is indicative of hypothermia of the preterm infant?

Nasal flaring Correct Explanation: Nasal flaring is a sign of respiratory distress. Infants with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

Which of the following data is indicative of hypothermia of the preterm infant? a) Regular respirations b) Oxygen saturation of 95% c) Nasal flaring d) Pink skin

Nasal flaring Correct Explanation: Nasal flaring is a sign of respiratory distress. Infants with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

What is the first action the nurse takes in surfactant administration? a) Hold feedings. b) Call pharmacy for medication. c) Obtain and document baseline vital signs. d) Change the infant's diaper.

Obtain and document baseline vital signs. Correct Explanation: Obtaining a baseline set of vital signs is the first step in surfactant administration. The nurse will need a baseline in case there is any reaction to the medication administration. The other choices are not the first thing done before instilling this medication.

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? a) Lanugo covering the neonate's body b) A sleepy, lethargic neonate c) Vernix caseosa covering the neonate's body d) Peeling and wrinkling of the neonate's epidermis

Peeling and wrinkling of the neonate's epidermis Correct Explanation: Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.

When preparing to resuscitate a preterm newborn, which of the following would the nurse do first? a) Use positive-pressure ventilation. b) Administer epinephrine. c) Hyperextend the newborn's neck. d) Place the newborn's head in a neutral position.

Place the newborn's head in a neutral position. Correct Explanation: When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation.

The small-for-gestation neonate is at increased risk for which complication during the transitional period? a) Polycythemia probably due to chronic fetal hypoxia b) Hyperthermia due to decreased glycogen stores c) Hyperglycemia due to decreased glycogen stores d) Anemia probably due to chronic fetal hypoxia

Polycythemia probably due to chronic fetal hypoxia

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? a) Administration of chilled oxygen to reduce lung spasm b) Administration of dry oxygen to avoid over-humidification c) Increased inspiratory pressure; decreased expiratory pressure d) Positive end-expiratory pressure to increase oxygenation

Positive end-expiratory pressure to increase oxygenation

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? a) Administration of chilled oxygen to reduce lung spasm b) Positive end-expiratory pressure to increase oxygenation c) Increased inspiratory pressure; decreased expiratory pressure d) Administration of dry oxygen to avoid over-humidification

Positive end-expiratory pressure to increase oxygenation Correct Explanation: Positive end-expiratory pressure, like expiratory grunting, prevents alveoli from fully closing on expiration and reduces the respiratory effort needed for inspiration.

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. Preterm infants are able to focus at short distances before they can see well at long distances. A mobile offers short-distance stimulation.

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer? a) Radiation b) Convection c) Evaporation d) Conduction

Radiation Correct Explanation: Radiation heat loss results from the transfer of heat in an environment from warmer to cooler objects that are not in direct contact with each other.

Meconium is the first stool passed in a newborn. What would be the correct documentation of the meconium? a) Soft brown b) Sticky forest green c) Seedy yellow d) Formed green

Sticky forest green Correct Explanation: Meconium is usually a sticky, forest-green liquid. It contains bile acids, salts, and mucus. The other choices describe stool at various stages after the passage of meconium.

A danger sign is the reappearance of bright-red blood after lochia rubra has stopped. Reevaluation by a health care provider is essential if this occurs.

TRUE

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 most likely be classified as which of the following? a) Term, small for gestational age, and very-low-birth-weight infant b) Term, small for gestational age, and low-birth-weight infant c) Late preterm and appropriate for gestational age d) Late preterm, large for gestational age, and low-birth-weight infant

Term, small for gestational age, and low-birth-weight infant Correct Explanation: Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small for gestational age (SGA). Those who fall above the 90th percentile in weight are considered large for gestational age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLB). Those born weighing 500 to 1000 g are considered extremely very-low-birth-weight infants (EVLB).

Which statement describes why hypertonic contractions tend to become very painful?

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. Hypertonic contractions cause uterine cell anoxia, which is painful.

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

The pinna of the ear is soft and flat and stays folded. Correct Explanation: The ear has a soft pinna that's flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which of the following interventions should the nurse implement at this point? a) Tip the infant into an upright position b) Immediately suction the infant's airway c) Take a blood sample d) Place the infant supine in a radiant heat warmer

Tip the infant into an upright position Explanation: It's important the infant is tipped to an upright position following administration of surfactant and the infant's airway is not suctioned for as long a period as possible after administration of surfactant to help it reach lower lung areas and avoid suctioning the drug away. A blood sample may be taken to rule out a streptococcal infection, which mimics the signs of RDS, but this would have been done before administration of surfactant. The infant should not be placed supine in a radiant heat warmer at this time but should be held in an upright position.

A preterm infant is transferred to a distant hospital for care. When her parents visit her, which of the following would be most important for you to urge them to do? a) Stand so the baby can see them. b) Touch and, if possible, hold her. c) Bring a piece of clothing for her. d) Call the baby by her name.

Touch and, if possible, hold her.

In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus.

True

a nurse has placed an infant with asphyxia on a radiant warmer. Which sign indicates that the resuscitation method have been successful? A. heart rate of 80 bpm B. jitteriness C. hypotonia D. strong cry

d

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

Your infant cannot sustain respirations yet due to the lack of assistance from surfactant."

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention?

a forceps and vacuum-assisted birth A forceps-and-vacuum-assisted birth is required for the client having a prolonged second stage of labor. The client may require a cesarean birth if the fetus cannot be delivered with assistance. A precipitous birth occurs when the entire labor and birth process occurs very quickly. Artificial rupture of membranes is done during the first stage of labor.

breast crawl

a newborns instinct to move up to mothers breast with leg and arm movement. once near breast baby will bounce head to find nipple and eventually latch

Which finding would alert the nurse to suspect that a newborn has developed NEC? a) bilious vomiting b) clay-colored stools c) sunken abdomen d) irritability

a) bilious vomiting Explanation: The newborn with NEC may exhibit bilious vomiting with lethargy, abdominal distention and tenderness, and bloody stools.

A woman's prepregnant weight is within the normal range. During her second trimester, the nurse would determine that the woman is gaining the appropriate amount of weight when her weight increases by how much per week? a. 1 lb b. 2 lb c. 2/3 lb d. 1.5 lb

a. 1 lb

An 18-year-old client is being evaluated for school soccer by the school nurse. The expected weight for the young woman's height is 120 lb. Her actual weight is 96 lb. The client states that she runs 6 miles every morning and swims 5 miles every afternoon. Which of the following actions should the nurse take at this time? a. Ask the client the date of her last menstrual period. b. Encourage the client to continue her excellent exercise schedule. c. Congratulate the client on her ability to maintain such a good weight. d. Advise the client that she will have to stop swimming once soccer starts.

a. Ask the client the date of her last menstrual period.

Which of the following laboratory test results would the nurse consider as a normal finding in a newborn soon after birth? a. Hemoglobin: 17.5 g/dL b. Platelets: 400,000/uL c. White blood cells: 5,000/mm3 d. Red blood cells: 3,500,000/uL

a. Hemoglobin: 17.5 g/dL

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

a. Hypoxia

During a routine antepartal visit, a pregnant woman says, "I've noticed my gums bleeding a bit since I've become pregnant. Is this normal?" The nurse bases the response on the understanding of which of the following? a. Influence of estrogen and blood vessel proliferation b. Effects of regurgitation from relaxation of the cardiac sphincter c. Elevated progesterone levels cause smooth muscle relaxation. d. Increased venous pressure leads to increased gingival friability.

a. Influence of estrogen and blood vessel proliferation

Which factors could increase the risk of overheating in a newborn? (Select all that apply.) a. Limited ability of diaphoresis b. Underdeveloped lungs c. Isolette that is too warm d. Limited sugar stores e. Lack of brown fat

a. Limited ability of diaphoresis c. Isolette that is too warm

To properly assess for developmental dysplasia of the hip in the newborn, the nurse should perform what procedure to get the sensation of the dislocated hip going back into the acetabulum? a. Ortolani maneuver b. Barlow maneuver c. Pavlik maneuver d. Bill maneuver

a. Ortolani maneuver

In explaining how hormones affect the pregnancy, which hormone do you describe as being responsible for stimulating uterine contractions during labor and delivery? a. Oxytocin b. Estrogen c. Progesterone d. Prolactin

a. Oxytocin

A nurse is assigned to care for a newborn with high bilirubin levels. Which of the following symptoms should the nurse monitor the newborn for? a. Yellow mucous membranes b. Pinkish appearance of tongue c. Heart rate of 130 bpm d. Bluish skin discoloration

a. Yellow mucous membranes

A mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that:a. this is a normal finding.b. this is most likely a symptom of impending diarrhea.c. her child may be developing an allergy to breast milk.d. her child will need to be isolated until the stool can be cultured.

a. this is a normal finding.

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

a. within 24 hours after birth

What is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight?

ability to tolerate early oral feeding

A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication?

atelectasis

Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which of the following would the nurse be least likely to identify as a risk factor for this condition? A) Cesarean birth B) Shortened labor C) Central nervous system depressant during labor D) Maternal asthma

b Shortened labor

A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents state which of the following? A) "We can put a tiny bit of lotion on his skin and then rub it in gently." B) "We should avoid using any kind of baby powder." C) "We need to bathe him at least four to five times a week." D) "We should clean his eyes after washing his face and hair.

b. "We should avoid using any kind of baby powder."

The diagonal conjugate of a pregnant woman's pelvis is measured. Which measurement would suggest a potential problem? a. 12.5 cm b. 12.0 cm c. 13.0 cm d. 13.5 cm

b. 12.0 cm

A woman with human papilloma virus (HPV) is likely to present with which nursing assessment finding? a. Profuse, pus-filled vaginal discharge b. Clusters of genital warts c. Single painless ulcer d. Multiple vesicles on genitalia

b. Clusters of genital warts

A nurse is documenting a dietary plan for a pregnant client with pregestational diabetes. What instructions should the nurse include in the dietary plan for this client? a. Include more dairy products in the diet b. Include complex carbohydrates in the diet c. Eat only two meals per day d. Eat at least one egg per day

b. Include complex carbohydrates in the diet

A woman is using the contraceptive sponge as a birth control method. Which of the following actions is important for her to perform to maximize the sponge's effectiveness? a. Insert the sponge at least one hour before intercourse. b. Thoroughly moisten the sponge with water before inserting. c. Spermicidal jelly must be inserted at the same time the sponge is inserted. d. A new sponge must be inserted every time a couple has intercourse.

b. Thoroughly moisten the sponge with water before inserting.

When caring for a newborn, the nurse observes that the neonate has developed white patches on the mucus membranes of the mouth. Which of the following conditions is the newborn most likely to be experiencing? a. Rubella b. Thrush c. Cytomegalovirus infection d. Toxoplasmosis

b. Thrush

Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5T's tool will recognize which of the following as being a potential cause of postpartum hemorrhage? (Select all that apply.) a. Time b. Tissue c. Thrombin d. Tone e. Technique of delivery

b. Tissue c. Thrombin d. Tone

The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding?a. tan in color with a firm consistencyb. yellowy mustard color with seedy appearancec. greenish black with a tarry consistencyd. brownish black with a mucus-like appearance

b. yellowy mustard color with seedy appearance

A client breastfeeding a newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the clients condition? A. recommend a moisturizing soap to clean nipples. b. encourage use of breast pads with plastic liners c. offer suggestions based on observation to correct positioning or latching d. fasten the nursing bra flaps immediately after feeding

c offer suggestions based on observation to correct positioning or latching

After teaching a woman about hyperemesis gravidarum and how it differs from the typical nausea and vomiting of pregnancy, which statement by the woman indicates that the teaching was successful? a. "I can expect the nausea to last through my second trimester" b. "I should drink fluids with my meals instead of in between them" c. "I need to avoid strong odors, perfumes, or flavors" d. "I should lie down after I eat for about 2 hours"

c. "I need to avoid strong odors, perfumes, or flavors"

A 49-year-old client who is in the perimenopausal phase of life reports to the nurse a loss of lubrication during intercourse, which she feels is hampering her sex life. Which of the following responses is appropriate for the nurse? a. "Don't worry! This is a normal process of aging." b. "Have you considered contacting a support group for women your age?" c. "You can manage the condition by using over-the-counter (OTC) moisturizers or lubricants" d. "All you need is a positive outlook and a supportive partner."

c. "You can manage the condition by using over-the-counter (OTC) moisturizers or lubricants"

When discussing the physiologic changes that occur to new parents, the nurse explains it usually takes how long? a. First 2 to 4 hours of life b. First 8 to 12 hours of life c. First 6 to 10 hours of life d. First 4 to 6 hours of life

c. First 6 to 10 hours of life

The nurse enters the room and notes the infant is in it's bed sleeping, close to the outside window. Which action should the nurse prioritize?a. Place another blanket on the infant.b. Observe infant's status.c. Move the infant away from the window.d. Check the infant's vital signs.

c. Move the infant away from the window.

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

c. On admission to the nursery

When applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate? a. Between the scapulae b. In the mediastinal area c. Over the liver d. Over the opposite hip

c. Over the liver

Which of the following statements would the nurse include in the teaching plan for a pregnant woman related to changes in the uterus? a. The uterus reaches its maximum height in the abdomen at 39 weeks. b. The uterus moves into the abdomen by the second month of pregnancy. c. The uterus changes from a pear-shaped organ to an oval one. d. Uterine growth occurs because of an increase in the number of cells in the uterus.

c. The uterus changes from a pear-shaped organ to an oval one.

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

conduction A conduction heat loss results from direct contact with an object that is cooler.

Which factors in a maternal birth record are risks for fetal growth restriction?

congenital malformations, infections, or placental insufficiency

Fourth-degree laceration

continues through anterior rectal wall

When assessing a newborn for meconium aspiration syndrome, which of the following would be less likely to indicate this has occurred? a. Prolonged labor and delivery b. Vacuum extraction c. Maternal diabetes d. Apgar of 8

d. Apgar of 8

A pregnant woman with chronic hypertension presents challenges in controlling the hypertension and preventing additional complications. Which hypertensive medication is prescribed due to its safety record during pregnancy? a. Labetalol b. Atenolol c. Nifedipine d. Methyldopa

d. Methyldopa

As a nurse involved with community health nursing, your primary focus is primarily on: a. Providing nursing care in the local schools b. Collecting epidemiologic information c. Providing staffing support d. Preventing illnesses

d. Preventing illnesses

A nurse is working in an ambulatory health care clinic located in a poor neighborhood. Which nursing intervention would most likely provide the greatest benefit for the women and their children seen at this clinic? a. Educating the parents about preventive care b. Promoting healthy sleep and rest habits c. Cautioning them about home safety issues d. Providing them with drug samples for therapy

d. Providing them with drug samples for therapy

The physician has ordered a karyotype for a newborn. The mother questions what the type of information that will be provided by the test. What information should be included in the nurse's response? a. The karyotype will provide information about the severity of your baby's condition b. A karyotype is useful in determining the potential complications the baby may face as a result of its condition c. The karyotype will assess the baby's chromosomal makeup d. The karyotype will determine the treatment needed for the infant

d. The karyotype will determine the treatment needed for the infant

A 16-year-old woman who had unprotected intercourse 24 hours ago has entered the emergency department seeking assistance. Which of the following responses by the nurse is appropriate? a. "You can walk into your local pharmacy and buy Plan B (levonorgestrel)." b. "I am sorry but because of your age I am unable to assist you." c. "The emergency room doctor can prescribe high-dose birth control pills (BCP) for you." d. The nurse's response is dependent upon which state he or she is practicing in.

d. The nurse's response is dependent upon which state he or she is practicing in.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the a) aorta or aortic valve strictures. b) foramen ovale closes prematurely. c) pulmonary artery closes. d) ductus arteriosus remains open.

ductus arteriosus remains open.

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 premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the a) foramen ovale closes prematurely. b) ductus arteriosus remains open. c) pulmonary artery closes. d) aorta or aortic valve strictures.

ductus arteriosus remains open. Explanation: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

The nurse assesses that the fetus of a woman is in an occiput posterior position. Which description identifies the way the nurse would expect the client's labor to differ from others?

experience of additional back pain Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction birth.

source of bilirubin in new born is the ___________ of erythrocyte.

hemolysis

An infant has a grade 3 intraventricular hemorrhage (IVH). The nurse monitors the infant for which complication?

hydrocephalus

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

hypoglycemia Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.

primary body temperature regulators are located in the ___________ and the central nervous system

hypothalamus

Commonly, an ___________ is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration.

ice pack

A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?

identical The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical).

Radiation heat loss

is the loss of heat from the body surface to COOLER SOLID SURFACES NOT in direct contact but in relative proximity

The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?

jitteriness Jitteriness is evident with a newborn with hypoglycemia as well as poor feeding with feeble sucking. The newborn would have tachypnea. Jaundice is not part of the newborn hypoglycemic syndrome. Positive Moro reflex and palmar creases are normal.

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?

less than 3 hours Precipitous labor is completed in less than 3 hours.

Which finding would the nurse expect to assess in an infant with hypoglycemia?

limpness or jitteriness Hypoglycemia (reduced glucose serum level) usually presents with jitteriness.

Bilirubin is cleared from the body by:

liver

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

meconium stained fluids followed by tachypnea

nurse is caring for a newborn with meconium aspiration syndrome. Which intervention should the nurse perform when caring for this newborn?

place new born under radiant warmer oxygen therapy antibiotics

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant?

placental factors

A woman the nurse is caring for during labor is having contractions 2 minutes apart but rarely over 50 mm Hg in strength; the resting tone is high, 20 to 25 mm Hg. She asks what she can do to make contractions more effective. The nurse's best response would be that:

she needs to rest because her contractions are hypertonic. These contractions appear to be hypertonic because of the high resting tone. Hypertonic contractions occur because the uterus is being overstimulated or erratically stimulated. Rest is effective in helping contractions become more productive.

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

tea-colored urine Hyperbilirubinemia is associated with jaundice and tea-colored urine. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?

the 41-year-old client who conceived by in vitro fertilization The nurse should assess infertility treatment as a contributor to increased probability of multiple gestations. Multiple gestations do not occur with an adolescent birth; instead, chances of multiple gestations are known to increase due to the increasing number of women giving birth at older ages.

A nurse initiates bag and mask ventilation with an anesthesia bag on a newborn with no spontaneous respiratory effort. What controls the pressure of breaths delivered by an anesthesia bag?

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

The "three Cs" of choking, coughing, and cyanosis in conjunction with feeding are considered the classic signs of ________________ and ________.

tracheoesophageal fistula and atresia

A cesarean birth results in an 11-pound (5-kg) infant. The nurse assesses the infant for which complication?

transient lung fluid A large for gestational age (LGA) infant born by cesarean is at risk for transient lung fluid. Broken clavicle and diaphragmatic paralysis are birth injuries associated with a vaginal birth of an LGA infant. All LGA infants are at risk for a serum glucose 45 mg/dL (2.50 mmol/L).

PHYSIOLOGIC JAUNDICE

unconjugated hyperbilirubinemia that occurs after the first postnatal day and can last up to 1 week. Total serum bilirubin concentrations peak in the first 3 to 5 postnatal days and decline to adult values over the next several weeks.

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of:

very low birth weight. A birth weight of 1.2 kg would be classified as very low birth weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low birth weight. A birth weight between 1,000 g and 1,500 g is termed a very low birth weight. A birth weight less than 1,000 g is termed an extremely low birth weight.

An infant is born with respiratory depression. The provider begins actions to maintain effective ventilation. When would the nurse initiate chest compressions?

when the heart rate is less than 60 beats per minute

An infant is born with respiratory depression. The provider begins actions to maintain effective ventilation. When would the nurse initiate chest compressions?

when the heart rate is less than 60 beats per minute In a newborn, cardiac compressions are initiated when the heart rate is less than 60 beats per minute.

A client just delivered a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Dress the baby in a stockinette cap. b) Carry and handle the baby frequently. c) Place the baby under isolette care. d) Dress the baby to keep the body warm. e) Estimate the urinary flow by weighing the diaper.

• Dress the baby in a stockinette cap. • Place the baby under isolette care. • Estimate the urinary flow by weighing the diaper.

Which of the following would be most effective in reducing pain in the preterm newborn? Select all that apply. a) Increasing the volume on device alarms b) Using cool blankets to soothe the newborn c) Swaddling the newborn closely d) Offering a pacifier prior to a procedure e) Encouraging kangaroo care during procedures f) Removing tape quickly from the skin

• Swaddling the newborn closely • Encouraging kangaroo care during procedures • Offering a pacifier prior to a procedure