Ricci → Ch. 23: Nursing Care of the Newborn With Special Needs PrepU

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

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

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

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

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

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

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

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

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

0.15 mL Correct Explanation: The newborn weighs 1,500 g, which is equivalent to 1.5 kg. Calculating the dose based on 0.1 mL/kg, the nurse would administer 0.15 mL.

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule?

1 cm/hour for cervical dilation In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 10% c) 50% d) 5%

10% Correct Explanation: Most newborns transition to extrauterine life smoothly. About 10% of newborns need some type of assistance at birth.

x

100 mm Hg

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

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

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

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

Assessment of a newborn at 40 weeks' gestation reveals that he is a low birth weight newborn. Which of the following weights would the nurse identify as being low birth weight? a) 4400 g b) 1400 g c) 2400 g d) 3400 g

2400 g Correct Explanation: A birth weight of less than 2500 g is categorized as a low birth weight in infants. The normal birth weight of term infants ranges from 3000-4000 g. Hence infants with a birth weight of 3500 g or 4500 g will not be categorized as low birth weight infants. Infants having birth weights lower than 1500g are termed as very low birth weight infants, and not merely low birth weight.

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

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

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?

45 ml urine output in 2 hours The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.

Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a) 6 b) 3 c) 4 d) 5

5

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

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

While assessing a full-term neonate, which symptom would cause the nurse to suspect a neurologic impairment? a) A positive Babinski's reflex b) A positive rooting reflex c) A weak sucking reflex d) Startle reflex in response to a loud noise

A weak sucking reflex Correct Explanation: Normal neonates have a strong, vigorous sucking reflex. The rooting reflex is present at birth and disappears when the infant is between ages 3 and 4 months. A positive Babinski's reflex is present at birth and disappears by the time the infant is age 2. The startle reflex is present at birth and disappears when the infant is approximately age 4 months.

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

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

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated? a) Administer 0.5 ml/kg/hr of breast milk enterally b) Administer dextrose intravenously c) Administer iron supplements d) Administer vitamin D supplements

Administer 0.5 ml/kg/hr of breast milk enterally

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate? a) Monitor the infant's hematocrit levels closely b) Place the infant on a radiant warmer c) Administer PO glucose water immediately d) Administer dextrose intravenously

Administer dextrose intravenously

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?

Administer oxytocin diluted as a "piggyback" infusion. Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

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

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

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Sleepiness b) Tachycardia c) Apnea d) Crying

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

A newborn with high serum bilirubin is receiving phototherapy. Which of the following is the most appropriate nursing intervention for this client? a) Gentle shaking of the baby b) Placing light 6 inches above the newborn's bassinet c) Application of eye dressings to the infant d) Delay of feeding until bilirubin levels are normal

Application of eye dressings to the infant Correct Explanation: Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or formula), therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor. In a client with the risk for injury, continuous assessment of contractions using external monitor and palpation to ensure the presence of a low resting tone will assist in collecting information about labor and the need for further intervention. Turning down oxytocin administration by half is required if hyperstimulation occurs not to prevent it. Tocolytic therapy is generally employed when preterm labor has been definitively diagnosed. Administering hydration and sedation frequently and bedrest are employed to halt preterm labor since these stop uterine activity by increasing intravascular volume and uterine blood flow.

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.

What assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn? a) Monitor for fall in temperature, indicative of dehydration b) Assess for decrease in urinary output c) Assess for increased muscle tone d) Measure weight once every 2-3 days

Assess for decrease in urinary output

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth?

Assess uterine tone to determine fundal firmness. When caring for a client who has undergone a cesarean birth, the nurse should assess the client's uterine tone to determine fundal firmness. The nurse should assist with breastfeeding initiation and offer continued support. The nurse can also suggest alternate positioning techniques to reduce incisional discomfort while breastfeeding. Delaying breastfeeding may not be required. The nurse should encourage the client to cough, perform deep-breathing exercises, and use the incentive spirometer every 2 hours. The nurse should assist the client with early ambulation to prevent respiratory and cardiovascular problems.

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

Asymmetrical movement Correct Explanation: A birth injury is typically characterized by asymmetrical movement. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time?

Avoid any discussion of the situation with the couple. The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time.

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn? a) Focus on decreasing blood viscosity by introducing feedings b) Give dextrose intravenously before oral feedings c) Place infant on radiant warmer immediately d) Begin early feedings either by the breast or bottle

Begin early feedings either by the breast or bottle

Before calling the primary care provider to notify him or her of a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?

Check for a full bladder. A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.

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

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

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? a) Conduction b) Convection c) Evaporation d) Radiation

Conduction Correct Explanation: A conduction heat loss results from direct contact with an object that is cooler.

A nurse is working with a client who has just begun labor and who has given birth vaginally five previous times. Which of the following interventions will the nurse most likely need to implement to meet the needs of this particular client?

Convert the birthing room to birth readiness before full dilatation is obtained Both grand multiparas (women who have given birth five or more times) and women with histories of precipitate labor should have the birthing room converted to birth readiness before full dilatation is obtained. Then, even if a sudden birth should occur, it can be accomplished in a controlled surrounding. As the client is likely to give birth relatively quickly, there is no need for oxytocin or to darken the room lights. There is also no indication that cesarean birth will be necessary, particularly because all of the client's previous births were vaginal.

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. Which of the following is the priority nursing intervention? a) Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute b) Transfer to a transitional or high-risk nursery for continuous cardiac surveillance c) Administration of IV epinephrine, as prescribed d) Palpation for a femoral pulse

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute Explanation: If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats per minute, closed-chest massage should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both your thumbs, on the lower third of the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 times per minute. If the pressure and the rate of massage are adequate, it should be possible, in addition, to palpate a femoral pulse. If heart sounds are not resumed above 60 beats per minute after 30 seconds of combined positive-pressure ventilation and cardiac compressions, intravenous epinephrine may be prescribed. Following cardio-resuscitation, newborns need to be transferred to a transitional or high-risk nursery for continuous cardiac surveillance to be certain cardiac function is maintained.

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

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

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

Diabetes mellitus Postdates gestation Prepregnancy obesity

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

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

If the nurse manages a new infant with low blood sugar, which of the following would be an appropriate intervention to prevent hypoglycemia? a) Check the heart rate. b) Hold all feedings. c) Feed the infant. d) Give antibiotics.

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

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

Focus on decreasing blood viscosity by increasing fluid volume

After teaching a group of students about the effects of prematurity on various body systems, the instructor determines that the class was successful when the students identify which of the following as an effect of prematurity? a) Fragile cerebral blood vessels b) Enhanced ability to digest proteins c) Enlarged respiratory passages d) Rapid glomerular filtration rate

Fragile cerebral blood vessels Explanation: Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate.

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

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

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

Head larger than body

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

Head larger than body Explanation: Head being larger than the rest of the body is the characteristic feature of small for gestational age infants. Small for gestational age infants weigh below the 10th percentile on the intrauterine growth chart for gestational age. The heads of SGA infants appear larger in proportion to their body. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large for gestational age (LGA) infants. Preterm infants, and not SGA infants, are covered with brown lanugo hair all over the body.

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

Heart rate of 162 bpm

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

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

Which of the following is a consequence of hypothermia in a newborn? a) Skin pink and warm b) Holds breath 25 seconds c) Heart rate of 126 d) Respirations of 46

Holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

You care for a child born with a tracheoesophageal fistula. Which finding during pregnancy would have caused you to suspect this might be present? a) Oligohydramnios b) A difficult second stage of labor c) Hydramnios d) Bleeding at 32 weeks of pregnancy

Hydramnios

The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which of the following? a) Asphyxia b) Meconium aspiration c) Hypoglycemia d) Polycythemia

Hypoglycemia Correct Explanation: Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.

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

Hypoglycemia Correct Explanation: LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes which was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.

A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that he's at risk for which complication? a) Anemia b) Hypoglycemia c) Nitrogen loss d) Thrombosis

Hypoglycemia Correct Explanation: Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus through the placenta. The neonate's liver can't initially adjust to the changing glucose levels after birth. This inability may result in an overabundance of insulin in the neonate, causing hypoglycemia. Neonates of mothers with diabetes aren't at increased risk for anemia, nitrogen loss, or thrombosis.

In an infant who has hypothermia, what would be an appropriate nursing diagnosis? a) Ineffective parental attachment b) Impaired tissue perfusion c) Alteration in nutrition d) Impaired skin integrity

Impaired tissue perfusion Correct Explanation: Impaired tissue perfusion would be appropriate and may be related to cardiopulmonary, cerebral, gastrointestinal, peripheral, or renal issues.

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

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

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

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

An infant that is diagnosed with meconium aspiration displays which symptom? a) Pink skin b) No heart murmur c) Respirations of 45 d) Intercostal and substernal retractions

Intercostal and substernal retractions

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

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

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

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

A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) Approximately 2,500 g b) More than 4,000 g c) Less than 1,500 g d) Less than 1,000 g

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

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

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

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

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

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

Maternal pregravid obesity Correct Explanation: The nurse should identify maternal pregravid obesity as a risk factor for the development of LGA newborns. The other risk factors for the development of LGA newborns include fetal exposure to high estrogen, excess weight gain during pregnancy, gestational diabetes and high maternal birth weight.

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?

McRobert's maneuver The McRobert's maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the client in the lithotomy position, while each holds a leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. What is the first maneuver tried to deliver an infant with shoulder dystocia?

McRoberts maneuver McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

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

Meconium aspiration in utero or at birth Correct Explanation: Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.

Which of the following data is indicative of hypothermia of the preterm infant? a) Regular respirations b) Oxygen saturation of 95% c) Nasal flaring d) Pink skin

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

Which intervention should a nurse implement to promote thermal regulation in a preterm newborn? a) Observe for clinical signs of cold stress such as weak cry b) Check the blood pressure of the infant every 2 hours c) Assess the newborn's temperature every 8 hours until stable d) Set the temperature of the radiant warmer at a fixed level

Observe for clinical signs of cold stress such as weak cry

What is the first action the nurse takes in surfactant administration? a) Hold feedings. b) Call pharmacy for medication. c) Obtain and document baseline vital signs. d) Change the infant's diaper.

Obtain and document baseline vital signs. Correct Explanation: Obtaining a baseline set of vital signs is the first step in surfactant administration. The nurse will need a baseline in case there is any reaction to the medication administration. The other choices are not the first thing done before instilling this medication.

A client with diabetes delivers a full-term neonate who weights 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse palpates the clavicles for which reason? a) Clavicles are commonly absent in neonates of mothers with diabetes. b) Neonates of mothers with diabetes have brittle bones. c) LGA neonates have glucose deposits on their clavicles. d) One of the neonate's clavicles may have been broken during delivery.

One of the neonate's clavicles may have been broken during delivery. Correct Explanation: Because of the neonate's large size, clavicular fractures are common during delivery. The nurse should assess all LGA neonates for this occurrence. None of the other options are true.

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? a) Lanugo covering the neonate's body b) A sleepy, lethargic neonate c) Vernix caseosa covering the neonate's body d) Peeling and wrinkling of the neonate's epidermis

Peeling and wrinkling of the neonate's epidermis Correct Explanation: Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.

Which of the following places newborns at risk for ongoing health problems? a) Average weight b) Term birth c) Vaginal delivery d) Perinatal asphyxia

Perinatal asphyxia Correct Explanation: Several disorders can place newborns at risk for ongoing health problems such as prematurity, low birth weight, congenital abnormalities, perinatal asphyxia, and birth trauma. These conditions need further nursing assessment and care for optimal growth and healing. The other choices do not place a risk on the infant.

When preparing to resuscitate a preterm newborn, which of the following would the nurse do first? a) Use positive-pressure ventilation. b) Administer epinephrine. c) Hyperextend the newborn's neck. d) Place the newborn's head in a neutral position.

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

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

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

A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning? a) Administration of chilled oxygen to reduce lung spasm b) Positive end-expiratory pressure to increase oxygenation c) Increased inspiratory pressure; decreased expiratory pressure d) Administration of dry oxygen to avoid over-humidification

Positive end-expiratory pressure to increase oxygenation Correct Explanation: Positive end-expiratory pressure, like expiratory grunting, prevents alveoli from fully closing on expiration and reduces the respiratory effort needed for inspiration.

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth. The findings are consistent with uterine rupture. An abrupt change in the fetal heart rate pattern is often the most significant finding associated with uterine rupture. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. Falling blood pressure and rising pulse may be associated with hypovolemia caused by occult bleeding. The treatment is immediate cesarean birth.

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

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

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

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

An 18-year-old client has given birth to a very-low-birth-weight preterm infant. Which of the following should the nurse consider to prevent the newborn from losing body temperature? a) Hold the newborn close, rocking gently. b) Provide isolette or radiant warmer care to the newborn. c) Give the newborn a warm water bath. d) Administer vitamin K to the newborn.

Provide isolette or radiant warmer care to the newborn. Correct Explanation: The nurse should place the infant in an isolette to simulate the uterine environment as closely as possible and to keep the infant warm. The isolette maintains even levels of temperature, humidity, and oxygen. A hood covers it, and nurses can give care through portholes. Holding and frequent handling of the newborn should be avoided to prevent loss of energy. Minimal handling helps the neonate to conserve energy. Administration of vitamin K to the infant is necessary to prevent bleeding in the infant because the newborn is unable to produce its own vitamin K during the early stages of life. It does not help in providing warmth to the baby. The infant is not given baths until later because this often results in loss of body temperature.

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

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

A woman near term presents to the clinic highly agitated because her membranes have just ruptured and she felt something come out when they did. The nurse is alone with her and notices that the umbilical cord is hanging out of the vagina. What should the nurse do next?

Put her in bed immediately, call for help, and hold the presenting part of the cord. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, when the presenting part compresses the cord oxygen, and nutrients are cut off to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and the nurse does not leave the woman. A vaginal birth is contraindicated in this situation.

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which is true for a newborn with RDS? a) Respiratory symptoms of RDS typically improve within a short period of time. b) RDS is caused by a lack of alveolar surfactant. c) Glucocorticosteroid is given to the newborn following birth. d) RDS is characterized by heart rates below 50 beats per minute.

RDS is caused by a lack of alveolar surfactant. Correct Explanation: Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest x-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute).

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer? a) Radiation b) Convection c) Evaporation d) Conduction

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

What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? a) Respirations as increased and high b) Skin as pink c) Chest expansion as normal d) Heart rate as normal

Respirations as increased and high Correct Explanation: Infants with meconium aspiration syndrome may show signs of respiratory distress (tachypnea, cyanosis, retractions, chest retractions). The other choices document normal findings.

A newborn is being monitored for retinopathy of prematurity. Which of the following conditions predisposes an infant to this condition? a) Esophageal atresia b) Down syndrome c) Respiratory distress syndrome d) Hydrocephalus

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

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which of the following should the nurse consider as a complication of oxygen administration at a high concentration? a) Retinopathy of prematurity b) Diminished erythropoiesis c) Bronchopulmonary dysplasia d) Necrotizing enterocolitis

Retinopathy of prematurity Correct Explanation: Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.

When caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant? a) Using minimal amount of tape b) Rocking and massaging c) Using distraction through objects d) Swaddling and positioning

Rocking and massaging

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression. Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.

A nurse is caring for a baby girl born at 34 weeks' gestation. Which of the following features should the nurse identify as those of a preterm newborn? a) Scant coating of vernix b) Closely approximated labia c) Paper-thin eyelids d) Shiny heels and palms

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

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which of the following additional signs should the nurse consider as indications of respiratory distress syndrome (RDS) in the newborn? a) Inspiratory grunt b) Deep inspiration c) Sternal retraction d) Expiratory lag

Sternal retraction Correct Explanation: The nurse should consider sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration.

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

Sticky forest green Correct Explanation: Meconium is usually a sticky, forest-green liquid. It contains bile acids, salts, and mucus. The other choices describe stool at various stages after the passage of meconium.

A nurse is assessing an infant who has experienced asphyxia at birth. Which finding indicates that the resuscitation methods have been successful? a) Heart rate of 80 bpm b) Jitteriness c) Hypotonia d) Strong cry

Strong cry

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

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

A 39-year-old multigravida with diabetes presents to the clinic at 32 weeks' gestation because she has not felt the fetus moving lately. FHR is absent; sonogram confirms that the fetus has died. The nurse's institution has a policy of taking photographs of such fetuses once they are born. The nurse informs the woman that pictures have been taken and asks her if she wants them; she angrily tells the nurse no, then bursts into tears. How should the nurse respond?

Tell her that the hospital will keep the photos for her in case she changes her mind. Emotional care of the woman is complex. The woman may need time to move through the stages of grief and the responses of grief vary from person to person. The mother may request the items later and they should be stored or kept for a year after the delivery. There is no need to apologize to the client. It would be inappropriate to console her with the fact that she has other children. It negates her feelings and is not supportive of the woman at this time.

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

Term Correct Explanation: A term newborn is one born from the first day of the 38th week of gestation through 42 weeks. A postterm newborn is one born after completion of 42 weeks' gestation. A preterm newborn is one born before completion of 37 weeks' gestation. A late preterm newborn is one who is bone between 34 and 36-6/7 weeks' gestation

A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will most likely be classified as which of the following? a) Term, small for gestational age, and very-low-birth-weight infant b) Term, small for gestational age, and low-birth-weight infant c) Late preterm and appropriate for gestational age d) Late preterm, large for gestational age, and low-birth-weight infant

Term, small for gestational age, and low-birth-weight infant Correct Explanation: Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small for gestational age (SGA). Those who fall above the 90th percentile in weight are considered large for gestational age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLB). Those born weighing 500 to 1000 g are considered extremely very-low-birth-weight infants (EVLB).

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

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

Which statement describes why hypertonic contractions tend to become very painful?

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. Hypertonic contractions cause uterine cell anoxia, which is painful.

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

The newborn may look wrinkled and old at birth.

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

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

The nurse observes a neonate delivered at 28 weeks' gestation. Which finding would the nurse expect to see? a) The pinna of the ear is soft and flat and stays folded. b) The neonate has 7 to 10 mm of breast tissue. c) The skin is pale, and no vessels show through it. d) Creases appear on the interior two-thirds of the sole.

The pinna of the ear is soft and flat and stays folded. Correct Explanation: The ear has a soft pinna that's flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.

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

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

A preterm infant is transferred to a distant hospital for care. When her parents visit her, which of the following would be most important for you to urge them to do? a) Call the baby by her name. b) Touch and, if possible, hold her. c) Stand so the baby can see them. d) Bring a piece of clothing for her.

Touch and, if possible, hold her. Correct Explanation: Preterm infants may be hospitalized for an extended time, so parents need to be encouraged to touch and interact with the infant to begin bonding.

In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus.

True

Preterm infant deaths account for 80% to 90% of infant mortality in the first year of life. a) False b) True

True

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

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

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

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

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?

Use a fist to apply counter pressure to the lower back. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position.

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

Very low birth weight Correct Explanation: A birth weight of 1.2 kg would be classified as very low birth weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low birth weight. A birth weight between 1,000 g and 1,500 g is termed a very low birth weight. A birth weight less than 1,000 g is termed an extremely low birth weight

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

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. Explanation: After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance.

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention?

a forceps and vacuum-assisted birth A forceps-and-vacuum-assisted birth is required for the client having a prolonged second stage of labor. The client may require a cesarean birth if the fetus cannot be delivered with assistance. A precipitous birth occurs when the entire labor and birth process occurs very quickly. Artificial rupture of membranes is done during the first stage of labor.

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

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

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

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

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

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

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

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

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to:

assess the rate of flow of the oxytocin infusion. A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?

brachial plexus assessment The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation?

breech presentation Breech presentation is when the fetal buttocks present first rather than the head. Face and brow presentation has complete extension of the fetal head. Brow presentation is when the fetal head is between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis. Persistent occiput posterior position is the engagement of fetal head in the left or right occiputo-transverse position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position. Normal presentation is head first or occiput anterior.

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

continuing to monitor maternal and fetal status Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus.

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction?

contractions most forceful in the middle of uterus rather than the fundus Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction. Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet.

A woman is admitted to the labor suite with contractions every five minutes lasting one minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth?

cord compression Oligohydramnios and meconium staining of the amniotic fluid are common complications of postterm pregnancy. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor.

The nurse providing care for a woman with preterm labor on magnesium sulfate would include which assessment for safe administration of the drug?

deep tendon reflexes (DTR)s Assessing deep tendon reflexes hourly in a client receiving magnesium sulfate is appropriate as depressed DTRs are a sign of magnesium toxicity. Elevated blood glucose is a fetal side effect but not noted to assess with the mother. Assessing for depressed respiration and hypotension not tachypnea or tachycardia would be appropriate assessments needed for the safe administration of magnesium sulfate.

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

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

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the a) foramen ovale closes prematurely. b) ductus arteriosus remains open. c) pulmonary artery closes. d) aorta or aortic valve strictures.

ductus arteriosus remains open. Explanation: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

A nurse is assessing a pregnant woman who has come to the clinic. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply.

dull low backache malodorous vaginal discharge dysuria Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and heaviness or aching in the thighs. Constipation is not known to be a sign of preterm labor. Preterm labor is assessed when there are more than six contractions per hour.

The nurse assesses that the fetus of a woman is in an occiput posterior position. Which description identifies the way the nurse would expect the client's labor to differ from others?

experience of additional back pain Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction birth.

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

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

A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?

external cephalic version External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilatation of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called?

external version External version is the process of manipulating the position of the fetus in order to try to turn the fetus to a cephalic presentation.

The client is 35 weeks of gestation and is being admitted for vaginal bleeding. She is stable at the time of admission. The priority nursing assessment for the client is for:

fetal heart tones. When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. The other options are not a higher priority than fetal heart tones.

At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what does the nurse prepare her?

hospitalization, tocolytic therapy, and IM corticosteroids At 31 weeks gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allow for monitoring and a safe place if the woman continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the woman home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal kick counts is typically done with a postterm pregnancy.

A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?

identical The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical).

A nurse is reading a journal article about cesarean births and the indications for them. Place the indications for cesarean birth below in the proper sequence from most frequent to least frequent. All options must be used.

labor dystocia abnormal fetal heart rate tracing fetal malpresentation multiple gestation suspected macrosomia The most common indications for primary cesarean births include, in order of frequency, labor dystocia, abnormal fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected macrosomia.

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?

less than 3 hours Precipitous labor is completed in less than 3 hours.

A nursing student correctly identifies the most desirable position to promote an easy birth as which position?

occiput anterior Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm. dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?

occiput posterior position A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor."

A client is at 23 weeks' gestation and was admitted for induction and birth after noting the infant was an intrauterine fetal death. The client had fallen 3 days prior to the diagnosis and landed on her side. What is the most likely attributable cause to the fetal death?

placental abruption The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. The scenario does not indicate that there has been a premature rupture of membranes or the possibility of preeclamsia.

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

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

The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which term?

precipitous labor When the expulsive forces of the uterus become dysfunctional, the uterus may either never fully relax (hypertonic contractions) placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions. Another dysfunction can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place (precipitous labor).

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

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

A woman the nurse is caring for during labor is having contractions 2 minutes apart but rarely over 50 mm Hg in strength; the resting tone is high, 20 to 25 mm Hg. She asks what she can do to make contractions more effective. The nurse's best response would be that:

she needs to rest because her contractions are hypertonic. These contractions appear to be hypertonic because of the high resting tone. Hypertonic contractions occur because the uterus is being overstimulated or erratically stimulated. Rest is effective in helping contractions become more productive.

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?

the 41-year-old client who conceived by in vitro fertilization The nurse should assess infertility treatment as a contributor to increased probability of multiple gestations. Multiple gestations do not occur with an adolescent birth; instead, chances of multiple gestations are known to increase due to the increasing number of women giving birth at older ages.

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

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

While in labor a woman with a prior history of cesarean birth reports light-headedness and dizziness. The nurse assesses the client and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms?

uterine rupture The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.

A client just delivered a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Estimate the urinary flow by weighing the diaper. b) Dress the baby in a stockinette cap. c) Dress the baby to keep the body warm. d) Place the baby under isolette care. e) Carry and handle the baby frequently.

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

The nurse in the NICU is caring for preterm newborns. Which of the following are recommended guidelines for care of these newborns? Select all that apply. a) Take the newborn's temperature often. b) Discourage contact with parents to maintain asepsis. c) Dress the newborn in ways to preserve warmth. d) Supply oxygen for the newborn, if necessary. e) Handle the newborn as much as possible. f) Give the newborn a warm bath immediately.

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

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply. a) Offer early feedings b) Stop breastfeeding until jaundice resolves c) Increase the infant's hydration d) Initiate phototherapy e) Administer vitamin supplements

• Increase the infant's hydration • Offer early feedings • Initiate phototherapy

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

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

The nurse caring for newborns on an obstetrical ward assesses a SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) Diminished muscle tissue b) Tight and moist skin c) Sparse or absent hair d) Narrow skull sutures e) Poor skin turgor f) Increased fatty tissue

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

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

• Sunken abdomen • Poor muscle tone over buttocks • Dry or thin umbilical cord Explanation: A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.

Which of the following would be most effective in reducing pain in the preterm newborn? Select all that apply. a) Removing tape quickly from the skin b) Swaddling the newborn closely c) Offering a pacifier prior to a procedure d) Encouraging kangaroo care during procedures e) Increasing the volume on device alarms f) Using cool blankets to soothe the newborn

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

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply. a) Avoid using disposable equipment b) Use sterile gloves for an invasive procedure c) Avoid coming to work when ill d) Cover jewelry while washing hands e) Initiate universal precautions when caring for the infant

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