Pregnancy Complications Practice Question (Test #5, Fall 2020)

A woman is receiving Paxil (paroxetine) for postpartum depression. To prevent a drug-food interaction, the client must be advised to refrain from consuming which of the following? 1. Alcohol. 2. Grapefruit. 3. Milk. 4. Cabbage.

1 1. Clients should be warned about consuming alcohol when taking Paxil. 2. Grapefruit is not contraindicated for clients who have been prescribed Paxil. 3. Milk is not contraindicated for clients who have been prescribed Paxil. 4. Cabbage is not contraindicated for clients who have been prescribed Paxil. TEST-TAKING TIP: Paxil is an antidepressant. Although the concurrent use of alcohol and Paxil has not been shown to adversely affect clients' abilities, it is advised that alcohol not be consumed while taking the medication. Some clients have actually reported that they experienced a craving for alcohol while taking the medication.

The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication? 1. Inhibit the mother's active immune response. 2. Aggressively destroy the Rh antibodies produced by the mother. 3. Prevent fetal cells from migrating throughout the mother's circulation. 4. Change the maternal blood type to Rh-positive.

1 1. The goal of the injection of RhoGAM is to inhibit the mother's immune response. 2. Immune globulin is composed of antibodies. When a client receives RhoGAM, she receives passive antibodies to inhibit her immune response. 3. Passive antibodies cannot prevent the migration of fetal cells throughout the mother's bloodstream. 4. A client's blood type is determined by her DNA. RhoGAM cannot change a client's DNA. TEST-TAKING TIP: When a client receives RhoGAM, she receives passive Rh antibodies. If any Rh antigen is circulating in the mother's bloodstream, the antibodies will destroy it. As a result, there will be no antigen in the mother's body to stimulate her mast cells to have an active antibody response. In essence, therefore, RhoGAM is injected to inhibit the client's immune response.

A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho (D) immune globulin (RhoGAM). The nurse should administer the medication within which of the following time frames after birth? 1.8 hours. 2.24 hours. 3.72 hours. 4.96 hours.

3 For maximum effectiveness, RhoGAM should be administered within 72 hours postpartum. Most Rh-negative clients also receive RhoGAM during the prenatal period at 28 weeks' gestation and then again after birth. The drug is given to Rh-negative mothers who have a negative Coombs test and give birth to Rh-positive neonates. If there is doubt about the fetus's blood type after pregnancy is terminated, the mother should receive the medication.

A multiparous client who has a neonate diagnosed with hemolytic disease of the newborn asks the nurse why the neonate has developed this problem. Which of the following responses by the nurse would be most appropriate? 1."You are Rh positive and the baby is Rh negative." 2."You and the baby are both Rh negative." 3."You are Rh negative and the baby is Rh positive." 4."The baby and you are both Rh positive.

3 Hemolytic disease of the newborn is associated with Rh problems. Hemolytic disease of the newborn occurs most commonly when the mother is Rh-negative the infant is Rh-negative. About 13% of Caucasians, 7% to 8% of people of African descent, and 1% of people of Asian descent are Rh-negative. Rh-positive cells enter the mother's Rh-negative bloodstream, and antibodies to the Rh-positive cells are produced. In a subsequent pregnancy, the antibodies cross the placenta to the Rh-positive fetus and begin the destruction of Rh-positive cells through hemolysis. This results in severe fetal anemia

A neonate is under phototherapy for elevated bilirubin levels. The baby's stools are now loose and green. Which of the following actions should the nurse take at this time? 1. Discontinue the phototherapy. 2. Notify the healthcare practitioner. 3. Take the baby's temperature. 4. Assess the baby's skin integrity.

4 1. The stools are green from the increase in excreted bilirubin. 2. There is no need to inform the healthcare practitioner. Green stools are an expected finding. 3. Although green stools can be seen with diarrheal illnesses, in this situation, the green stools are expected and not related to an infectious state. 4. The stools can be very caustic to the baby's delicate skin. The nurse should cleanse the area well and inspect the skin for any sign that the skin is breaking down. TEST-TAKING TIP: The test taker must know the difference between signs that are normal and those that reflect a possible illness. Although green stools can be seen with diarrheal illnesses, in this situation, the green stools are expected. The green stools are due to the increased bilirubin excreted and not related to an infectious state.

A baby born addicted to cocaine is being given oral morphine. The nurse knows that which of the following are the main reasons for its use? Select all that apply. 1. Oral morphine contains no alcohol. 2. Oral morphine helps to correct the diarrhea. 3. Oral morphine is nonsedating. 4. Oral morphine improves respiratory effort. 5. Oral morphine helps to control seizures

1,2,5 1. This statement is correct. While older medications, for example, paregoric, were effective, they contained alcohol. Oral morphine does not. 2. This statement is correct. Oral morphine does help to correct the diarrhea. 3. This statement is false. Oral morphine is sedating. 4. Oral morphine can adversely affect the neonate's respiratory effort. Some babies develop apnea spells when treated with oral morphine. 5. This statement is correct. Oral morphine helps to control seizures. TEST-TAKING TIP: Oral morphine, a liquid medication, is an especially effective therapy for a baby who is experiencing severe neonatal abstinence syndrome. The narcotic relieves the cravings that the baby has for the addicted drug as well as minimizing many of the baby's adverse symptoms such as diarrhea, poor feeding, seizures, and the like. Other medications that have been administered to affected neonates are methadone, phenobarbital, clonidine, and buprenorphine

A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin (RHIG) injection for which of the following reasons? 1.To prevent Rh-positive sensitization with the next pregnancy. 2.To provide active antibody protection for this pregnancy. 3.To decrease the amount of Rh-negative sensitization for the next pregnancy. 4.To destroy fetal Rh-positive cells during the next pregnancy.

1. The purpose of the RhoGAM is to provide passive antibody immunity and prevent Rh-positive sensitization with the next pregnancy. It should be given within 72 hours after birth of an Rh-positive neonate. Clients who are Rh-negative and conceive an Rh-negative fetus do not need antibody protection. Rh-positive cells contribute to sensitization, not Rh-negative cells. The RhoGAM does not cross the placenta and destroy fetal Rh-positive cells.

A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.

2 1. Athough there is evidence that some fathers experience postpartum depression during the months following a birth, fathers have not been shown to experience postpartum blues. 2. This information is correct. The blues usually resolve within 2 weeks of delivery. 3. Medications are usually not administered to relieve postpartum blues. Medications can be prescribed for clients who experience postpartum depression or postpartum psychosis. 4. This information is incorrect. The majority of women will experience postpartum blues during the first week or two postpartum. TEST-TAKING TIP: There are three psychological changes that mothers may experience postpartum: postpartum blues, postpartum depression, and postpartum psychosis. Postpartum blues is a normal phenomenon experienced by the majority of women and is related to fatigue, hormonal shifts, and the enormous responsibility of becoming a mother. Postpartum depression and postpartum psychosis are pathological conditions that only some women experience.

An ultrasound is being done on an Rh-negative woman. Which of the following pregnancy findings would indicate that the baby has developed erythroblastosis fetalis? 1. Caudal agenesis. 2. Cardiomegaly. 3. Oligohydramnios. 4. Hyperemia.

2 1. Caudal agenesis is a severe birth defect that can result from maternal hyperglycemia in early pregnancy. 2. Cardiomegaly is one of the common signs of erythroblastosis fetalis. 3. The nurse would expect to see polyhydramnios, not oligohydramnios. 4. Hyperemia is not related to erythroblastosis fetalis or Rh incompatibility. TEST-TAKING TIP: Erythroblastosis fetalis is the fetal condition that results when an Rh − mother who is sensitized to Rh+ blood is pregnant with an Rh+ baby. Maternal antibodies cross the placenta and destroy the fetal red blood cells. As a result, the baby becomes severely anemic. Cardiomegaly is one of the complications that occurs as a result of the severe anemia.

A woman with postpartum depression has been prescribed Zoloft (sertraline) 50 mg daily. Which of the following should the client be taught about the medication? 1. Chamomile tea can potentiate the effect of the drug. 2. Therapeutic effect may be delayed a week or more. 3. The medication should only be taken whole. 4. A weight gain of up to ten pounds is commonly seen.

2 1. Chamomile tea has not been shown to potentiate the effect of Zoloft but St. John's wort has. 2. The therapeutic effect of selective serotonin reuptake inhibitors (SSRIs) like Zoloft is delayed about 1 to 2 weeks from the time the medication is initiated. 3. This response is incorrect. The medication can be crushed. 4. A 10-lb weight gain is not associated with the medication. TEST-TAKING TIP: Clients who receive medications for emotional problems as well as for physiological complaints expect to experience resolution of their symptoms in a timely fashion. If postpartum depression clients are not forewarned of the delay of the therapeutic effects, they may stop taking the medications prematurely, believing that the medicines are useless.

An infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. The nurse should monitor this baby carefully for which of the following? 1. Jaundice. 2. Jitters. 3. Erythema toxicum. 4. Subconjunctival hemorrhages

2 1. Jaundice is not related to blood glucose levels. 2. Babies who are hypoglycemic will often develop jitters (tremors). 3. Erythema toxicum is the newborn rash. It is unrelated to blood glucose levels. 4. Subconjunctival hemorrhages are often evident in neonates. They are related to the trauma of delivery, not to blood glucose levels. TEST-TAKING TIP: The normal glucose level for neonates in the immediate postdelivery period—approximately 40 to 90 mg/dL—is less than that seen in older babies and children. Jitters—related to central nervous system irritability—are the classic symptom of hypoglycemia in the neonate.

A newborn nursery nurse notes that a 36-hour-old baby's body is jaundiced. Which of the following nursing interventions will be most therapeutic? 1. Maintain a warm ambient environment. 2. Have the mother feed the baby frequently. 3. Have the mother hold the baby skin to skin. 4. Place the baby naked by a closed sunlit window.

2 1. The ambient temperature will affect the baby's temperature, but it will not affect the bilirubin level. 2. Bilirubin is excreted through the bowel. The more the baby consumes, the more stools she or he will produce; in other words, the more feces the baby excretes, the more bilirubin the baby will expel. 3. Holding the baby skin to skin has no direct effect on the bilirubin level. 4. The bilirubin levels of babies exposed to direct sunlight will drop. It is unsafe, however, to expose a baby's skin to direct sunlight. TEST-TAKING TIP: This is one example of a change in practice that has occurred because of updated knowledge. In the past, babies have been placed in sunlight to reduce their bilirubin levels, but that practice is no longer considered to be safe. It is important, therefore, for the test taker to be up to date on current practice.

At 28 weeks' gestation, an Rh-negative woman receives RhoGAM. Which of the following would indicate that the medication is effective? 1. The baby's Rh status changes to Rh-negative. 2. The mother produces no Rh antibodies. 3. The baby produces no Rh antibodies. 4. The mother's Rh status changes to Rh-positive.

2 1. The baby's Rh status cannot change. 2. That the mother produces no Rh antibodies is the goal of RhoGAM administration. 3. The baby will not produce antibodies. 4. The mother's Rh status cannot change. TEST-TAKING TIP: The test taker should review the immune response to an antigen. In this situation, the antigen is the baby's Rh+ blood. It can leak into the maternal bloodstream from the fetal bloodstream at various times during the pregnancy. Most commonly it happens at the time of placental delivery. Because the mother is antigen negative—that is, Rh-, when exposed to Rh+ blood, her immune system develops antibodies. RhoGAM is composed of Rh+ antibodies. It acts as passive immunity. Because antibodies are already present in the mother's bloodstream, her immune system is suppressed and fails to develop antibodies via the active immune response.

An 18-hour-old baby with an elevated bilirubin level is placed under the bili-lights. Which of the following is an expected nursing action in these circumstances? 1. Give the baby oral rehydration therapy in place of all feedings. 2. Rotate the baby from side to back to side to front every two hours. 3. Apply restraints to keep the baby under the light source. 4. Administer intravenous fluids via pump per doctor orders.

2 1. The neonate needs nourishment with formula and/or breast milk. 2. Rotating the baby's position maximizes the therapeutic response because the more skin surface that is exposed to the light source, the better the results are. 3. It is unnecessary to restrain the baby while under the bili-lights. 4. Intravenous fluids would be administered only under extreme circumstances. TEST-TAKING TIP: Bilirubin levels decrease with exposure to a light source. The more skin surface that is exposed, the more efficient the therapy is. Although fluids are needed to maintain hydration and to foster stooling, oral rehydration therapy is nutritionally insuffi cient.

A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz, 21 inches long, TPR: 96.6°F/35.9°C, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following nursing actions is of highest importance? 1. Swaddle the baby to provide warmth. 2. Assess the glucose level of the baby. 3. Take the baby to the mother for feeding. 4. Administer the neonatal medications.

2 1. This baby is hypothermic, but the best intervention would be to place the baby under a warmer rather than to swaddle the baby. Plus, the baby's glucose levels must be assessed to determine whether or not this baby is hypoglycemic. The glucose can be evaluated while the baby is under the warmer. 2. The glucose level should be assessed to determine whether or not this baby is hypoglycemic. 3. A feeding will elevate the glucose level if it is below normal. The nurse does need to assess the level, however, to make a clear determination of the problem. 4. The administration of the neonatal medicines is not a priority at this time. TEST-TAKING TIP: The test taker should note that this baby is macrosomic and hypothermic, both of which make the baby at high risk for hypoglycemia. Plus, jitters are a classic symptom in hypoglycemic babies. To make an accurate assessment of the problem, the baby's glucose level must be assessed.

A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O- (negative), the baby's type is A+ (positive), and the direct Coombs test is negative. Which of the following actions by the nurse is appropriate? 1. Advise the client to keep her physician appointment at the end of the week to receive her RhoGAM injection. 2. Make sure that the client receives a RhoGAM injection before she is discharged from the hospital. 3. Notify the client that because her baby's Coombs test was negative she will not receive an injection of RhoGAM. 4. Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.

2 1. This response is incorrect. RhoGAM must be administered within 72 hours of delivery. 2. This response is correct. The nurse should not finalize an Rh- (negative) client's discharge until the client has received her RhoGAM injection. 3. This response is incorrect. A negative direct Coombs test means that no maternal antibodies were detected in the baby's circulatory system. The nurse would expect to detect a negative direct Coombs test. 4. This response is unacceptable. Rh- (negative) clients should receive their RhoGAM injection before 72 hours postpartum or by discharge, whichever is earlier. TEST-TAKING TIP: The administration of RhoGAM is the only way to prevent an Rh- (negative) client's body from mounting a full antibody response to the delivery of an Rh+ (positive) baby. It is malpractice for a nurse to discharge the client before she receives her injection or to delay the injection beyond the 72-hour deadline

A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotics during her pregnancy. A primary nursing intervention when caring for a drug-exposed neonate is to: 1.Assess vital signs including blood pressure every hour. 2.Minimize environmental stimuli. 3.Place the infant in a well-lighted area for observation. 4.Provide stimulation to increase adaptation to the environment.

2 A quiet environment with decreased stimulation is the best treatment for a drug-exposed neonate. The drug-exposed neonate has limited ability to deal with stress and cope with stimuli. Assessing vital signs with blood pressure every hour will disturb the neonate's rest periods and cause increased physical and psychological demands. Placement in a well-lighted or stimulating environment is overwhelming for the neonate and will increase the neonate's stress level.

A woman who is Rh-negative has given birth to an Rh-positive infant. The nurse explains to the client that she will receive Rho (D) Immune Globulin (RhoGAM). The nurse determines that the client understands the purpose of RhoGAM when she states: 1."RhoGAM will protect my next baby if it is Rh-negative." 2."RhoGAM will prevent antibody formation in my blood." 3."RhoGAM will be given to prevent German measles." 4."RhoGAM will be used to prevent bleeding in my newborn.

2 RhoGAM is given to new mothers who are Rh-negative and not previously sensitized and who have given birth to an Rh-positive infant. RhoGAM must be given within 72 hours of the birth of the infant because antibody formation begins at that time. The vaccine is used only when the mother has borne an Rh-positive infant—not an Rh-negative infant. RhoGAM does not prevent German measles and is not given to a newborn.

A client at 4 weeks postpartum tells the nurse that she can't cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider because the mother should be evaluated further for: 1.Postpartum blues. 2.Postpartum depression. 3.Poor bonding. 4.Infant abuse.

2 The client is experiencing and verbalizing signs of postpartum depression, which usually appears at about 4 weeks postpartum but can occur at any time within the first year after birth. It is more severe and lasts longer than postpartum blues, also called "baby blues." Baby blues are the mildest form of depression and are seen in the later part of the first week after birth. Symptoms usually disappear shortly. Depression may last several years and is disabling to the woman. Poor bonding may be seen at any time but commonly becomes evident as the mother begins interacting with the infant shortly after birth. Infant abuse may take the form of neglect or injuries to the infant. A depressed mother is at risk for injuring or abusing her infant.

A 6-month-old child developed kernicterus immediately after birth. Which of the following tests should be done to determine whether or not this child has developed any sequelae to the illness? 1. Blood urea nitrogen and serum creatinine. 2. Alkaline phosphatase and bilirubin. 3. Hearing testing and vision assessment. 4. Peak expiratory flow and blood gas assessments.

3 1. Blood urea nitrogen and serum creatinine tests are done to assess the renal system. Kernicterus does not affect the renal system. It results from an infiltration of bilirubin into the central nervous system. 2. Although alkaline phosphatase and bilirubin would be evaluated when a child is jaundiced, they are not appropriate to assess a child's sequelae to kernicterus. 3. Because the central nervous system (CNS) may have been damaged by the high bilirubin levels, testing of the senses as well as motor and cognitive assessments are appropriate. 4. The respiratory system is unaffected by high bilirubin levels. TEST-TAKING TIP: Kernicterus is the syndrome that develops when a neonate is exposed to high levels of bilirubin over time. The bilirubin crosses the blood-brain barrier, often leading to toxic changes in the CNS. The term sequelae refers to the disorders that result after an individual has experienced a disease or injury.

A full-term baby's bilirubin level is 12 mg/dL on day 3. Which of the following neonatal behaviors would the nurse expect to see? 1. Excessive crying. 2. Increased appetite. 3. Lethargy. 4. Hyperreflexia.

3 1. Excessive crying is not a symptom of hyperbilirubinemia. 2. Babies often feed poorly when their bilirubin levels are elevated. 3. Lethargy is one of the most common early symptoms of hyperbilirubinemia. 4. Hyperreflexia is seen with prolonged periods of markedly elevated serum bilirubin. TEST-TAKING TIP: The test taker should be familiar with the normal bilirubin values of the healthy full-term baby (less than 2 mg/dL in cord blood to approximately 12 to 14 mg/dL on days 3 to 5) as well as those values that may result in kernicterus—a disease characterized by an infiltration of bilirubin into neural tissue. When bilirubin levels rise, babies will exhibit some neurological depression, such as lethargy and poor feeding. When levels are markedly elevated, permanent brain damage can result.

The nurse should expect to observe which behavior in a 3-week-multigravid postpartum client with postpartum depression? 1. Feelings of infanticide. 2. Difficulty with breastfeeding latch. 3. Feelings of failure as a mother. 4. Concerns about sibling jealousy.

3 1. Feelings of infanticide are rare in clients diagnosed with postpartum depression. 2. Difficulty latching babies to the breast is an independent problem from postpartum depression. Some mothers with depression are successful breastfeeders, while some mothers who do not experience depression have difficulty latching their babies to the breast. 3. Mothers who experience postpartum depression often do feel like failures. 4. Concerns about sibling rivalry are not related to postpartum depression. TEST-TAKING TIP: If a mother who is diagnosed with postpartum depression does have difficulty latching her baby to the breast, she may view this as yet another example of her poor parenting skills. The difficulty itself, however, is unrelated to the diagnosis.

There is a baby in the neonatal intensive care unit (NICU) who is exhibiting signs of neonatal abstinence syndrome. Which of the following medications is contraindicated for this neonate? 1. Morphine. 2. Methadone. 3. Narcan. 4. Phenobarbital.

3 1. Morphine is an opiate narcotic. It may be administered to an addicted baby to control diarrhea associated with neonatal abstinence syndrome. 2. Methadone may be administered to neonates who are exhibiting signs of severe neonatal abstinence syndrome. 3. Narcan is an opiate-antagonist. If it were to be given to the neonate with neonatal abstinence syndrome, the baby would go into a traumatic withdrawal. 4. Phenobarbital is sometimes administered to drug-exposed neonates to control seizures. TEST-TAKING TIP: "Neonatal abstinence syndrome" is the term used to describe the many behaviors exhibited by neonates who are born drug addicted. The behaviors range from hyperrefl exia to excessive sneezing and yawning to loose diarrheal stools. Medications may or may not be administered to control the many signs/symptoms of the syndrome.

A woman is to receive RhoGAM at 28 weeks' gestation. Which of the following actions must the nurse perform before giving the injection? 1. Validate that the baby is Rh-negative. 2. Assess that the direct Coombs test is positive. 3. Verify the identity of the woman. 4. Reconstitute the globulin with sterile water.

3 1. RhoGAM is administered to all Rh − mothers because fetal blood type is usually not known. 2. Although in rare instances the Coombs test may be positive, the direct Coombs test is usually negative. 3. Although this is an important action that must be taken before the administration of any medication, it is especially critical in this situation. 4. RhoGAM is not reconstituted. TEST-TAKING TIP: When RhoGAM is given, the nurse is administering Rh antibodies to Rh − mothers. If the nurse should make a mistake and administer the dosage to an Rh+ mother, the client would then have been injected with antibodies that would act to destroy her own blood.

A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.

3 1. The client is not exhibiting signs of social isolation. 2. The client is not exhibiting signs of child neglect. 3. The client is exhibiting normal postpartum behavior. 4. The client is not exhibiting signs of postpartum depression. TEST-TAKING TIP: This client is exhibiting signs of the postpartum taking in phase. She is a primigravida who delivered only 2 hours earlier. Her comments are well within those expected of a client at this point during her postpartum period.

A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure? 1. Cover the foot with an iced wrap for one minute prior to the procedure. 2. Avoid puncturing the lateral heel to prevent damaging sensitive structures. 3. Allow the site to dry after rubbing it with an alcohol swab. 4. Firmly grasp the calf of the baby during the procedure to prevent injury.

3 1. The foot should be covered with a warm wrap to draw blood to the area for the heel stick. 2. The lateral heel is the site of choice because it contains no major nerves or blood vessels. 3. Alcohol can irritate the punctured skin and can cause hemolysis. 4. The ankle and foot should be firmly grasped during the procedure. TEST-TAKING TIP: If the posterior surface of the heel is punctured, the posterior tibial nerve and artery could be injured. Only the lateral aspects of the heel, therefore, should be punctured.

The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what is wrong with me. I feel terrible. I should be happy, but I'm not." Which of the following nursing diagnoses is appropriate for this client? 1. Suicidal thoughts related to psychotic ideations. 2. Post-trauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.

3 1. This diagnosis is inappropriate. There is no indication that this client is suicidal or psychotic. 2. This diagnosis is inappropriate. There is no indication in the scenario that the client had a traumatic delivery. 3. This diagnosis is appropriate. This client is showing signs of postpartum blues; one of the main reasons for this problem is related to the hormonal changes that occur after delivery. 4. This diagnosis is inappropriate. Nothing in the scenario implies that the client is in spiritual difficulties. TEST-TAKING TIP: It is essential that nurses discuss postpartum blues with clients. When clients are unfamiliar with the phenomenon, they often feel like they are going crazy or that there is something very wrong with them. Other members of the family, especially the woman's partner, should also be forewarned.

Which of the following would the nurse most expect to assess in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? 1.Increased muscle tone. 2.Hyperbilirubinemia. 3.Bulging fontanels. 4.Hyperactivity.

3 A common finding of IVH is a bulging fontanel. The most common site of hemorrhage is the periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile. Rapid volume expansion, hypercarbia, and hypoglycemia contribute to the development of IVH. Other common manifestations include neurologic signs such as hypotonia, lethargy, temperature instability, nystagmus, apnea, bradycardia, decreased hematocrit, and increasing hypoxia. Seizures also may occur. Hyperbilirubinemia refers to an increase in bilirubin in the blood and may be seen if bleeding was severe.

After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which of the following? 1.Degree of anemia in the neonate. 2.Electrolyte imbalances in the neonate. 3.Antibodies coating the neonate's red blood cells. 4.Antigens coating the neonate's red blood cells

3 A direct Coombs test is done on umbilical cord blood to detect antibodies coating the neonate's red blood cells. Hematocrit is used to detect anemia. Sodium, potassium, and chloride are used to detect electrolyte imbalances. Antigens on the neonate's red blood cells are proteins that help determine the neonate's blood type

After teaching the mother of a neonate with erythroblastosis fetalis who is to receive an exchange transfusion, which of the following, if stated by the mother as the purpose of the transfusion, indicates effective teaching? 1.To replenish the neonate's leukocytes. 2.To restore the fluid and electrolyte balance. 3.To correct the neonate's anemia. 4.To replace Rh-negative blood with Rh-positive blood.

3 An exchange transfusion is done to reduce the blood concentration of bilirubin and correct the anemia. The exchange transfusion does not replenish the white blood cells or restore the fluid and electrolyte balance. The neonate's Rh-positive blood is replaced by Rh-negative blood.

Which of the following characteristics should the nurse teach the mother about her neonate diagnosed with fetal alcohol syndrome (FAS)? 1.Neonates are commonly listless and lethargic. 2.The IQ scores are usually average. 3.Hyperactivity and speech disorders are common. 4.The mortality rate is 70% unless treated.

3 Central nervous system disorders are common in neonates with FAS. Speech and language disorders and hyperactivity are common manifestations of central nervous system dysfunction. Mild to severe mental retardation and feeding problems also are common. Delayed growth and development is expected. These neonates feed poorly and commonly have persistent vomiting until age 6 to 7 months. These neonates do not have a 70% mortality rate, and there is no treatment for FAS

A 16-year-old girl gave birth to a baby boy a week ago. She has an appointment with her obstetrician today who is concerned about the possibility of postpartum depression because the girl has been treated for depression in the past and the girl's mother suffered postpartum depression when the girl was born 16 years ago. Which comment by the client would indicate that she understood the nurse's teaching about the postpartum period and her risks for postpartum depression? 1."Sleep shouldn't be too much of a problem because the baby will soon start to sleep through the night." 2."Since I'm breast-feeding, I can eat all the food I want and not feel fat. The baby will use all the calories." 3."If I'm feeling guilty or not capable of caring for the baby and am not sleeping or eating well, I need to contact the office." 4."I'm going to give the baby the best care possible without asking anyone for help to show all those people who think I can't do it.

3 Feelings of guilt combined with a lack of self-care (not eating or sleeping enough) can predispose a new mother to postpartum depression, especially one who has had previous episodes of depression. Sleep is essential to both the mother and baby, but sleeping through the night does not usually occur in the first few weeks after birth. While breast-feeding mothers do need good nutrition, eating as much as you want after childbirth may inhibit the return to a normal weight and could create depression in a new mother, especially a vulnerable one. Attempting to care for an infant with no help from others is likely to cause stress that could lead to depression, especially in an adolescent

After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she says which of the following? 1."My other baby had a different father." 2."Like most women, I have immunity against the Rh factor." 3."Antibodies are not usually formed until after exposure to an antigen." 4."My blood couldn't neutralize antibodies formed from my first pregnancy."

3 The problem of Rh sensitivity arises when the mother's blood develops antibodies after fetal red blood cells enter the maternal circulation. In cases of Rh sensitivity, this usually does not occur until after the first pregnancy. Hence, hemolytic disease of the newborn is rare in a primiparous client. A mismatched blood transfusion in the past or an unrecognized spontaneous abortion could also result in hemolytic disease because the transfusion or abortion would have the same effects on the client. The statement about the other baby having a different father may be true. However, if both fathers were Rh-positive, then sensitization could occur. Most women do not have immunity against the antibodies formed when Rh-positive cells enter the mother's bloodstream. Antibodies are not neutralized by the mother's system.

A baby is exhibiting signs of neonatal abstinence syndrome. Which action would be appropriate for the nursery nurse to make? 1. Cover the baby with at least two blankets. 2. Stimulate the baby with rattles. 3. Play soft classical music in the nursery. 4. Attach a mobile to the crib.

3 1. Neonates who are exhibiting signs of neonatal abstinence syndrome are not at high risk of becoming hypothermic. In addition, neonates should be swaddled rather than covered with blankets. When a baby is covered, the blankets may inadvertently cover the baby's face, obstructing the baby's nasal passages. 2. Neonates who are exhibiting signs of neonatal abstinence syndrome should be kept in a low-stimulation environment. 3. Neonates who are exhibiting signs of neonatal abstinence syndrome are often soothed by the playing of soft classical music. 4. Neonates who are exhibiting signs of neonatal abstinence syndrome should be kept in a low-stimulation environment. TEST-TAKING TIP: Neonatal abstinence syndrome is the title given to the signs and symptoms exhibited by babies during the drug or alcohol withdrawal period. The babies are hyperreflexic and agitated during this period; therefore, keeping them in a soothing, low-stimulation environment is optimal.

During a home visit to a primiparous client who gave birth vaginally 14 days ago, the client says, "I've been crying a lot the last few days. I just feel so awful. I am a rotten mother. I just don't have any energy. Plus, my husband just got laid off from his job." The nurse observes that the client's appearance is disheveled. Which of the following would be the nurse's best response? 1."These feelings commonly indicate symptoms of postpartum blues and are normal. They'll go away in a few days." 2."I think you're probably overreacting to the labor and birth process. You're doing the best you can as a mother." 3."It's not unusual for some mothers to feel depressed after the birth of a baby. I think I should contact your doctor." 4."This may be a symptom of a serious mental illness. I think you should probably go to the hospital."

3. The client is probably experiencing postpartum depression, and the doctor should be contacted. Postpartum depression is usually treated with psychotherapy, social support groups, and antidepressant medications. Contributing factors include hormonal fluctuations, a history of depression, and environmental factors (eg, job loss). An estimated 50% to 70% of women experience some degree of postpartum "blues," but these feelings of sadness disappear within 1 to 2 weeks after birth. However, the client is voicing more than just sadness. Telling her that she is overreacting is not helpful and may make her feel even less worthy. She is not exhibiting symptoms of a serious mental illness (loss of contact with reality) and does not need hospitalization.

A young client is being admitted to the psychiatric unit after her obstetrician's staff suspected she was experiencing a postpartum psychosis. Her husband said she was doing fine for 2 weeks after the birth of the baby, except for pain from the C-section and trouble sleeping. These symptoms subsided over the next 4 weeks. Then 3 days ago, the client started having anxiety, irritability, vomiting, diarrhea, and delirium, resulting in her inability to care for the baby. Then the husband says, "I saw that my bottles of alprazolam and oxycodone were empty even though I haven't been taking them." In what order of priority from first to last should the nurse do the following? 1. Call the physician for prescriptions for appropriate treatment for opiate and benzodiazepine withdrawal. 2. Immediately place the client on withdrawal precautions. 3. Confirm with the client that she has in fact been using her husband's medications. 4. Assess the client for prior and current use of any other substances.

3. Confirm with the client that she has in fact been using her husband's medications. 4. Assess the client for prior and current use of any other substances. 2. Immediately place the client on withdrawal precautions. 1. Call the physician for prescriptions for appropriate treatment for opiate and benzodiazepine withdrawal. It crucial to confirm that the client was taking her husband's opiates and benzodiazepines and that her symptoms are due to the sudden withdrawal from these medications. It is also important to know if she has been using other substances (such as alcohol) that may cause other withdrawal symptoms. Even before calling the physician for prescriptions, the nurse can initiate withdrawal precautions for client safety.

While caring for a neonate born at 32 weeks' gestation, the nurse assesses the neonate daily for symptoms of necrotizing enterocolitis (NEC). Which of the following would alert the nurse to notify the neonatologist? 1.The presence of 1 mL of gastric residual before a gavage feeding. 2.Jaundice appearing on the face and chest. 3.An increase in bowel peristalsis. 4.Abdominal distention.

4 Indications of NEC include abdominal distention with gastric retention and vomiting. Other signs may include lethargy, irritability, positive blood culture in stool, absent or diminished bowel sounds, apnea, diarrhea, metabolic acidosis, and unstable temperature. A gastric residual of 1 mL is not significant. Jaundice of the face and chest is associated with the neonate's immature liver function and increased bilirubin, not NEC. Typically with NEC, the neonate would exhibit absent or diminished bowel sounds, not increased peristalsis

Rho (D) immune globulin (RhoGAM) is prescribed for a client before she is discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which of the following? 1.Development of a future Rh-positive fetus. 2.An antibody response to Rh-negative blood. 3.A future pregnancy resulting in abortion. 4.Development of Rh-positive antibodies.

4 Rh sensitization can be prevented by Rho(D) immune globulin, which clears the maternal circulation of Rh-positive cells before sensitization can occur, thereby blocking maternal antibody production to Rh-positive cells. Administration of this drug will not prevent future Rh-positive fetuses, nor will it prevent future abortions. An antibody response will not occur to Rh-negative cells. Rh-negative mothers do not develop sensitivities if the fetus is also Rh negative.

A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following? 1."The way my baby's face looks now will stay that way." 2."My baby may be irritable as a newborn." 3."I may need some help coping with my newborn." 4."My baby will be fine soon after we are home."

4. Changes seen in the facial features of newborns with fetal alcohol syndrome remain that way. These include epicanthal folds, whorls, irregular hair, cleft lip or palate, small teeth, and lack of philtrum. Newborns with fetal alcohol syndrome are usually difficult to calm and frequently cry for long periods of time. Parents do need assistance with caring for themselves and their infants, particularly with continued alcohol use. A supportive family or support systems are essential. The problems seen with this newborn do not go away and remain with the infant throughout life and are compounded when the child begins to develop mentally.

A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which of the following instructions should the nurse expect to include when developing the teaching plan for the mother about FAS? 1.Withdrawal symptoms usually do not occur until 7 days postpartum. 2.Large-for-gestational-age size is common with this condition. 3.Facial deformities associated with FAS can be corrected by plastic surgery. 4.Symptoms of withdrawal include tremors, sleeplessness, and seizures

4. The long-term prognosis for neonates with FAS is poor. Symptoms of withdrawal include tremors, sleeplessness, seizures, abdominal distention, hyperactivity, and inconsolable crying. Symptoms of withdrawal commonly occur within 6 to 12 hours or, at the latest, within the first 3 days of life. The neonate with FAS is usually growth deficient at birth. Most neonates with FAS are mildly to severely mentally retarded. The facial deformities, such as short palpebral fissures, epicanthal folds, broad nasal bridge, flattened midface, and short, upturned nose, are not easily corrected with plastic surgery.

A full-term infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. Which of the following actions should the nurse perform at this time? 1. Feed the baby formula or breast milk. 2. Assess the baby's blood pressure. 3. Tightly swaddle the baby. 4. Monitor the baby's urinary output

1 1. A baby with a blood glucose of 35 mg/dL is hypoglycemic. The action of choice is to feed the baby either formula or breast milk. 2. The baby's blood pressure is not a relevant factor at this time. 3. Tightly swaddling the baby may disguise a common finding, jitters or tremors, seen in babies who are hypoglycemic. 4. The baby's urinary output is not a relevant factor at this time. TEST-TAKING TIP: Although the test taker may believe that glucose water should be fed to the baby at this time, the substance of choice is either formula or breast milk. The sugars in the milk will elevate the baby's blood values in the short term and the proteins and fats in the milk will help to maintain the glucose values in the normal range

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O negative. 2. Type A negative. 3. Type B positive. 4. Type AB positive.

1 1. ABO incompatibility can arise when the mother is type O and the baby is either type A or type B. 2. Hemolytic jaundice from ABO incompatibility is rarely seen when the maternal blood type is anything other than type O. Rh incompatibility can occur only if the mother is Rh-negative and the baby is Rh-positive. 3. Hemolytic jaundice from ABO incompatibility is rarely seen when the maternal blood type is anything other than type O. Rh incompatibility can only occur if the mother is Rh-negative and the baby is Rh-positive. 4. Hemolytic jaundice from ABO incompatibility is rarely seen when the maternal blood type is anything other than type O. Rh incompatibility can only occur if the mother is Rh-negative and the baby is Rh-positive. TEST-TAKING TIP: A mother whose blood type is O, the blood type that is antigen negative, will produce anti-A and/or anti-B antibodies against blood types A and/or B, respectively. The anti-A (and/or anti-B) that passes into the baby's bloodstream via the placenta can attack the baby's red blood cells if he or she is type A or B. As a result of the blood cell destruction, the baby becomes jaundiced.

A nurse is about to inject RhoGAM into an Rh-negative mother. Which of the following is the preferred site for the injection? 1. Deltoid. 2. Dorsogluteal. 3. Vastus lateralis. 4. Ventrogluteal.

1 1. Although the dosage can be administered in the gluteal muscles, the deltoid is the preferred site of the RhoGAM injection. 2. Although the dosage can be administered in the gluteal muscles, the deltoid is the preferred site of the RhoGAM injection. 3. Although the dosage can be administered in the vastus lateralis, the deltoid is the preferred site of the RhoGAM injection. 4. Although the dosage can be administered in the gluteal muscles, the deltoid is the preferred site of the RhoGAM injection. TEST-TAKING TIP: Whenever possible, it is preferable to inject the antibodies into the recommended injection site. The antibodies are absorbed optimally from that site and, therefore, are more apt to suppress the mother's immune response.

Based on maternal history of alcohol addiction, a baby in the neonatal nursery is being monitored for signs of fetal alcohol syndrome (FAS). The nurse should assess this baby for which of the following? 1. Poor suck reflex. 2. Ambiguous genitalia 3. Webbed neck. 4. Absent Mororeflex.

1 1. FAS babies usually have a very weak suck. 2. Ambiguous genitalia is not a characteristic anomaly seen in FAS. 3. A webbed neck is not a characteristic anomaly seen in FAS. 4. FAS babies usually have an intact CNS system with a positive Moro reflex. TEST-TAKING TIP: The characteristic facial signs of fetal alcohol syndrome— shortened palpebral (eyelid) fissures, thin upper lip, and hypoplastic philtrum (median groove on the external surface of the upper lip)—are rarely evident in the neonatal period. They typically appear later in the child's life. Rather, the behavioral characteristics of the FAS baby, such as weak suck, irritability, tremulousness, and seizures, are present at birth.

A nursing diagnosis for a 5-day-old newborn under phototherapy is: Risk for fluid volume deficit. Which of the following client care outcomes should be included in the nursing care plan? During the next 24 hour period, the baby will: 1. Urinate at least 6 times. 2. Breastfeed 2 to 4 times. 3. Lose less than 12% of the baby's birth weight. 4. Have an apical heart rate of 160 to 170 bpm.

1 1. Healthy, hydrated neonates saturate their diapers a minimum of 6 times in 24 hours. 2. To consume enough fluid and nutrients for growth and hydration, babies should breastfeed at least 8 times in 24 hours. 3. A weight loss of over 10% is indicative of dehydration. 4. Tachycardia can indicate dehydration. TEST-TAKING TIP: This is an evaluation question. The test taker is being asked to identify signs that would indicate a baby who is fully hydrated. It is important for the test taker to know the expected intake and output of the neonate and to understand the evaluation phase of the nursing process.

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client? 1. The woman should never be left alone with her infant. 2. Symptoms rarely last more than one week. 3. Clinical response to medications is usually poor. 4. The woman must have her vitals assessed every two days.

1 1. It is essential that the client never be left alone with her baby. 2. The statement is untrue. There is no set time frame for the resolution of the symptoms of postpartum psychosis. 3. Clinical response to medications is usually quite good. 4. The client's vital signs need not be assessed frequently. TEST-TAKING TIP: Clients who have been diagnosed with postpartum psychosis have been known to have homicidal and suicidal ideations. Because the baby and other children are vulnerable, the mother should always be supervised when in their presence. In addition, if she exhibits suicidal behaviors, she should be supervised at all times.

Which of the following laboratory findings would the nurse expect to see in a baby diagnosed with erythroblastosis fetalis? 1. Hematocrit 24%. 2. Leukocyte count 45,000 cells/mm 3 3. Sodium 125 mEq/L. 4. Potassium 5.5 mEq/L.

1 1. The baby with erythroblastosis fetalis would exhibit signs of severe anemia, which a hematocrit of 24% reflects. 2. Erythroblastosis fetalis is not an infectious condition. Leukocytosis is not a part of the clinical picture. 3. Hyponatremia is not part of the disorder. 4. Hyperkalemia is not part of the disorder. TEST-TAKING TIP: The test taker must be familiar with the pathophysiology of Rh incompatibility. If a mother who is Rh-negative has been sensitized to Rh-positive blood, she will produce antibodies against the Rh-positive blood. If she then becomes pregnant with an Rh-positive baby, her anti-Rh antibodies will pass directly through the placenta into the fetal system. Hemolysis of fetal red blood cells results, leading to severe fetal anemia.

A baby was born 24 hours ago to a mother who received no prenatal care. The infant has tremors, sneezes excessively, constantly mouths for food, and has a shrill, high-pitched cry. The baby's serum glucose levels are normal. For which of the following should the nurse request an order from the pediatrician? 1. Urine drug toxicology test. 2. Biophysical profile test. 3. Chest and abdominal ultrasound evaluations. 4. Oxygen saturation and blood gas assessments.

1 1. The symptoms are characteristic of neonatal abstinence syndrome. A urine toxicology would provide evidence of drug exposure. 2. Biophysical profiles are done during pregnancy to assess the well-being of the fetus. 3. There is no indication from the question that this child has any chest or abdominal abnormalities. 4. This child is not exhibiting signs of respiratory distress. TEST-TAKING TIP: It is important for the test taker to attend to the fact that this child has normal serum glucose levels. When babies exhibit tremors, the first thing the nurse should consider is hypoglycemia. Once that has been ruled out, and as the baby is exhibiting other signs of drug withdrawal, the nurse should consider drug exposure.

A 2-day-old baby's blood values are: Blood type, O- (negative). Direct Coombs, negative. Hematocrit, 50%. Bilirubin, 1.5 mg/dL. The mother's blood type is A+. What should the nurse do at this time? 1. Do nothing because the results are within normal limits. 2. Assess the baby for opisthotonic posturing. 3. Administer RhoGAM to the mother per doctor's order. 4. Call the doctor for an order to place the baby under bili-lights.

1 1. These findings are all within normal limits. 2. There is no indication that this child has developed any signs of kernicterus, which is associated with opisthotonic posturing. 3. The mother is Rh-positive. Only mothers who are Rh-negative and who deliver babies who are Rh-positive receive RhoGAM. 4. The bilirubin level is very low. There is no indication that phototherapy is needed. TEST-TAKING TIP: Blood incompatibilities are seen when the mother is Rh-negative and the baby is Rh-positive or when the mother is type O and the baby is either type A or type B. When the baby is either Rh-negative or type O, there is actually a reduced risk that pathological jaundice will result

A baby whose mother was addicted to heroin during pregnancy is in the NICU. Which of the following nursing actions would be appropriate for the nurse to perform? 1. Tightly swaddle the baby. 2. Place the baby prone in the crib. 3. Provide needed stimulation to the baby. 4. Feed the baby half-strength formula.

1 1. Tightly swaddling drug-addicted babies often helps to control the hyperreflexia that they may exhibit. 2. Placing hyperactive babies on their abdomens can result in skin abrasions on the face and knees from rubbing against the linens. And, like all babies, drug-addicted babies should be placed supine during all unsupervised time periods. 3. Drug-exposed babies should be placed in a low-stimulation environment. 4. The babies should be given small, frequent feedings either of full-strength formula or of breast milk. TEST-TAKING TIP: Drug-exposed babies exhibit signs of neonatal abstinence syndrome including hyperactivity, hyperreflexia, and the like. The test taker should look for a nursing intervention that would minimize those behaviors. Tightly swaddling the baby would help to reduce the baby's behavioral responses.

The nursing management of a neonate with physiological jaundice should be directed toward which of the following client care goals? 1. The baby will exhibit no signs of kernicterus. 2. The baby will not develop erythroblastosis fetalis. 3. The baby will have a bilirubin of 16 mg/dL or higher at discharge. 4. The baby will spend at least 20 hours per day under phototherapy.

1 1. When bilirubin levels elevate to toxic levels, babies can develop kernicterus. 2. Erythroblastosis fetalis is a syndrome resulting from the antigen-antibody reaction related to maternal-fetal blood incompatibility. 3. This bilirubin level is above the level most neonatologists consider acceptable for discharge. 4. Phototherapy is ordered when hyperbilirubinemia is present or when the development of hemolytic jaundice is very likely. TEST-TAKING TIP: This question asks the test taker to identify a client care goal for a newborn with physiological jaundice. The client care goal reflects the nurse's desired patient care outcome. The development of kernicterus is a potential pathological outcome resulting from hyperbilirubinemia. The client care goal, therefore, is that the neonate not develop kernicterus.

A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform? 1. Cover the baby's eyes with eye pads. 2. Turn the lights off for ten minutes every hour. 3. Clothe the baby in a shirt and diaper only. 4. Tightly swaddle the baby in a baby blanket

1 1. When phototherapy is administered, the baby's eyes must be protected from the light source. 2. Although the lights should be turned off and the pads removed periodically during the therapy, the lights should be on whenever the baby is in his or her crib. 3. The therapy is most effective when the skin surface exposed to the light is maximized. The shirt should be removed while the baby is under the lights. 4. The blanket should be removed while the baby is under the lights. TEST-TAKING TIP: There is a difference between phototherapy administered by fl uorescent light and phototherapy administered via fi ber-optic tubing to a bili-blanket. When a bili-blanket is used, the baby can be clothed and the baby's eyes do not need to be protected.

Three days after admission of a neonate born at 30 weeks' gestation, the neonatologist plans to assess the neonate for intraventricular hemorrhage (IVH). The nurse should plan to assist the neonatologist by preparing the neonate for which of the following? 1.Cranial ultrasonography. 2.Arterial blood specimen collection. 3.Radiographs of the skull. 4.Complete blood count specimen collection.

1 Neonates who weigh less than 1,500 g or are born at less than 34 weeks' gestation are susceptible to IVH. Cranial ultrasound scanning can confirm the diagnosis. The spinal fluid will show an increased number of red blood cells. Arterial blood gas specimen collection is done to evaluate the neonate's oxygen saturation level. Skull radiographs are not commonly used because of the danger of radiation. Additionally, computed tomography scans have replaced the use of skull x-ray films because they can provide more definitive results. Complete blood count specimen collection is usually performed to determine the hemoglobin, hematocrit, and white blood cell count. The results are not specific for PIVH.

Which of the following best identifies the reason for assessing a neonate weighing 1,500 g at 32 weeks' gestation for retinopathy of prematurity (ROP)? 1.The neonate is at risk because of multiple factors. 2.Oxygen is being administered at a level of 21%. 3.The neonate was alkalotic immediately after birth. 4.Phototherapy is likely to be prescribed by the primary health care provider.

1 ROP, previously called retrolental fibroplasia, is associated with multiple risk factors, including high arterial blood oxygen levels, prematurity, and very low birth weight (less than 1,500 g). In the early acute stages of ROP, the neonate's immature retinal vessels constrict. If vasoconstriction is sustained, vascular closure follows, and irreversible capillary endothelial damage occurs. Normal room air is at 21%. Acidosis, not alkalosis, is commonly seen in preterm neonates, but this is not related to the development of ROP. Phototherapy is not related to the development of ROP. However, during phototherapy, the neonate's eyes should be constantly covered to prevent damage from the lights

An infant is born with facial abnormalities, growth retardation, mental retardation, and vision abnormalities. These abnormalities are likely caused by maternal: 1.Alcohol consumption. 2.Vitamin B6 deficiency. 3.Vitamin A deficiency. 4.Folic acid deficiency.

1 These effects and others when seen after birth are known as a cluster of symptoms called fetal alcohol syndrome. Vitamin B6 and vitamin A deficiency can affect growth and development but not with these specific effects. Folic acid deficiency contributes to neural tube defects.

A newborn in the nursery is exhibiting signs of neonatal abstinence syndrome. Which of the following signs/symptoms is the nurse observing? Select all that apply. 1. Hyperphagia. 2. Lethargy. 3. Prolonged periods of sleep. 4. Hyporefexia. 5. Persistent shrill cry.

1 and 5 are correct. 1. Babies with signs of neonatal abstinence syndrome repeatedly exhibit signs of hunger. 2. Babies with neonatal abstinence syndrome are hyperactive, not lethargic. 3. Babies with neonatal abstinence syndrome often exhibit sleep disturbances rather than prolonged periods of sleep. 4. Babies with signs of neonatal abstinence syndrome are hyperreflexic, not hyporeflexic. 5. Babies with signs of neonatal abstinence syndrome often have a shrill cry that may continue for prolonged periods. TEST-TAKING TIP: The baby who is exhibiting signs of neonatal abstinence syndrome is craving an addicted drug. The baby's body is in distress because the addictive substances he or she has been exposed to have affected the central nervous system and their removal has agitated him or her. The test taker, therefore, should consider symptoms that reflect central nervous system stimulation as correct responses.

A neonate is being assessed for necrotizing enterocolitis (NEC). Which of the following actions by the nurse is appropriate? Select all that apply. 1. Perform hemoccult test on stools. 2. Monitor for an increase in abdominal girth. 3. Measure gastric contents before each feed. 4. Assess bowel sounds before each feed. 5. Assess for anal fissures daily.

1, 2, 3, and 4 are correct. 1. Babies with NEC have blood in their stools. 2. The abdominal girth measurements of babies with NEC increase. 3. When babies have NEC, they have increasingly larger undigested gastric contents after feeds. 4. The neonates' bowel sounds are diminished with NEC. 5. The presence of anal fissures is unrelated to NEC. TEST-TAKING TIP: NEC is an acute inflammatory disorder seen in preterm babies. It appears to be related to the shunting of blood from the gastrointestinal tract, which is not a vital organ system, to the vital organs. The baby's bowel necroses with the shunting and the baby's once normal fl ora become pathological. Resection of the bowel is often necessary

A 6-month-old child is being seen in the pediatrician's office. The child was born preterm and remained in the neonatal intensive care unit for the first 5 months of life. The child is being monitored for 5 chronic problems. Which of the following problems are directly related to the prematurity? Select all that apply. 1. Bronchopulmonary dysplasia. 2. Cerebral palsy. 3. Retinopathy. 4. Hypothyroidism. 5. Seizure disorders

1, 2, 3, and 5 are correct 1. Bronchopulmonary dysplasia often is a consequence of the respiratory therapy that preemies receive in the NICU. 2. Cerebral palsy results from a hypoxic insult that likely occurred as a result of the baby's prematurity. 3. Retinopathy of the premature is a disease resulting from the immaturity of the vascular system of the eye. 4. Hypothyroidism is one of the diseases assessed for in the neonatal screen. It is unlikely that this problem resulted from the baby's stay in the NICU. 5. Seizure disorders can result either from a hypoxic insult to the brain or from a ventricular bleed. Both of these conditions likely occurred as a result of the prematurity. TEST-TAKING TIP: Many parents are of the opinion that babies, even when born many weeks prematurely, will be healthy as they mature because there are so many machines and medications that can be given to the babies. Unfortunately, many babies suffer chronic problems as a result of their prematurity even when they receive excellent medical and nursing care

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit? 1. Hallucinations. 2. Polyphagia. 3. Induced vomiting. 4. Weepy sadness.

1 1. The client with postpartum psychosis will experience hallucinations. 2. Clients with diabetes mellitus, not postpartum psychosis, are polyphagic. 3. Clients with bulimia induce vomiting. 4. Clients with postpartum blues and/or postpartum depression are weepy and sad. TEST-TAKING TIP: Clients who have been diagnosed with postpartum psychosis have a psychiatric disease. They experience hallucinations, usually auditory, including voices that may tell them to kill their babies. They should never be left alone with their babies.

Which of the following subjects should the nurse include when teaching the mother of a neonate diagnosed with retinopathy of prematurity (ROP) about possible treatment for complications? 1.Laser therapy. 2.Cromolyn sodium eye drops. 3.Frequent testing for glaucoma. 4.Corneal transplants.

1 Because the retina may become detached with ROP, laser therapy has been used successfully in some medical centers to treat ROP. Cromolyn sodium is used to treat seasonal allergies. ROP is not associated with glaucoma, so frequent testing is not necessary. Because the vessels of the eye are affected, not the corneas, corneal transplantation is not used.

A full-term, 36-hour-old neonate's bilirubin level is 13 mg/dL. Which of the following signs and symptoms would the nurse expect to see? Select all that apply. 1. Lethargy. 2. Jaundice. 3. Polyphagia. 4. Diarrhea. 5. Excessive yawning.

1 and 2 are correct 1. Babies who have hyperbilirubinemia are usually very lethargic. 2. Babies who have hyperbilirubinemia are jaundiced. 3. Babies who have hyperbilirubinemia usually feed poorly. 4. Because babies who have hyperbilirubinemia feed poorly, they stool less frequently. They do not exhibit diarrhea. 5. Babies who have hyperbilirubinemia do not exhibit excessive yawning. Babies who are withdrawing from narcotic addiction exhibit excessive yawning as well as other signs and symptoms of withdrawal. TEST-TAKING TIP: Kernicterus is the syndrome that results when babies' brains are exposed to high levels of bilirubin over time. When the bilirubin level rises, the babies initially exhibit signs of lethargy and hypotonia, including difficulty in awaking for feeds and poor suck. When exposure is prolonged or when levels rise significantly, the symptoms of spasticity develop, including high-pitched cry and seizures. In addition, the marked exposure can lead to permanent damage to the brain, including developmental disabilities, learning disabilities, and sensory losses. When a neonate is jaundiced, the nurse should consult the Bhutani nomogram to determine the likelihood of the bilirubin rising

The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the clients who had which of the following deliveries state that they understand why they must receive a RhoGAM injection? Select all that apply. 1. Abortion at 10 weeks' gestation. 2. Amniocentesis at 16 weeks' gestation. 3. Fetal demise at 24 weeks' gestation. 4. Birth of Rh-negative twins at 35 weeks' gestation. 5. Delivery of a 40-week-gestation, Rh-positive baby.

1, 2, 3, and 5 are correct. 1. The client should receive a RhoGAM injection after a spontaneous abortion. 2. The client should receive a RhoGAM injection after an amniocentesis. 3. The client should receive a RhoGAM injection after the delivery of a fetal demise. 4. The client does not need a RhoGAM injection after the delivery of Rh-negative twins. 5. The client should receive a RhoGAM injection after birth of an Rh-positive baby. TEST-TAKING TIP: RhoGAM, or Rh immune globulin, is administered to pregnant women at 28 weeks' gestation; after any invasive procedure such as an amniocentesis; after a preterm disruption of a pregnancy such as an abortion or placental previa bleed; and after the delivery of an Rh+ infant. Because Rh-negative infants carry no Rh antigen, it is unnecessary to administer RhoGAM to their Rh-negative mothers.

A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply. 1. Fever 2. Flank pain. 3. Dark-colored urine. 4. Nausea. 5. Polycythemia.

1, 2, and 3 are correct. 1. The nurse would expect to see fever, flank pain, and dark-colored urine. 2. The nurse would expect to see fever, flank pain, and dark-colored urine. 3. The nurse would expect to see fever, flank pain, and dark-colored urine. 4. The nurse would not expect the client to complain of nausea. 5. The nurse would expect to see a hemolytic response, not polycythemia. TEST-TAKING TIP: When RhoGAM is administered to an Rh+ (positive) client, antibodies against the client's red blood cells are being injected into her body. A hemolytic response similar to one seen when a client receives the wrong type of blood may develop

A baby is born with erythroblastosis fetalis. Which of the following signs/ symptoms would the nurse expect to see? 1. Ruddy complexion. 2. Anasarca. 3. Alopecia. 4. Erythema toxicum

2 1. Babies born with erythroblastosis fetalis are markedly anemic. They are not ruddy in appearance. 2. Babies born with erythroblastosis fetalis often are in severe congestive heart failure and, therefore, exhibit anasarca. 3. Babies with erythroblastosis fetalis are not at high risk for alopecia. 4. Erythema toxicum is a normal newborn rash that many healthy newborns have. TEST-TAKING TIP: A baby with erythroblastosis fetalis has marked red blood cell destruction in utero secondary to the presence of maternal antibodies in the baby's bloodstream. The severe anemia that results often leads to congestive heart failure of the fetus in utero.

After teaching a multiparous client about the effects of hemolysis due to Rh sensitization on the neonate at birth, the nurse determines that the client needs further instruction when the mother reports that the neonate may have which of the following? 1.Cardiac decompensation. 2.Polycythemia. 3.Anemia. 4.Splenic enlargement.

2 The Rh-sensitized neonate generally does not have problems related to polycythemia. Therefore, the client needs additional teaching. In general, moderate to severe Rh sensitization can cause anemia, enlarged spleen, and cardiac decompensation. Cardiac decompensation (as in heart failure) occurs because of severe anemia. Anemia is caused by the destruction of red blood cells by antibodies as the severity of hemolytic disease of the neonate increases. Splenic enlargement is caused by the excessive destruction of fetal red blood cells.

The nurse explains to the mother of a neonate diagnosed with erythroblastosis fetalis that the exchange transfusion is necessary to prevent damage primarily to which of the following organs in the neonate? 1.Kidneys. 2.Brain. 3.Lungs. 4.Liver.

2 The organ most susceptible to damage from uncontrolled hemolytic disease is the brain. Bilirubin levels increase as the red blood cells are destroyed. Bilirubin crosses the blood-brain barrier and damages the cells of the central nervous system. This condition, called kernicterus, is potentially fatal. Although the kidneys, lungs, and liver may be affected by increased bilirubin levels, the brain will sustain the most life-threatening injury.

A client, whose baby is exhibiting signs of erythroblastosis fetalis, is admitted to the labor and delivery unit. The nurse would expect to see which of the following fetal heart monitor tracings? 1. Marked fetal heart variability. 2. Prolonged fetal heart accelerations. 3. Sinusoidal fetal heart pattern. 4. Periodic variable decelerations.

3 1. The nurse would not expect the fetal heart tracing to show marked fetal heart variability. 2. The nurse would not expect the fetal heart tracing to show prolonged fetal heart accelerations. 3. The nurse would expect to see a sinusoidal fetal heart pattern. 4. The nurse would not expect the fetal heart tracing to show periodic variable decelerations. TEST-TAKING TIP: A sinusoidal fetal heart pattern, as seen next, is an undulating pattern exhibiting no signs of normality. The pattern is seen when the fetus is markedly anemic, as in erythroblastosis fetalis.

A 6-month-old child has been diagnosed with a significant hearing loss. Which of the following complications that occurred immediately after delivery could have resulted in this condition? 1. Necrotizing enterocolitis. 2. Hypoglycemia. 3. Bronchopulmonary dysplasia. 4. Kernicterus.

4 1. Necrotizing enterocolitis does not result in hearing loss. 2. Hypoglycemia does not result in hearing loss. 3. Bronchopulmonary dysplasia does not result in hearing loss. 4. A baby who has had kernicterus can develop hearing loss. TEST-TAKING TIP: Kernicterus occurs when bilirubin in the bloodstream reaches toxic levels. Bilirubin is neurotoxic. Early signs of kernicterus are lethargy, sleepiness, and poor feeding. Severe kernicterus, when babies develop seizures and opisthotonus, can result in a number of neurological problems, including cerebral palsy, sensory deficits, and behavioral disorders.

A newborn admitted to the nursery has a positive direct Coombs test. Which of the following is an appropriate action by the nurse? 1. Monitor the baby for jitters. 2. Assess the blood glucose level. 3. Assess the rectal temperature. 4. Monitor the baby for jaundice.

4 1. The Coombs test assesses for the presence of antibodies in the blood. The test will not predict or explain jitters in the neonate. 2. The Coombs test will not predict or explain hypoglycemia in the neonate. 3. The Coombs test will not predict or explain a change in temperature in the neonate. 4. When the neonatal bloodstream contains antibodies, hemolysis of the red blood cells occurs and jaundice develops. TEST-TAKING TIP: The indirect Coombs test is performed on the pregnant woman to detect whether or not she carries antibodies against her fetus's red blood cells. The direct Coombs test is performed on the newborn's cord blood to detect whether or not he or she carries maternal antibodies against his or her blood.