Practice questions

a. Inform the friend to directly contact the family and offer assistance to them.

A friend of the parents of a newborn with a diagnosis of congenital tracheoesophageal fistula contacts the home health nurse with an offer to help. Which is the best nursing action at this time to address the needs and rights of the family? a. Inform the friend to directly contact the family and offer assistance to them. b. Request that the friend come to the client's home during the next home health visit. c. Report the friend's call to the nurse manager for referral to the client's social worker. d. Assure the friend that there is no need for assistance since the nurse is visiting daily.

b. Administering hepatitis vaccine e. Administering hepatitis B immune globulin

A hepatitis B screen is performed on a postpartum client, and the results indicate the presence of antigens in the maternal blood. Which intervention would the nurse anticipate to be prescribed to protect the neonate? Select all that apply. a. Obtaining serum liver enzymes b. Administering hepatitis vaccine c. Supporting breast-feeding every 5 hours d. Repeating hepatitis B screen in 1 week e. Administering hepatitis B immune globulin f. Administering antibiotics while hospitalized

d. "You must have many concerns. Please ask me any questions that you have so that I can explain your infant's care."

A neonatal intensive care nurse is caring for a newborn with a suspected diagnosis of erythroblastosis fetalis. Which therapeutic statement would the nurse make to the parents at this time? a. "Your infant is very sick. The next 24 hours are the most crucial." b. "This is a common neonatal problem, so the prognosis is very good." c. "You have reason to worry but we have everything needed to care for your baby right here in this hospital." d. "You must have many concerns. Please ask me any questions that you have so that I can explain your infant's care."

d. "I will massage my breasts before feeding to stimulate letdown."

A new breast-feeding mother experiencing breast engorgement is provided with instructions regarding care for the condition. Which statement by the mother indicates to the nurse that she understands the measures that will provide comfort for the engorgement? a. "I will breast-feed using only one breast." b. "I will apply cold compresses to my breasts." c. "I will avoid the use of a bra while my breasts are engorged." d. "I will massage my breasts before feeding to stimulate letdown."

d. "Circumcision is a difficult decision. Here, read this pamphlet that discusses the pros and cons, and we will talk about any questions that you have after you read it."

A new mother is trying to decide whether to have her baby boy circumcised. The nurse would make which statement to assist the mother with making the decision? a. "Discuss the procedure with the male members of your family." b. "You know they say it prevents cancer and sexually transmitted infections, so I would definitely have my son circumcised." c. "Circumcision is a difficult decision, but your primary health care provider is the best, and it's better to get it done now than later." d. "Circumcision is a difficult decision. Here, read this pamphlet that discusses the pros and cons, and we will talk about any questions that you have after you read it."

c. Arterial blood pH increases to ≥7.35

A newborn diagnosed with respiratory distress syndrome (RDS) is prescribed surfactant replacement therapy. The nurse evaluates the infant 1 hour after the therapy and determines that the infant's condition has improved somewhat. Which finding indicates improvement? a. An audible respiratory grunt b. Gradual increase in the respiratory rate c. Arterial blood pH increases to ≥7.35 d. Fine inspiratory crackles heard over both lungs

b. Incomplete development of the anus

A newborn infant is diagnosed with imperforate anus. Which description of this disorder would the nurse provide to the parents? a. The presence of fecal incontinence b. Incomplete development of the anus c. The infrequent and difficult passage of dry stools d. Invagination of a section of the intestine into the distal bowel

d. 1 to 2 months of age and then 6 months after the initial dose

A newborn infant receives the first dose of hepatitis B vaccine within 12 hours of birth. The nurse instructs the parent regarding the immunization schedule for this vaccine and tells the parent that the second vaccine is administered at which time periods? a. 3 years of age and then during the adolescent years b. 8 months of age and then 1 year after the initial dose c. 6 months of age and then 8 months after the initial dose d. 1 to 2 months of age and then 6 months after the initial dose

b. Infertility

A newborn male infant is diagnosed with an undescended testicle (cryptorchidism), and these findings are shared with the parents. The parents ask questions about the condition. The nurse would respond to the parents that which condition can occur and have a psychosocial impact if the undescended testicle is not corrected? a. Atrophy b. Infertility c. Malignancy d. Feminization

d. "It is primarily done to reduce the possibility of transmitting an environmental infection to the infant."

A nurse working in the neonatal intensive care unit (NICU) teaches hand-washing techniques to the parents of an infant who is receiving antibiotic treatment for a neonatal infection. The nurse determines that the parents understand the primary purpose of hand washing if which statement is made? a. "It is primarily done to reduce their fears." b. "It is primarily done to minimize the spread of infection to other siblings." c. "It is primarily done to allow them an opportunity to communicate with each other and staff." d. "It is primarily done to reduce the possibility of transmitting an environmental infection to the infant."

d. Fever over 38° C (100.4° F), beginning 2 days postpartum

The nurse caring for a postpartum client should suspect that the client is experiencing endometritis if what is noted during an assessment? a. Breast engorgement b. Elevated white blood cell count c. Lochia rubra on the second day postpartum d. Fever over 38° C (100.4° F), beginning 2 days postpartum

d. evaporation

The nurse checks a newborn's axillary temperature after giving a bath. What type of heat loss may occur as a result? a. conduction b. convection c. radiation d. evaporation

c. "All newborns lack intestinal bacteria to produce this vitamin."

The nurse determines that a client understands the purpose of a phytonadione injection for her newborn when she is heard making which statement to the baby's father? a. "The baby's liver cannot produce that vitamin." b. "Most newborns need a supplement of this vitamin." c. "All newborns lack intestinal bacteria to produce this vitamin." "d. It's unusual but our baby lack's the vitamin that helps the blood to clot."

b. Encourage the parents to touch and speak to their infant.

The nurse in the newborn nursery is caring for a preterm infant. Which is the best method the nurse can implement to assist the parents with developing attachment behaviors? a. Support visits by family and friends. b. Encourage the parents to touch and speak to their infant. c. Report only positive qualities and progress to the parents. d. Provide information regarding infant development and stimulation.

b. Heel stick blood glucose

The nurse in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant whose mother is diabetic. In preparing to care for this infant, the nurse would obtain equipment to perform which diagnostic test? a. Serum insulin level b. Heel stick blood glucose c. Rh and ABO blood typing d. Indirect and direct bilirubin levels

3. Notify the primary health care provider (PHCP).

The nurse in the postpartum unit checks the temperature of a client who delivered a healthy newborn 4 hours ago. The mother's temperature is 100.8° F (38.2° C). The nurse provides oral hydration to the mother and encourages fluid intake. Four hours later, the nurse rechecks the temperature and notes that it is still 100.8° F. Which action would the nurse take at this time? 1. Document the temperature. 2. Increase the intravenous fluids. 3. Notify the primary health care provider (PHCP). 4. Continue hydration and recheck the temperature in 4 hours.

a. The infant exhibits dimpling of the cheeks. b. The infant makes smacking or clicking sounds. e. The infant falls asleep after feeding less than 5 minutes.

The nurse in the postpartum unit is assessing for signs of breast-feeding problems demonstrated by either the newborn or the mother. Which findings indicate a problem? Select all that apply. a. The infant exhibits dimpling of the cheeks. b. The infant makes smacking or clicking sounds. c. The mother's breast gets softer during a feeding. d. Milk drips from the mother's breast occasionally. e. The infant falls asleep after feeding less than 5 minutes. f. The infant can be heard swallowing frequently during a feeding.

b. Maintain intravenous site and fluids. d. Position infant in a side-lying position with a blanket roll to support the viscera. e. Keep exposed viscera covered with sterile moistened saline gauze and plastic wrap.

The nurse includes which interventions in the plan of care for a newborn diagnosed with gastroschisis? Select all that apply. a. Place infant in an open crib. b. Maintain intravenous site and fluids. c. Plan time for parents to hold the infant. d. Position infant in a side-lying position with a blanket roll to support the viscera. e. Keep exposed viscera covered with sterile moistened saline gauze and plastic wrap.

a. Naloxone

The nurse is caring for a client in labor who has butorphanol tartrate prescribed for the relief of labor pain. During the administration of the medication, the nurse would ensure that which priority item is readily available? a. Naloxone b. Meperidine hydrochloride c. An intravenous form of an antiemetic d. An intravenous solution of normal saline

c. Encouraging the mother to breast-feed the infant every 2 to 3 hours

The nurse is caring for a newly delivered breast-feeding infant. Which nursing intervention would best prevent jaundice in this infant? a. Placing the infant under phototherapy b. Keeping the infant NPO until the second period of reactivity c. Encouraging the mother to breast-feed the infant every 2 to 3 hours d. Encouraging the mother to supplement breast-feeding with formula

d. Administer prescribed anticoagulant therapy.

The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism? a. Enforce bed rest. b. Monitor the vital signs frequently. c. Assess the breath sounds frequently. d. Administer prescribed anticoagulant therapy.

a. Presence of a cephalhematoma

The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice? a. Presence of a cephalhematoma b. Infant blood type of O negative c. Birth weight of 8 pounds 6 ounces d. A negative direct Coombs' test result

c. Massage the fundus gently until it is firm.

The nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially? a. Encourage the mother to ambulate. b. Notify the primary health care provider. c. Massage the fundus gently until it is firm. d. Document fundal position, consistency, and height.

c. If casting is needed, it will begin at birth and continue for 12 weeks, at which time the condition will be reevaluated.

The nurse is creating a plan of care for a newborn diagnosed with bilateral club feet. Which information would the nurse plan to include in the parents education? a. The regimen of manipulation and casting is effective in all cases of bilateral club feet. b. Genetic testing is wise for future pregnancies because other children born to this couple may also be affected. c. If casting is needed, it will begin at birth and continue for 12 weeks, at which time the condition will be reevaluated. d. Surgery performed immediately after birth has been found to be the most effective for achieving a complete recovery.

c. The client will be able to identify measures to prevent infection.

The nurse is developing goals for the postpartum client who is at risk for uterine infection. Which goal is most appropriate for this client? a. The client will verbalize a reduction of pain. b. The client will report how to treat an infection. c. The client will be able to identify measures to prevent infection. d. The client will identify the presence of Braxton Hicks contractions.

a. Obtain the newborn infant's blood type and direct Coombs' results from the laboratory.

The nurse is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, which action would the nurse take? a. Obtain the newborn infant's blood type and direct Coombs' results from the laboratory. b. Obtain the necessary equipment from the blood bank needed for an exchange transfusion. c. Call the maintenance department and ask for a phototherapy unit to be brought to the nursery. d. Obtain a vial of vitamin K from the pharmacy and prepare to administer an injection to prevent isoimmunization.

a. Connecting the resuscitation bag to oxygen

The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the nursery. The nurse determines that which intervention is the priority? a. Connecting the resuscitation bag to oxygen b. Turning on the apnea and cardiorespiratory monitor c. Preparing for the insertion of an intravenous (IV) line with D5W d. Setting up the radiant warmer control temperature at 36.4° C (97.6° F)

c. Potential for compromised parenting

The nurse is observing the parents at the bedside of their small-for-gestational-age (SGA) infant, who was born at 27 weeks' gestation. The infant's mother states, "She is so tiny and fragile. I'll never be able to hold her with all those tubes." Considering this statement, which concern should the nurse identify for the mother? a. Impaired adjustment b. Trouble with family coping c. Potential for compromised parenting d. Difficulty understanding health concerns

c. 6

The nurse is performing a 1 minute APGAR assessment of a newborn infant. A: body pink, hands blue P: 118 bpm G: minimal response A: some flexion R: slow and irregular What is the APGAR score? a. 8 b. 7 c. 6 d. 5

a. Peeling of the skin

The nurse is performing an assessment on a postterm infant. Which physical characteristic would the nurse expect to observe in this infant? a. Peeling of the skin b. Smooth soles without creases c. Lanugo covering the entire body d. Vernix that covers the body in a thick layer

b. The woman and her family will discuss plans for going home without the infant. c. The woman and her family will express their grief about the loss of their desired infant. e. The woman and her family will contact their pastor or grief counselor for support after discharge.

The nurse is planning care for a client with an intrauterine fetal demise. Which are appropriate goals for this client? Select all that apply. a. The woman's grieving process will be limited to 6 months. b. The woman and her family will discuss plans for going home without the infant. c. The woman and her family will express their grief about the loss of their desired infant. d. The woman will recognize that thoughts of worthlessness and suicide are normal after a loss. e. The woman and her family will contact their pastor or grief counselor for support after discharge.

b. A respiratory rate of 46 breaths/min in an awake newborn

The nurse is preparing to assess the respirations of several newborns in the nursery. The nurse performs the procedure and determines that the respiratory rate is normal if which finding is noted? a. A respiratory rate of 28 breaths/min in a crying newborn b. A respiratory rate of 46 breaths/min in an awake newborn c. A respiratory rate of 65 breaths/min in a sleeping newborn d. A respiratory rate of 76 breaths/min in a newly delivered newborn

c. After stabilization of the infant during the early stages of hospitalization

The nurse is preparing to care for the mother of a preterm infant. When should the nurse plan to begin discharge planning? a. When the mother is in labor b. When the discharge date is set c. After stabilization of the infant during the early stages of hospitalization d. When the parents feel comfortable with and can demonstrate adequate care of the infant

c. Prenatal care began during the third trimester d. History of substance abuse during pregnancy e. Dietary assessment identified poor eating habits f. Spontaneous rupture of membranes 24 hours ago

The nurse is reviewing the antenatal history of a several clients in early labor. The nurse recognizes which factor documented in the history as having the potential for causing neonatal sepsis after delivery? Select all that apply. a. Of Asian heritage b. Two previous miscarriages c. Prenatal care began during the third trimester d. History of substance abuse during pregnancy e. Dietary assessment identified poor eating habits f. Spontaneous rupture of membranes 24 hours ago

b. A client with a history of previous infections c. A client who had numerous vaginal examinations f. A client who experienced prolonged rupture of the membranes

The nurse is reviewing the records of recently admitted clients to the postpartum unit. The nurse determines that which clients would have an increased risk for developing a puerperal infection? Select all that apply. a. A client who has given birth to a set of twins b. A client with a history of previous infections c. A client who had numerous vaginal examinations d. A client who has experienced three previous miscarriages e. A client who underwent a vaginal delivery of the newborn f. A client who experienced prolonged rupture of the membranes

b. "I will allow my baby to sleep through the night because rest is most important"

The nurse is teaching a mother diagnosed with diabetes mellitus who delivered a large-for-gestational-age (LGA) infant about the care of the infant. The nurse tells the mother that LGA infants appear to be more mature because of their large size, but that, in reality, these infants frequently need to be aroused to facilitate nutritional intake and attachment. Which statement by the mother indicates the need for further teaching about the care of the infant? a. "It's best to talk to babies when they are in a quiet, alert state." b. "I will allow my baby to sleep through the night because rest is most important" c. "I will breast-feed my baby every 2½ to 3 hours and will use arousal techniques." d. "I will watch my baby closely because I know that LGA babies may not be as mature concerning motor development."

b. Neonatal screening

The nurse is teaching health education classes to a group of expectant parents, and the topic is preventing cognitive impairment caused by congenital hypothyroidism. What would the nurse tell the parents is the most effective means of promoting early intervention? a. Vitamin intake b. Neonatal screening c. Adequate protein intake d. Limiting alcohol consumption

d. Apply the prescribed cleansing agent to the cord, ensuring that all areas around the cord are cleaned two to three times a day.

The nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse would instruct the mothers to take which action? a. If antibiotic ointment has been applied to the cord, it is not necessary to do anything else to it. b. All that is necessary is to wash the cord with antibacterial soap and allow it to air-dry once a day. c. Apply alcohol thoroughly to the cord, being careful not to move the cord because it will cause pain to the newborn infant. d. Apply the prescribed cleansing agent to the cord, ensuring that all areas around the cord are cleaned two to three times a day.

b. 10 to 20 mL

The nurse provides bottle-feeding instructions to the mother of a newborn infant about the amount of formula to be given, knowing that what is the approximate stomach capacity for a newborn? a. 5 to 10 mL b. 10 to 20 mL c. 30 to 90 mL d. 75 to 100 mL

d. Places a clean finger in the side of the newborn's mouth to break the suction before removing the newborn from the breast

The nurse provides instructions to a new mother who is about to breast-feed her newborn infant. The nurse observes the new mother as she breast-feeds for the first time and determines the mother needs further teaching if the new mother applies which technique? a. Turns the newborn infant on his side, facing the mother b. Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth c. Draws the newborn the rest of the way onto the breast when the newborn opens his mouth d. Places a clean finger in the side of the newborn's mouth to break the suction before removing the newborn from the breast

c. WBCs of 40,000

The nurse recognizes the following postpartum changes are normal except: a. low grade fever (<100.2) in the first 24 hours b. profuse night-time sweating in the first few days postpartum c. WBCs of 40,000 d. intense shivering in the first hour postpartum without feeling cold

a. Red

The nurse teaches a postpartum client about postdelivery lochia. The nurse determines that the education has been effective when the client says that on the second day postpartum, the lochia should be which color? a. Red b. Pink c. White d. Yellow

b. "I need to check for bleeding every hour for the first 12 hours."

The nurse teaches the mother of a newly circumcised infant about postcircumcision care. Which statement by the mother indicates an understanding of the care required? a. "I need to clean the penis every hour with baby wipes." b. "I need to check for bleeding every hour for the first 12 hours." c. "My baby will not urinate for the next 24 hours because of swelling." d. "I need to wrap the penis completely in dry sterile gauze, making sure that it is dry when I change his diaper."

a. No action is required.

The nurse, while caring for a hospitalized infant being monitored for hydrocephalus, notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which conclusion would the nurse draw? a. No action is required. b. The head of the bed needs to be lowered. c. The infant needs to be placed on nothing by mouth (NPO) status. d. The primary health care provider should be notified immediately.

d. Depression associated with the birth of a child with defects

The parents of a newborn infant diagnosed with congenital hypothyroidism and Down syndrome tell the nurse how despondent they are that their child was born with these problems. They had many plans for a normal child, and now these will need to be adjusted. On the basis of these statements, the nurse identifies which concern for the parents? a. Inability to cope with change b. Anger about lost opportunities c. Trouble adjusting to a child born with medical issues d. Depression associated with the birth of a child with defects

b. 2-day old infant born at 35 weeks c. 18 hour old SGA baby who is having difficulty breastfeeding d. a 2-day old baby diagnosed with cephalohematoma

Which infants are at greatest risk of developing physiological jaundice? a. 3-hour old infant born at term b. 2-day old infant born at 35 weeks c. 18 hour old SGA baby who is having difficulty breastfeeding d. a 2-day old baby diagnosed with cephalohematoma e. 2 hour old infant who is O- and the mother is B+ blood type

c. Pulse, 144 beats/min; respiratory rate, 48 breaths/min

Which nursing assessment findings indicate normal vital signs in a newborn infant? a. Pulse, 112 beats/min; respiratory rate, 24 breaths/min b. Pulse, 124 beats/min; respiratory rate, 28 breaths/min c. Pulse, 144 beats/min; respiratory rate, 48 breaths/min d. Pulse, 164 beats/min; respiratory rate, 55 breaths/min

a. respiratory rate of 70 c. intercostal retractions e. grunting f. nasal flaring

Which of the following findings indicate respiratory distress in the newborn when all are present simultaneously? SATA a. respiratory rate of 70 b. apnea for 10 seconds c. intercostal retractions d. acrocyanosis e. grunting f. nasal flaring

d. Direct (internal) fetal heart rate monitoring

Which procedure would be avoided in order to help prevent the transmission of the human immunodeficiency virus (HIV) from a positive pregnant mother to her fetus during the intrapartum period? a. Cesarean birth b. Epidural anesthesia c. External fetal heart rate monitoring d. Direct (internal) fetal heart rate monitoring

c. assess the perineum

If a postpartum client complains of extreme perineal pain, especially after having received pain medication, the first action by the nurse should be: a. notify the provider b. apply an ice pack to the perineum c. assess the perineum d. check the client's vital signs and fundus

b. A normal finding

On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition? a. Dehydration b. A normal finding c. Increased intracranial pressure d. Postterm by at least 2 weeks

b. the uterus should not be palpable abdominally after 2 days

Related to uterine involution, the nurse recognizes all of the following statements are true except: a. the fundus descends at a rate of about 1-2 cm every 24 hours b. the uterus should not be palpable abdominally after 2 days c. oxytocin causes the uterus to contract, causing the hemostasis of blood vessels in the uterine myometrium d. the most common causes of subinvolution are retained placental fragments and infection

b. Continuous drooling

A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis? a. Slowed reflexes b. Continuous drooling c. Diaphragmatic breathing d. Passage of large amounts of frothy stool

b. The mother begins to wash the newborn infant by starting with the eyes and face.

A postpartum nurse has instructed a new mother regarding how to bathe her newborn. The nurse demonstrates the procedure to the mother and, on the following day, asks the mother to perform the procedure. Which observation by the nurse indicates that the mother is performing the procedure correctly? a. The mother cleans the ears and then moves to the eyes and the face. b. The mother begins to wash the newborn infant by starting with the eyes and face. c. The mother washes the arms, chest, and back followed by the neck, arms, and face. d. The mother washes the entire newborn infant's body and then washes the eyes, face, and scalp.

a. Hypertension

A primary health care provider has written a prescription to administer methylergonovine maleate to a postpartum client. The nurse would contact the primary health care provider to verify the prescription if which condition is present in the mother? a. Hypertension b. Excessive lochia c. Difficulty locating the uterine fundus d. Excessive bleeding and saturation of more than one peripad per hour

a. taking in

Rubin describes one of the phases of maternal postpartum adjustment as "Mothers focus attention on themselves and their recovery needs. Mothers are dependent on others to make decisions and to care for their newborns" Which phases is she describing? a. taking in b. letting in c. talking hold d. letting go

a. Cyanosis b. Tachypnea c. Retractions d. Nasal flaring f. Grunting respirations

The nurse monitoring a preterm newborn infant for manifestations of respiratory distress syndrome (RDS) would assess the infant for which manifestations? Select all that apply. a. Cyanosis b. Tachypnea c. Retractions d. Nasal flaring e. Acrocyanosis f. Grunting respirations

d. Place the newborn on a warm crib pad.

After assisting with a vaginal delivery, what would the nurse do to prevent heat loss via conduction in the newborn? a. Wrap the newborn in a blanket. b. Close the doors to the delivery room. c. Dry the newborn with a warm blanket. d. Place the newborn on a warm crib pad.

a. high pitched shrill cry

An infant admitted to the NICU is exhibiting signs of neonatal abstinence syndrome. Which of the following behaviors would support this diagnosis? a. high pitched shrill cry b. hyper-dynamic precordium c. depressed fontanells d. excessive regurgitation

c. Inspecting the anterior fontanel for bulging

The nurse prepares to admit a newborn with spina bifida, myelomeningocele. Which nursing action is most important for the care for this infant? a. Monitoring the temperature b. Monitoring the blood pressure c. Inspecting the anterior fontanel for bulging d. Monitoring the specific gravity of the urine

c. massage the fundus

Upon examining a patient on day 2 after spontaneous vaginal delivery, a nurse finds the perineal pad to be completely saturated with bright red blood over the last 15 minutes. The priority in this scenario is: a. start a second intravenous line of NS b. notify the provider c. massage the fundus d. assess vital signs

c. Blood pressure

Methylergonovine maleate is prescribed for a woman who has just delivered a healthy newborn. Which is the priority assessment to complete before administering the medication? a. Lochia b. Uterine tone c. Blood pressure d. Deep tendon reflexes

c. we need to monitor for respiratory distress and aspiration

You are caring for a couple who has a baby with a cleft lip and palate. Which statement by the mother displays that she understands priority interventions while feeding? a. we need to monitor for jaundice b. we need to monitor for pain c. we need to monitor for respiratory distress and aspiration d. we need to monitor for hypoglycemia

b. hepatitis B

Which vaccine does the newborn receive before discharge? a. rubella b. hepatitis B c. hepatitis C d. Tdap

c. "Notify your primary health care provider because you may need medication."

A 10-day postpartum breast-feeding client telephones the postpartum unit reporting a reddened, painful breast and elevated temperature. Based on assessment of the client's complaints, which action would the nurse tell the client to do? a. "Breast-feed only with the unaffected breast." b. "Stop breast-feeding because you probably have an infection." c. "Notify your primary health care provider because you may need medication." d. "Continue breast-feeding since this is a normal response in breast-feeding mothers."

b. prevent conjunctivitis c. prevent complications associated with gonorrhea e. prevent neonatal blindness

Erythromycin eye ointment is administered to newborns after delivery to help which of the following? SATA a. treat discharge from leaking from the eyes b. prevent conjunctivitis c. prevent complications associated with gonorrhea d. prevent GBS infections vertically transmitted from the mother e. prevent neonatal blindness

b. Blood glucose levels

The nurse developing a plan of care for a postterm small-for-gestational-age (SGA) newborn would identify which assessment as the priority to monitor? a. Urinary output b. Blood glucose levels c. Total bilirubin levels d. Hemoglobin and hematocrit

b. given to prevent hemorrhage due to lack of vitamin K in the gut

What is the purpose of giving newborns vitamin K/phytonadione? a. it helps newborns create intestinal bacteria b. given to prevent hemorrhage due to lack of vitamin K in the gut c. it aids in the digestion of the baby's first feed d. given to enhance newborn immunity

c. hypertension

Which is not an anticipated outcome of cold stress? a. hypoglycemia b. respiratory distress c. hypertension d. lethargy

b. Absence of fever

A goal for a postpartum client states, "The client will remain free of infection during her hospital stay." Which assessment data would support that the goal has been met? a. Normal appetite b. Absence of fever c. Minimal vaginal bleeding d. Moderate breast tenderness

b. Taking acetylsalicylic acid (aspirin)

A postpartum client recovering from disseminated intravascular coagulopathy is to be discharged on low dosages of an anticoagulant medication. What action would the nurse encourage the client to avoid? a. Brushing her teeth b. Taking acetylsalicylic acid (aspirin) c. Walking long distances and climbing stairs d. All activities because bruising injuries can occur

d. "I have a car seat that I will put in the front seat to keep my baby safe."

A 17-year-old client is discharged to home with her newborn baby after the nurse provides information about home safety for children. Which statement by the client should alert the nurse that further teaching is required regarding home safety? a. "I can keep my aluminum pots and pans in my lower cabinets." b. "I will not use the microwave oven to heat my baby's formula." c. "I have locks on all my cabinets that contain my cleaning supplies." d. "I have a car seat that I will put in the front seat to keep my baby safe."

d. High-pitched cry, drinking 10 to 15 mL of formula per feeding

A 24-hour-old term infant had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for follow-up? a. Weight loss of 4 ounces and dry, peeling skin b. Blood glucose level of 40 mg/dL (2.28 mmol/L) before the last feeding c. Breast-feeding for 20 minutes or more, with strong sucking d. High-pitched cry, drinking 10 to 15 mL of formula per feeding

a. Promote fetal lung maturity.

A 30-week-gestation client admitted in preterm labor is prescribed betamethasone. What would the nurse tell the client is the purpose for this medication? a. Promote fetal lung maturity. b. Delay delivery for at least 48 hours. c. Stop the premature uterine contractions. d. Prevent premature closure of the ductus arteriosus.

d. Premature rupture of the membranes

A client at 35 weeks' gestation reports a sudden discharge of fluid from the vagina. Based on the data provided, which condition would the nurse suspect? a. Miscarriage b. Preterm labor c. Intrauterine fetal demise d. Premature rupture of the membranes

c. "You will be at risk for developing gestational diabetes with your next pregnancy and also for developing diabetes mellitus."

A postpartum client with a diagnosis of gestational diabetes is scheduled for discharge. During the discharge teaching, the client asks the nurse, "Do I have to worry about this diabetes anymore?" Which is the most appropriate response by the nurse? a. "Your blood glucose level is within normal limits now, so you will be all right." b. "You will have to worry about the diabetes only if you become pregnant again." c. "You will be at risk for developing gestational diabetes with your next pregnancy and also for developing diabetes mellitus." d. "When you have gestational diabetes, you have diabetes forever, and you must be treated with medication for the rest of your life."

d. Dark red-colored lochia

A postpartum nurse caring for a client who delivered vaginally 2 hours ago palpates the fundus and notes the character of the lochia. Which characteristic of the lochia would indicate to the nurse that the client's recovery is normal? a. Pink-colored lochia b. White-colored lochia c. Serosanguineous lochia d. Dark red-colored lochia

d. Avoid maternal or infant injury caused by the potential for syncope or overexertion.

After delivery, the postpartum nurse instructs the client with known cardiac disease to call for the nurse when she needs to get out of bed or when she plans to care for her newborn infant. Which rationale is the basis for these instructions? a. Help the mother assume the parenting role. b. Minimize the potential of postpartum hemorrhage. c. Provide an opportunity for the nurse to teach newborn infant care techniques. d. Avoid maternal or infant injury caused by the potential for syncope or overexertion.

b. assess the respiratory rate

An infant born at 35 weeks experiences grunting in the newborn nursery. What action is the priority? a. place pacifier in the baby's mouth b. assess the respiratory rate c. have the mother breastfeed the infant d. assess the infant's pulse

d. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool.

An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching condition-specific care, which action would the nurse instruct the mother to take to minimize the infant's risk for condition-related injury? a. Check the anterior fontanel for bulging and the sutures for widening each day. b. Feed the infant in an upright position with the head and chest tilted slightly back to avoid aspiration. c. Feed the infant with a special nipple and burp the infant frequently to decrease the tendency to swallow air. d. Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool.

d. Tachycardia

The nurse is monitoring a client whose membranes ruptured and is now receiving an oxytocin infusion for the induction of labor. The nurse would suspect water intoxication if which sign or symptom is noted? a. Fatigue b. Lethargy c. Sleepiness d. Tachycardia

a. "All babies have individual needs."

The mother of a newborn diagnosed with hydrocephalus is concerned about the complication of mental retardation. The mother states to the nurse, "I'm not sure if I can care for my baby at home." Which therapeutic response would the nurse make to the mother? a. "All babies have individual needs." b. "Mothers instinctively know what is best for their babies." c. "You have concerns about your baby's condition and care?" d. "There is no reason to worry. You have a good pediatrician."

d. Test for equality of extremity reflexes.

The newborn nursery nurse is performing an admission assessment on a newborn with the diagnosis of cephalohematoma. Which intervention would the nurse implement to assess for the primary symptom associated with subdural hematoma? a. Monitor the urine for blood. b. Monitor the urinary output pattern. c. Test for contractures of the extremities. d. Test for equality of extremity reflexes.

b. 140 beats/min

The nurse assessing the apical heart rates of several different newborn infants notes that which heart rate is normal for this newborn population? a. 90 beats/min b. 140 beats/min c. 180 beats/min d. 190 beats/min

a. Changes in vital signs

The nurse caring for a client who recently received an epidural anesthesia for a vaginal delivery suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma? a. Changes in vital signs b. Signs of vaginal bruising c. Client reporting a tearing sensation d. Client reporting intense vaginal pressure

a. Notify the primary health care provider.

While obtaining the vital signs on a mother who delivered a healthy newborn 2 hours ago the nurse notes that the mother's temperature is 102° F (38.8° C). Which is the appropriate nursing action at this time? a. Notify the primary health care provider. b. Remove the blanket from the client's bed. c. Document the finding and recheck the temperature in 4 hours. d. Administer acetaminophen and recheck the temperature in 4 hours.

a. "I can show you how to gently stroke the face and not cause pain."

A client has just delivered a large-for-gestational-age (LGA) infant by the vaginal route. The client verbalizes concern regarding the infant's facial bruising and causing pain to the site if touched. Which therapeutic statement would the nurse make to alleviate the client's concerns? a. "I can show you how to gently stroke the face and not cause pain." b. "It is a normal finding in large babies and nothing to be concerned about." c. "The bruising is caused by polycythemia, which usually leads to jaundice." d. "Because the bruising is painful, it is advisable that you not touch the baby's face."

b. Grief

A client has just given birth to a newborn who has a cleft lip and palate. When planning to talk with the client, the nurse recognizes that the client needs to first work through which emotion before maternal bonding can occur? a. Guilt b. Grief c. Anger d. Depression

c. "You have concerns about how HIV will affect your baby?"

A client who is in labor has human immunodeficiency virus (HIV) and states to the nurse, "I know I will have a sick-looking baby." Which appropriate therapeutic response would the nurse make? a. "You are very sick, but your baby may not be." b. "All babies are beautiful. I am sure your baby will be too." c. "You have concerns about how HIV will affect your baby?" d. "There is no reason to worry. Our neonatal unit offers the latest treatments available."

b. Prevent postpartum hemorrhage.

A new mother was administered methylergonovine maleate intramuscularly after delivery. The nurse understands that this medication was administered for which action? a. Decrease uterine contractions. b. Prevent postpartum hemorrhage. c. Maintain a normal blood pressure. d. Reduce the amount of lochia drainage.

d. Erythromycin

A nursing childbirth educator tells a class of expectant parents that it is standard routine to instill the ophthalmic ointment form of which medication into the eyes of a newborn infant as a preventive measure against ophthalmia neonatorum? a. Penicillin b. Neomycin c. Vitamin K d. Erythromycin

a. At the umbilicus

Twelve hours after delivery, the nurse assesses the client for uterine involution. The nurse determines that the uterus is progressing normally toward its prepregnancy state when palpation of the client's fundus is at which level? a. At the umbilicus b. One finger breadth below the umbilicus c. Two finger breadths below the umbilicus d. Midway between the umbilicus and the symphysis pubis

d. "I need to position my infant with her ear, shoulder, and hip in straight alignment and place her stomach against me."

When a breast-feeding mother reports experiencing nipple soreness, the nurse provides teaching regarding measures to relieve the soreness. Which statement by the mother indicates an understanding of the teaching? a. "I need to avoid rotating breast-feeding positions so that the nipple will toughen." b. "I need to stop nursing during the period of nipple soreness to allow the nipples to heal." c. "I need to nurse less frequently and substitute a bottle feeding until the nipples become less sore." d. "I need to position my infant with her ear, shoulder, and hip in straight alignment and place her stomach against me."

d. "I need to prevent becoming pregnant for 2 to 3 months after the vaccination."

When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication? a. "I need to stay out of the sunlight for 3 days." b. "The injection site may itch, but I can scratch it if I need to." c. "I need to avoid sexual intercourse for 2 to 3 days after the vaccination." d. "I need to prevent becoming pregnant for 2 to 3 months after the vaccination."

b. At the level of the umbilicus

When performing an assessment on a mother who just delivered a healthy newborn, the nurse would expect to note that the fundus is positioned at which location? a. To the right of the abdomen b. At the level of the umbilicus c. Above the level of the umbilicus d. One fingerbreadth above the symphysis pubis

b. Hoarse cry c. Bradycardia d. Constipation f. Excessive sleeping

Which clinical manifestations are observed in infants who have been diagnosed with congenital hypothyroidism? Select all that apply. a. Irritability b. Hoarse cry c. Bradycardia d. Constipation e. Fused fontanels f. Excessive sleeping

a. frequent feedings

Which of the following is not a risk factor associated with mastitis? a. frequent feedings b. cracked nipples c. fatigue d. inadequate emptying of the breast