Exam 3: Adaptive Quizzing
A mother asks the neonatal nurse why her infant must be monitored for hypoglycemia when her type 1 diabetes was in excellent control during her pregnancy. How should the nurse respond? 1 "A newborn's glucose level drops after birth, so we're being especially cautious with your baby because of your diabetes." 2 "A newborn's pancreas produces an increased amount of insulin during the first day of birth, so we're checking to see whether hypoglycemia has occurred." 3 "Babies of mothers with diabetes do not have large stores of glucose at birth, so it's difficult for them to maintain the blood glucose level within an acceptable range." 4 "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."
"Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop." The infant of a diabetic mother (IDM) produces a higher level of insulin in response to the increased maternal glucose level; after birth it takes several hours for the newborn to adjust to the loss of the maternal glucose. A healthy newborn's glucose level does not drop significantly after birth. A newborn's pancreas usually produces more insulin as a response to the maternal glucose level, but this response is not specific to the IDM. IDMs have the same glucose stores as other newborns; their responses to the loss of maternal glucose levels differ.
While observing a mother visiting her preterm son in the neonatal intensive care nursery, the nurse notes that she has not yet begun the bonding process. Which statement by the mother supports the nurse's conclusion? 1 "It's such a tiny baby." 2 "Do you think he'll make it?" 3 "Why does he need to be in an incubator?" 4 "My baby looks so much like my husband."
"It's such a tiny baby." By failing to acknowledge the infant as a person, the client indicates that she has not released her fantasy baby and accepted the real baby. Acknowledging the infant by using the word "he" denotes a relationship. Saying that the baby looks like her husband indicates that the mother has incorporated the infant into the family.
A nurse watches as a new mother timidly approaches her critically ill preterm son for the first time in the neonatal intensive care unit. Which statement by the nurse would best foster the bonding process between the mother and her baby? 1 "I'll teach you how to take care of him." 2 "He'll gain weight gradually, and it won't be long till he'll start to look better." 3 "I know it's hard for you to see him like this, hooked up to so many machines, and you don't know what to expect." 4 "Many mothers are shocked when they first see their babies; you'll see him grow."
"I know it's hard for you to see him like this, hooked up to so many machines, and you don't know what to expect." Focusing on the client's feelings permits her to work through her fears, which she must do before she can focus on her son and his care. Telling the client that the infant will gain weight and look better gradually or that that she will see her baby grow is false reassurance; the focus should be on the mother's feelings at this time, not her infant's future.
During the second postpartum hour after a long labor and birth, a nurse identifies that the client has heavy vaginal bleeding that does not diminish after fundal massage. The client reports, "I'm so thirsty. May I have some ginger ale?" How should the nurse reply? 1 "It's good to replenish your fluids. I'll bring you some ginger ale right now." 2 "I can imagine how thirsty you are, but I need to get clearance from the obstetrician before I can give you anything to drink." 3 "Your fluid level should return to normal as quickly as possible. The blood loss can begin to balance itself if you drink enough fluids." 4 "I know this is difficult, but it's best for you to wait until the bleeding has subsided. I can give you a moisturizer for your lips to relieve the dryness."
"I know this is difficult, but it's best for you to wait until the bleeding has subsided. I can give you a moisturizer for your lips to relieve the dryness." The client should receive nothing by mouth while heavy bleeding continues because surgical intervention may become necessary. Providing oral fluids at this time is inappropriate and could result in aspiration if surgery becomes necessary. The nurse does not need a prescription to give fluids to a postpartum client; the nurse must make an independent judgment regarding the withholding of fluids. Although oral fluids can increase the blood volume, it would be inappropriate to provide fluids while the client is bleeding.
On her first visit to the neonatal intensive care unit to see her preterm newborn daughter, the mother stands 2 feet away and does not touch the infant. The mother's only comment to the nurse is, "She looks so fragile. Do you think she'll make it?" What is the most appropriate response by the nurse? 1 "Many infants born as small as she is have done just fine." 2 "The staff is confident, because preterm babies do look like this at first." 3 "She's not as fragile as she appears. Do you find it so frightening that you can't touch her?" 4 "It's understandable that she looks fragile to you. What have you learned about her condition?"
"It's understandable that she looks fragile to you. What have you learned about her condition?" The correct statement conveys acceptance by the nurse and encourages the mother to verbalize additional concerns; also, it explores the mother's understanding of the practitioner's explanation. Comparing the baby to other infants denies the mother the opportunity of further exploration. Telling the mother that the staff members are confident or asking what it is she finds so frightening about her daughter belittle the mother's concerns and cuts off further communication.
A client who has six living children has just given birth. After expulsion of the placenta, an infusion of lactated Ringer's solution with 10 units of oxytocin (Pitocin) is prescribed. What should the nurse explain to the client when she asks why this infusion is needed? 1 "You had a precipitous birth." 2 "This is required for an extramural birth." 3 "The medication helps your uterus contract." 4 "It will help you expel the retained fragments of your placenta."
"The medication helps your uterus contract." Multiple full-term pregnancies and births result in overstretched uterine muscles that do not contract efficiently, and bleeding may ensue. Oxytocin (Pitocin) promotes uterine contractions. A precipitous birth does not predispose a client to uterine atony unless there is a complication. Giving birth outside the birthing area does not predispose the client to uterine atony. Multiparity does not predispose the client to retained placental fragments.
A nurse is giving discharge instructions to a new mother. What is the most important instruction to help prevent postpartum infection? 1 "Don't take tub baths for at least 6 weeks." 2 "Wash your hands before and after changing your sanitary napkins." 3 "Douche with a dilute antiseptic solution twice a day and continue for a week." 4 "Tampons are better than sanitary napkins for inhibiting bacteria in the postpartum period."
"Wash your hands before and after changing your sanitary napkins." Infection is most commonly transmitted through contaminated hands. Tub baths are permitted. Douching is contraindicated. Tampons are contraindicated in the postpartum period until the cervix has closed completely; they may promote infection when used too early.
While reviewing the health history of a newborn with suspected jaundice, the nurse recalls that some risk factors place infants at a higher risk developing jaundice. Which conditions are risk factors for jaundice? Select all that apply. 1 Infection 2 Female sex 3 Prematurity 4 Breastfeeding 5 Formula feeding 6 Maternal diabetes
1, 3, 4, 6 Infants are at a higher risk of jaundice if they are born prematurely, are exclusively breastfed, have an infection, or their mothers have diabetes. Jaundice is more common in male infants. Infants that are fed formula do not develop jaundice as often as breastfeed babies do.
During a home visit the nurse obtains information about a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. Correct 1 Lethargy 2 Ambivalence 3 Emotional lability 4 Increased appetite 5 Long periods of sleep
1, 2, 3 Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is associated with depression.
A nurse is assessing several postpartum clients. Which conditions increase the risk for postpartum hemorrhage? Select all that apply. 1 Twin birth 2 Overdistended bladder 3 Hypertonic uterine dystocia 4 Retained placental fragments 5 Mild gestational hypertension
1, 2, 4 Overdistention of the uterus may lead to delayed or inadequate uterine contractions. An overdistended bladder may inhibit uterine contractions. Retained placental fragments inhibit uterine contractions. Clients with ineffective uterine contractions are treated with rest and sedatives; although labor is prolonged, postpartum hemorrhage is not expected. Mild gestational hypertension does not interfere with uterine involution.
A nurse is caring for a new mother who has a chlamydial infection. For which complications should the nurse assess the client's neonate? Select all that apply. 1 Pneumonia 2 Preterm birth 3 Microcephaly 4 Conjunctivitis 5 Congenital cataracts
1, 2, 4 Pneumonia may develop in the newborn with a chlamydial infection; oral antibiotics such as erythromycin may be required. Preterm birth is a common complication of chlamydial infection. Ophthalmia neonatorum (neonatal conjunctivitis) is common in newborns whose mothers have chlamydial infection; ophthalmic antibiotic ointments are administered to all newborns prophylactically. Microcephaly is more likely to occur in newborns with severe infections of toxoplasmosis or cytomegalovirus. Cataracts may occur in a newborn whose mother had rubella during pregnancy.
A nurse is assessing a male newborn. Which characteristics should alert the nurse to conclude that the newborn is a preterm infant? Select all that apply. 1 Small breast buds 2 Wrinkled thin skin 3 Multiple sole creases 4 Presence of scrotal rugae 5 Pinnae that remain flat when folded
1, 2, 5 Breast buds are small, with underdeveloped nipples, in the preterm infant. Preterm newborns have little subcutaneous fat; the skin is wrinkled and blood vessels and bony structures are visible. Preterm infants' ears contain little cartilage and are very inelastic when folded; at term, the ears contain cartilage and the pinnae are firm. Sole creases develop progressively during pregnancy and cover the entire foot at term. A preterm male infant's testes are undescended; rugae develop progressively and cover the entire scrotum of the full-term male newborn.
Typical signs of neonatal abstinence syndrome related to opioid withdrawal usually begin within 24 hours after birth. What characteristics should the nurse anticipate in the infant of a suspected or known drug abuser? Select all that apply. 1 Tremors 2 Dehydration 3 Hyperactivity 4 Muscle hypotonicity 5 Prolonged sleep periods
1, 3 Opioid dependence in the newborn is physiological; as the drug is cleared from the body, signs of drug withdrawal become evident. Tremors are a typical sign of cerebral irritability. Hyperactivity is a typical sign of cerebral irritability. Dehydration is a result of inadequate feeding, not a direct result of opioid withdrawal. Muscle hypertonicity, not hypotonicity, occurs with opioid withdrawal. Signs of opioid withdrawal include excessive activity and sleep disturbances.
A nurse is testing a newborn's heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? Select all that apply. 1 Preterm infant 2 Infant with Down syndrome 3 Small-for-gestational-age infant 4 Large-for-gestational-age infant 5 Appropriate-for-gestational-age infant
1, 3, 4 Preterm infants have low glycogen stores. Small-for-gestational-age infants have low glycogen stores. Large-for-gestational-age infants are prone to hyperinsulinemia; often they are born to mothers who have diabetes, meaning that they are exposed to a high circulating glucose level while in utero. After prolonged exposure to a high glucose level, hyperplasia of the pancreas occurs, resulting in hyperinsulinemia. Infants with Down syndrome are not at risk for hypoglycemia but are at risk for congenital cardiac defects. Appropriate-for-gestational-age infants are not at risk for hypoglycemia.
A nurse is assigned to care for an infant in the newborn nursery who was born 4 hours ago. Maternal substance abuse is strongly suspected. Which symptoms are seen in neonates demonstrating signs of drug withdrawal? Select all that apply. 1 Tachypnea 2 Relaxed muscle tone 3 Exaggerated Moro reflex 4 Prolonged, high-pitched cry 5 Restlessness and excessive activity 6 Strong sucking and swallowing reflex
1, 3, 4, 5 In addition to these symptoms, an infant experiencing drug withdrawal has muscle rigidity with increased muscle tone and poor sleep patterns. Such infants are often difficult to console.
A nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn? Select all that apply. 1 Pallor 2 Irritability 3 Hypotonia 4 Ineffective sucking 5 Excessive birth weight
2, 3, 4 An inadequate amount of cerebral glucose causes irritability and restlessness. Hypoglycemia affects the central and peripheral nervous systems, resulting in hypotonia. Feeding difficulties are due to hypoglycemic effects on the fetal central nervous system. Hypoglycemia causes cyanosis, not pallor, in the newborn. Excessive birthweight is common but does not indicate hypoglycemia. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.
A nurse determines that a newborn is in respiratory distress. Which signs confirm this assessment? Select all that apply. 1 Crackles 2 Cyanosis 3 Wheezing 4 Tachypnea 5 Retractions
2, 4, 5 Cyanosis occurs because of inadequate oxygenation. Tachypnea is a compensatory mechanism to increase oxygenation. Retractions occur in an effort to increase lung capacity. Crackles occur in the healthy newborn. Wheezing in the newborn is benign.
The nurse is performing a gestational age assessment, using the New Ballard Scale. According to the following information and graph, at how many weeks gestation is the newborn? Total Neuromuscular Score: 16 Total Physical Maturity Score: 20
38 The fetus is at 38 weeks' gestation. Add the total neuromuscular score of 16 to the total physical maturity score of 20 for a total of 36. Look under the score total score column and you will find that the closest number to the total score of 36 is 35. Staying on the same row, move right, to the Gestational Age column, where you will find the gestational age of 38 weeks.
The nurse is caring for a group of postpartum clients. Which one should the nurse monitor most closely? 1 A primipara who had an 8-lb newborn 2 A grand multipara who just had her sixth child 3 A primipara who received 50 mcg of IV fentanyl during her labor 4 A multipara whose placenta was expelled 15 minutes after the birth
A grand multipara who just had her sixth child A grand multipara is a woman who has had at least 6 births. Multiparity contributes to an increased incidence of uterine atony because the uterine muscle may not contract effectively, leading to postpartum hemorrhage. A primipara should maintain a well-contracted uterus because with only one pregnancy the uterus usually maintains its tone. Fifty micrograms of fentanyl is not considered excessive for a primipara and will not contribute to uterine atony. A multipara is a woman who has given birth to at least two children. The birth of the placenta 15 minutes after birth of the neonate is expected and does not affect uterine tone.
A nurse on the postpartum unit is assessing several clients. Which clinical finding requires immediate investigation? 1 An inflamed episiotomy 2 A slow trickle of blood from the vagina 3 An estimated blood loss of half a liter during a vaginal birth 4 A boggy uterine fundus that becomes firm after prolonged massage
A slow trickle of blood from the vagina Vaginal bleeding may be an early sign of hemorrhage; hypovolemic shock can develop. An inflamed episiotomy is an expected finding; ice packs help resolve the inflammation. Expected blood loss for a vaginal birth is 300 to 500 mL. A fundus that has been overstretched or is multiparous may require prolonged massage until it becomes firm.
Which client is at risk for a postpartum infection? 1 A primipara who gives birth to an infant weighing more than 8.5 lb 2 A woman who required catheterization after voiding less than 75 mL 3 A multipara with a hemoglobin level of 11 g at the time of admission 4 A women who loses at least 350 mL of blood during the birthing process
A woman who required catheterization after voiding less than 75 mL Repeated catheterizations for residual urine increase the chance that bacteria will be introduced and their growth fostered. The size of the newborn does not predispose the mother to postpartum infection. Hemoglobin levels of 11 grams do not reflect the highest risk for infection; a hemoglobin of 11 grams is at the low end of the acceptable range. A loss of 250 to 500 mL of blood is considered acceptable.
During the postpartum period a client tells the nurse that she was very uncomfortable during her pregnancy because of varicose veins. In light of this information, what should the nurse's assessment include? 1 Monitoring daily clotting times 2 Assessing for peripheral pulses 3 Monitoring daily hemoglobin values 4 Assessing for signs of thrombophlebitis
Assessing for signs of thrombophlebitis Varicose veins predispose the client to thrombophlebitis; warmth, redness, and pain in the calf are signs of thrombophlebitis. The clotting mechanism is not affected; clot formation results because of venous pooling and decreased venous return caused by the impaired vasculature. The problem is venous, not arterial, so pulses are not affected. Hemoglobin values are affected by the amount of bleeding that occurred during the birth, which usually is not severe enough to impair circulatory competency.
An infant exhibits purulent conjunctivitis on the fourth day of life and is brought to the emergency department. What is the priority nursing action? 1 Assessing the infant for signs of pneumonia 2 Securing a prescription for allergy testing of the infant 3 Bathing the infant's eyes with a tepid boric acid solution 4 Teaching the mother to wash her hands before touching the infant
Assessing the infant for signs of pneumonia Chlamydia trachomatis is associated with the development of pneumonia in the newborn. Purulent conjunctivitis at this time suggests a Chlamydia infection, not an allergic response. Boric acid solution will not solve this problem; a prescribed antibiotic is required. Teaching the mother to wash her hands before touching the infant would be done eventually; however, the priority is assessing the infant for signs of pneumonia.
What is the priority nursing intervention during the 2 hours after a cesarean birth? 1 Evaluating fluid needs to maintain optimum hydration 2 Monitoring the incision to help prevent the onset of infection 3 Encouraging bonding to promote mother-infant interaction 4 Assessing the lochia to identify the complication of hemorrhage
Assessing the lochia to identify the complication of hemorrhage The amount and character of the lochia must be checked after a cesarean birth just as they are after a vaginal birth. Although it is important to maintain hydration, preventing hemorrhage is the priority. Although the area of the incision is monitored for signs of hemorrhage, it is too early for evidence of infection. Bonding is an important consideration after the conditions of both mother and newborn have stabilized.
A neonate born at 35 weeks' gestation has Apgar scores of 8 and 9. At 4 hours of age the newborn begins to experience respiratory distress, has a below-normal temperature in a warm environment, and has a low blood glucose level. What problem does the nurse suspect? 1 Hypoglycemia 2 Bacterial sepsis 3 Cocaine withdrawal 4 Meconium aspiration
Bacterial sepsis Preterm neonates react to infection with respiratory distress and subnormal temperatures. Although hypothermia is one sign of hypoglycemia, the newborn is not exhibiting other signs, such as tremors and lethargy. The data do not indicate that meconium was present at birth. Four hours of age is too early for signs of cocaine drug withdrawal to occur.
A nurse is caring for a postpartum client with a history of rheumatic heart disease. The nurse plans care for this client with the knowledge that the client should: 1 Increase her oral fluid intake 2 Maintain bedrest for a minimum of 4 days 3 Be out of immediate danger because the stress associated with pregnancy is over 4 Be monitored during the first 48 hours because of the stress on the cardiopulmonary system
Be monitored during the first 48 hours because of the stress on the cardiopulmonary system The blood volume was increased during pregnancy. The rapid fluid shift after the placenta is expelled causes hypervolemia, which increases the workload of the heart, making the first 48 postpartum hours crucial. Increasing the client's oral fluid intake is not recommended because it will further increase the circulating blood volume and necessitate an increased cardiac output. Progressive ambulation as tolerated is recommended. It takes 48 hours after the birth for the stress of childbearing to be minimized.
A nurse is caring for a postpartum client who had abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? 1 Boggy uterus 2 Hypovolemic shock 3 Multiple vaginal clots 4 Bleeding at the venipuncture site
Bleeding at the venipuncture site Bleeding at the venipuncture site indicates afibrinogenemia; massive clotting in the area of the separation has resulted in a decrease in the circulating fibrinogen level. A boggy uterus indicates uterine atony. Although hypovolemic shock may occur with DIC, there are other causes of hypovolemic shock, not just DIC. Blood clots indicate an adequate fibrinogen level; however, vaginal clots may indicate a failure of the uterus to contract and should be explored further.
A nurse withholds methylergonovine maleate (Methergine) from a postpartum client. What clinical finding supports the withholding of the medication? 1 Urine output of 50 mL/hr 2 Third-degree perineal laceration 3 Blood pressure of 160/90 mm Hg 4 Respiratory rate of 12 breaths/min
Blood pressure of 160/90 mm Hg Methylergonovine maleate can cause hypertension and should not be given to a client with an increased blood pressure. Urine output of 50 mL/hr is an expected finding in a healthy adult. Perineal lacerations are not related to methylergonovine maleate (Methergine) use. Methylergonovine maleate does not affect respiration.
A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy? 1 Stimulates the liver to dispose of the bilirubin 2 Breaks down the bilirubin into a conjugated form 3 Facilitates the excretion of bilirubin by activating vitamin K 4 Dissolves the bilirubin, allowing it to be excreted by the skin
Breaks down the bilirubin into a conjugated form Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by way of the skin.
A few weeks after discharge, a postpartum client experiences mastitis and telephones for advice concerning breastfeeding. The nurse notifies the practitioner to have antibiotics prescribed. What should the nurse recommend that the client do? 1 Wean the infant from the breast. 2 Start formula feedings immediately. 3 Breastfeed often to keep the breasts empty. 4 Apply ice packs to suppress milk production.
Breastfeed often to keep the breasts empty. Breastfeeding often keeps the breasts as empty as possible, limiting pressure within the ducts and thereby reducing pain. Also, milk stasis and exacerbation of the infection can be prevented. Weaning will cause stasis of milk ducts and increase the fullness of the breasts at this time, thereby increasing pain. Alternatives to weaning and bottle feeding should be tried first; breastfeeding should be continued. Ice packs will suppress milk production and impede breastfeeding.
A client who had a cesarean birth is unable to void 3 hours after the removal of an indwelling catheter. How can the nurse evaluate whether the client's bladder is distended? 1 By catheterizing the client for residual urine 2 By palpating the client's suprapubic area gently 3 By asking the client whether she still feels the urge to urinate 4 By determining whether the client is experiencing suprapubic pain
By palpating the client's suprapubic area gently Palpation will indicate whether bladder distention is present. The increased intra-abdominal space available after birth can result in bladder distention without discomfort. Assessment should be done first. Trauma to the area makes surrounding organs atonic; the client may have a full bladder and not feel the urge to void.
A woman who was discharged recently from the hospital after undergoing a hysterectomy calls the clinic and states that she has tenderness, redness, and swelling in her right calf. What should the nurse instruct the client to do? 1 Stay in bed for at least 3 days. 2 Keep the legs elevated while sitting. 3 Apply a warm compress to the affected calf twice a day. 4 Call an ambulance to go to the emergency department.
Call an ambulance to go to the emergency department. The client's description of her problem is indicative of thrombophlebitis; this is a medical emergency because it may precipitate a pulmonary embolism. The client must be assessed by a health care provider. Intravenous anticoagulants will probably be necessary. Although bedrest may be prescribed eventually, a delay in pharmacologic treatment may jeopardize the client's status. Elevation of the legs may be prescribed eventually, after the thrombophlebitis is resolved. Although warm compresses are frequently prescribed, a delay in pharmacologic treatment may jeopardize the client's status.
A woman in labor with no known complications rings the call bell to say she has had a "gush" from her vagina. The nurse identifies a large amount of bright-red blood. In what order should the nurse perform these interventions? 1. Start oxygen at 8 L/mask. 2. Call for help. 3. Check fetal heart tones. 4. Call the health care provider. 5. Increase the maintenance IV infusion rate.
Call for help. Check fetal heart tones. Increase the maintenance IV infusion rate. Start oxygen at 8 L/mask. Call the health care provider. Calling for help will allow all other actions to be completed more quickly. This is especially critical during an emergency situation. Next the nurse should assess the fetal heart tones to identify the effect of the bleeding on the fetus, because the fetus often shows signs of distress before the mother does. After checking the fetal heart tone the nurse should increase the IV infusion rate, which should take only seconds and can have a significant effect on circulation. Oxygen can be instituted after the IV infusion rate has been increased; this will be of benefit to both mother and fetus. Calling the primary health care provider is important, but instituting lifesaving measures takes precedence.
A neonate is born with exstrophy of the bladder, and the parents are upset. They are told that corrective surgery will be performed as soon as possible. How can the nurse best help the parents at this time? 1 Teaching the parents about preoperative and postoperative care 2 Caring for the newborn in the same manner as any other newborn 3 Keeping the newborn as clean as possible to decrease the odor of urine 4 Reassuring the parents that after surgery their newborn will grow and develop without any after-effects
Caring for the newborn in the same manner as any other newborn The nurse's role-modeling of acceptance of the infant, even with the newborn's altered physical appearance, can help the parents adjust. Teaching the parents about preoperative and postoperative care is appropriate later; the parents first need to deal with their feelings regarding the newborn's appearance. The parents' current major adjustment concern is the appearance of the infant; odor is secondary. Reassuring the parents that after surgery their newborn will grow and develop without any after effects is false reassurance; there are no guarantees related to the outcome of the surgery.
A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. What condition does the nurse suspect? 1 HIV infection 2 Chlamydia trachomatis infection 3 Retinopathy of prematurity (retrolental fibroplasia) 4 A reaction to the ophthalmic antibiotic instilled after birth
Chlamydia trachomatis infection Chlamydia trachomatis infection occurs 3 to 4 days after birth; if it is not treated prophylactically with an antibiotic at birth or within 3 days, chronic follicular conjunctivitis with conjunctival scarring will occur. HIV infection in the newborn does not manifest with conjunctivitis. The high oxygen concentrations given to severely compromised preterm infants cause vasoconstriction of retinal capillaries, which can lead to blindness; there are no data to indicate that this infant was preterm, severely compromised, or received oxygen. A chemical conjunctivitis occurs within the first 48 hours and is not purulent.
The postpartum nurse has just received report on four clients. Which client should the nurse care for first? 1 Client who vaginally delivered a 7-lb baby 1 hour ago 2 Client who vaginally delivered a 9-lb baby 1 hour ago 3 Client who vaginally delivered a preterm baby 4 hours ago 4 Client who had a planned cesarean delivery of an 8-lb baby 2 hours ago
Client who vaginally delivered a 9-lb baby 1 hour ago The nurse should assess the client at risk for postpartum hemorrhage first. Uterine atony after a vaginal delivery is the main cause of postpartum hemorrhage. An overdistended uterus caused by a large fetus (9-lb baby) can cause uterine atony. Delivering a 7-lb baby or a preterm baby is not a risk factor. Uterine atony is minimized in a planned cesarean delivery.
What are the initial nursing actions after the birth of a preterm baby with an Apgar score of 6? 1 Checking and clamping the umbilical cord 2 Obtaining a footprint and applying an identification band 3 Drying the infant and placing the infant in a warm controlled environment 4 Obtaining equipment and assisting the health care provider with resuscitative efforts
Drying the infant and placing the infant in a warm controlled environment Cold stress produces hypoxia and acidemia. Because of physiologic factors such as a lack of brown fat, the preterm infant is more vulnerable to cool temperatures. Preparing to resuscitate is necessary when the infant has an Apgar of 0 to 3. Neither checking and clamping the umbilical cord nor obtaining a footprint and applying an identification band are priorities.
A client at 36 hours' postpartum is being treated with subcutaneous enoxaparin (Lovenox) for deep vein thrombosis of the left calf. Which client adaptation is of most concern to the nurse who is monitoring the client? 1 Dyspnea 2 Pulse rate of 62 beats/min 3 Blood pressure of 136/88 mm Hg 4 Homan sign in the left leg
Dyspnea One complication of deep vein thrombosis is pulmonary embolism; dyspnea is a significant sign that should be reported immediately. A low pulse rate is common for several days after birth because of the cardiovascular changes that occur during the early postpartum period. This blood pressure is not significant in a client with a deep vein thrombosis. Checking for the Homan sign is contraindicated because the clot could be dislodged.
A client has a cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client's first postpartum day? 1 Providing oxygen therapy 2 Administering pain medication 3 Encouraging frequent ambulation 4 Recommending an increase in oral fluids
Encouraging frequent ambulation Ambulation involves muscle contractions that promote an increase in circulation in the legs. During pregnancy, hypercoagulation is associated with an increase in clotting factors and fibrinogen, which increases the risk for thromboembolism. Oxygen therapy will not prevent thromboembolism. Relieving pain does not prevent thromboembolism, but pain medication may be needed to help the client tolerate ambulation. Increasing fluid intake will not prevent thromboembolism.
A preterm newborn is admitted to the neonatal intensive care unit (NICU). Which concern is most commonly expressed by NICU parents? 1 Fear of handling the infant 2 Delayed ability to bond with the infant 3 Prolonged hospital stay needed by the infant 4 Inability to provide breast milk for the infant
Fear of handling the infant Because these infants are so tiny and frail, parents most commonly fear handling or touching them; they should be encouraged to do so by the NICU staff. The primary concern is the infant's fragility, not bonding; however, bonding should be encouraged. Although there may be concerns about a long hospital stay, they are not commonly expressed by mothers. The primary concern is the infant's fragility, not breastfeeding. Breasts may be pumped and breast milk given in gavage feedings.
During a newborn assessment a nurse reports a sign of respiratory distress. What clinical manifestation has the nurse identified? 1 Flaring nares 2 Rapid heart rate 3 Abdominal respirations 4 Decreased respiratory rate
Flaring nares According to the Silverman-Anderson Index for respiratory function, flaring of the nares indicates respiratory distress; it is a compensatory mechanism to increase the intake of air. The heart rate of a newborn in respiratory distress usually remains within the normal range of 100 to 160 beats/min. Abdominal respirations are expected in the neonate; respiratory function is largely a matter of diaphragmatic contraction and expansion of the rib cage is limited in the neonate. The respiratory rate of a newborn in respiratory distress is rapid, more than 60 breaths/min. The expected respiratory rate for neonates ranges between 30 and 60 breaths/min.
The nurse is caring for a group of postpartum clients. Which factor puts a client at increased risk for postpartum hemorrhage? 1 Breastfeeding in the birthing room 2 Receiving a pudendal block for the birth 3 Having a third stage of labor that lasts 10 minutes 4 Giving birth to a baby weighing 9 lb 8 oz
Giving birth to a baby weighing 9 lb 8 oz The chance of postpartum hemorrhage is five times greater with large infants because uterine contractions may be impaired after the birth. Early breastfeeding will stimulate uterine contractions and lessen the chance of hemorrhage. Having a pudendal block for the birth does not contribute to postpartum hemorrhage, because the anesthetic for a pudendal block does not affect uterine contractions. Ten minutes is a short third stage; a prolonged third stage of labor, 30 minutes or more, may lead to postpartum hemorrhage.
A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)? 1 Gravida III with twins 2 Gravida V with endometriosis 3 Gravida II who had a 9-lb baby 4 Gravida I who has had an intrauterine fetal death
Gravida I who has had an intrauterine fetal death Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and high birthweight are not risk factors for DIC.
A nurse must continually assess a preterm infant's temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant: 1 Cannot use shivering to produce heat 2 Cannot break down glycogen to glucose 3 Has a limited supply of brown fat available to provide heat 4 Has a limited amount of pituitary hormones with which to control internal heat
Has a limited supply of brown fat available to provide heat Because neonates are unable to shiver, they use the breakdown of brown fat to supply body heat; the preterm infant has a limited supply of brown fat available for this purpose. An inability to use shivering to produce heat is not specific to preterm neonates; all newborns are unable to use shivering to supply body heat. The breakdown of glycogen into glucose does not supply body heat. Pituitary hormones do not regulate body heat.
A health care provider prescribes carboprost (Hemabate) to be administered to a postpartum client with intractable vaginal bleeding. What client factor should alert the nurse to question the prescription? 1 History of asthma 2 Homan sign 3 Increased blood pressure 4 Absence of the Babinski reflex
History of asthma Carboprost (Hemabate) is contraindicated in clients with asthma because of its respiratory side effects of coughing and dyspnea. The Homan sign indicates thrombophlebitis and is not related to carboprost. Carboprost does not affect blood pressure. Absence of the Babinski reflex is an expected adult finding.
A nurse is planning for the discharge of a crack-addicted 17-year-old mother and her newborn. What is the most appropriate referral to meet the mother's and infant's needs? 1 Legal aid 2 Family court 3 Foster parent care 4 Home health nurse
Home health nurse A nurse, by going into the home, will be able to monitor both the mother's and the infant's health, as well as the mother's parenting skills, and will be able to gather evidence of drug abuse or rehabilitation. The court system is already involved because of the infant's positive toxicology screen. Foster care is not automatic if it has been determined that the mother is able to care for the infant.
Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL. The nurse explains that what the infant has is physiologic jaundice, a benign condition, caused by: 1 Immature liver function 2 An inability to synthesize bile 3 An increased maternal hemoglobin level 4 A high hemoglobin and low hematocrit level
Immature liver function Jaundice occurs because of the expected physiologic breakdown of fetal red blood cells and the inability of the newborn's immature liver to conjugate the resulting bilirubin. Breastfed neonates are more prone to physiologic jaundice because of diminished calorie and fluid intake in the 3 days before milk production reaches normal volume. Conjugation and excretion, not synthesis of bile, are compromised because of the immature liver. The mother's hemoglobin level is unrelated to the newborn's; the mother and the fetus had separate circulations. Newborns usually have high hemoglobin and high hematocrit levels.
A nurse is caring for a preterm neonate who is receiving gastric feedings. Which neonatal clinical finding unique to necrotizing enterocolitis (NEC) leads the nurse to suspect that the neonate is experiencing this complication? 1 Persistent diarrhea 2 Decreased abdominal circumference 3 Small amount of vomitus after each gastric feeding 4 Increased amount of residual gastric volume from earlier feedings
Increased amount of residual gastric volume from earlier feedings An increasing residual volume without increasing intake indicates that absorption is decreasing, a sign of NEC. Diarrhea may or may not be related to NEC. The abdominal circumference increases, not decreases, with NEC. Small amounts of vomitus (spitting up) are common in the neonate because the cardiac (lower esophageal) sphincter of the stomach is weak. Study Tip: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group.
A client's membranes ruptured 20 hours before admission. The client was in labor for 24 hours before giving birth. For which postpartum complication is she at risk? 1 Infection 2 Hemorrhage 3 Uterine atony 4 Amniotic fluid embolism
Infection When the membranes rupture, microorganisms from the vagina may travel into the embryonic sac, causing chorioamnionitis. The longer the time between the rupture of the membranes and the birth, the greater the risk for infection. The temperature should be assessed every 1 to 2 hours, and any increase to 100.4° F (38° C) should be reported.If there are no other complications, hemorrhage and uterine atony are not expected. Amniotic fluid embolism is not likely to occur when the membranes rupture before birth because the fluid exits by way of the vagina rather than being forced upward.
What signs and symptoms of withdrawal does the nurse identify in a postpartum client with a history of opioid abuse? 1 Paranoia and evasiveness 2 Extreme hunger and thirst 3 Depression and tearfulness 4 Irritability and muscle tremors
Irritability and muscle tremors The earliest sign of opioid withdrawal is central nervous system overstimulation. Paranoia and evasiveness are related to opioid drug abuse, not opioid withdrawal. Extreme hunger and thirst have no relation to opioid withdrawal; most postpartum women are hungry and thirsty. Depression and tearfulness are not specific to people who abuse opioids. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.
A nurse suspects that a newborn is experiencing opioid withdrawal. Which assessment finding supports this suspicion? 1 Lethargy and constipation 2 Grunting and low-pitched cry 3 Irritability and nasal congestion 4 Watery eyes and rapid respirations
Irritability and nasal congestion Opioid withdrawal affects the central nervous system and respiratory system. Lethargy and constipation may occur in a newborn with thyroid deficiency. Grunting and a low-pitched cry may indicate that the newborn is experiencing cold stress or respiratory distress. Watery eyes and rapid respirations may occur in a newborn affected with syphilis.
A nurse is concerned about a client's mother-infant bonding when on the first postpartum day she is reluctant to: 1 Undress the newborn. 2 Breastfeed her newborn. 3 Look at her newborn's face. 4 Attend classes for newborn care.
Look at her newborn's face. Looking at the face or seeking eye-to-eye contact with the infant is an early sign of the start of bonding with the infant. The mother may feel inept or worry about upsetting the nurse by undressing her infant; new mothers need encouragement to undress their infants. Refusing to breastfeed her newborn may indicate that the mother is worried that she does not have enough milk, a common concern. The client may have attended prenatal classes, may be otherwise occupied, may not be feeling well enough to attend the class, or may feel that she has enough experience to care for her infant without attending a class for newborn care.
A nurse is caring for preterm infants with respiratory distress in the neonatal intensive care unit. What is the priority nursing action? 1 Limiting caloric intake to decrease metabolic rate 2 Maintaining the prone position to prevent aspiration 3 Limiting oxygen concentration to prevent eye damage 4 Maintaining a high-humidity environment to promote gas exchange
Maintaining a high-humidity environment to promote gas exchange The moisture provided by the humidity liquefies the tenacious secretions, making gas exchange possible. Caloric intake is increased; the amount, number, and type of feedings are related to the metabolic rate. Infants should be placed in a side-lying rather than a prone position; the prone position is associated with apnea and sudden infant death syndrome. Limiting oxygen concentration to prevent eye damage is not a routine action; the concentration of oxygen depends on the oxygen concentration of the neonate's blood gases.
A breastfeeding mother experiences redness and pain in the left breast, a temperature of 100.8° F (38.2° C), chills, and malaise. What condition does the nurse suspect? 1 Mastitis 2 Engorgement 3 Blocked milk duct 4 Inadequate milk production
Mastitis Because of the presence of generalized symptoms, the nurse should suspect mastitis. Engorgement would involve both breasts, not one. A blocked milk duct is usually marked by swelling and pain in one area of the breast but does not have systemic symptoms. There is no indication of the volume of milk being produced.
A newborn is admitted to the nursery and classified as small for gestational age (SGA). What is the priority nursing intervention for this infant? 1 Testing the infant's stools for occult blood 2 Monitoring the infant's blood glucose level 3 Placing the infant in the Trendelenburg position 4 Comparing the infant's head circumference and chest circumference
Monitoring the infant's blood glucose level SGA infants are prone to hypoglycemia because they have little subcutaneous fat or glycogen stores. Intestinal bleeding is not common in SGA infants. Placing an SGA infant in the Trendelenburg position is of no therapeutic value. Hydrocephalus or microcephaly is not a characteristic of SGA infants.
A nurse is assessing several postpartum clients. Which problem does the nurse identify that will most likely predispose a client to postpartum hemorrhage? 1 Preeclampsia 2 Multifetal pregnancy 3 Prolonged first-stage labor 4 Cephalopelvic disproportion
Multifetal pregnancy More than one fetus overdistends the uterus, which may result in uterine atony. Preeclampsia and prolonged labor are not associated with postpartum hemorrhage. Cephalopelvic disproportion alone does not predispose a woman to postpartum hemorrhage.
A nurse determines that a postpartum client is gravida 1, para 1. Her blood type is B negative, and her baby's blood type is O positive. What should the nurse include in the plan of care? 1 Obtaining an order for RhoGAM 2 Determining the father's blood type 3 Checking for signs of ABO incompatibility 4 Obtaining blood for type and crossmatching
Obtaining an order for RhoGAM RhoGAM will prevent sensitization from Rh incompatibility that may arise between an Rh-negative mother and an Rh-positive infant. Because the newborn has type O blood with no ABO incompatibility, neither mother nor infant will require a transfusion; this is the mother's first pregnancy, so the risk for RH incompatibility is minimal. Only the mother's and the newborn's Rh factors are relevant at this time. ABO incompatibility does not exist; it may if the mother has O-positive and the newborn has type B blood.
An infant of a diabetic mother is admitted to the neonatal intensive care unit. What is the priority nursing intervention for this infant? 1 Clamping the cord a second time 2 Obtaining heel blood to test the glucose level 3 Starting an intravenous infusion of glucose in water 4 Instilling an ophthalmic antibiotic to prevent an eye infection
Obtaining heel blood to test the glucose level Hypoglycemia may be present because of the sudden withdrawal of maternal glucose and increased fetal insulin production, which continues after birth. The umbilical vein may be needed to start an IV; it should not be damaged. An IV infusion of glucose should not be started until the blood glucose level has been determined. Instilling an antibiotic into the eyes can be delayed until the blood glucose level has been determined.
While monitoring a client in labor the nurse observes a gush of fluid from the client's vagina. What are the next nursing actions? 1 Placing the client flat in bed and elevating her legs 2 Positioning the client on her side and taking her blood pressure 3 Testing the client's discharge for alkalinity and obtaining the fetal heart rate 4 Placing the client in a modified lithotomy position and inspecting the perineum
Placing the client in a modified lithotomy position and inspecting the perineum Rupture of the membranes and the resulting gush of fluid can carry the umbilical cord downward. Immediate placement of the patient in the lithotomy position and inspection of the perineum may lead to identification of cord prolapse. Appropriate intervention may prevent fetal complications. The supine position depresses the vena cava, which may decrease blood flow and cause hypoxia in the fetus, as well as hypotension in the mother. Taking the client's blood pressure and placing the client on her side are routine intrapartum nursing measures that do not reveal the status of the fetus. Engaging in these actions delays inspection of the perineum. The gush of amniotic fluid is the result of rupture of the membranes; it is expected during labor, and the fluid need not be tested.
A primigravida is concerned about the health of her baby and asks the nurse, "What is the most common cause of death in babies?" The nurse explains that the cause of more than half of the neonatal deaths in the United States is: 1 Atelectasis 2 Preterm birth 3 Congenital heart disease 4 Respiratory distress syndrome
Preterm birth About two thirds of neonatal deaths are associated with preterm birth; there appears to be a correlation with teenage and older age pregnancies, lack of prenatal care, women who are nonwhite, and those who have chronic health problems. Atelectasis may occur as a result of respiratory distress, which in turn is associated with preterm birth, the leading cause of death. Most infants who die of congenital heart disease do so after the neonatal period. Respiratory distress syndrome is one complication of a preterm birth.
What is most important for the nurse to assess if a client has a precipitous birth? 1 Sudden chilling 2 Profuse bleeding 3 Decrease in heart rate 4 Increased blood pressure
Profuse bleeding A precipitate birth may be injurious to both mother and neonate. The maternal morbidity rate is increased by hemorrhage and/or an infection resulting from the trauma of a rapid, forceful birth in a contaminated field. Sudden chilling is common to all clients after all types of birth; the exact cause is unknown. If the client is bleeding profusely, she should be observed for shock, which is evidenced by a weak, rapid pulse. Increased blood pressure may be a result of the use of oxytocin or to preeclampsia, not precipitous birth.
A new father tells the nurse that he is anxious about not feeling like a father. What is the priority nursing action to meet this father's needs? 1 Encouraging the father's participation in a parenting class 2 Providing time for the father to be alone with and get to know the baby 3 Offering the father a demonstration on newborn diapering, feeding, and bathing 4 Allowing time for the father to ask questions after viewing a film about a new baby
Providing time for the father to be alone with and get to know the baby Time alone provides the opportunity for paternal-infant attachment/bonding. Touching the infant may reduce some of the father's anxiety. Although helpful, a parenting class does not meet the need for paternal-infant attachment/bonding. A demonstration on newborn diapering, feeding, and bathing does not acknowledge the father's anxiety; also, he may not be ready to absorb this information. Allowing time for the father to ask questions after viewing a film about a new baby is a simplistic approach to the father's emotional needs and does not address the father's concerns.
A newborn is found to have neonatal abstinence syndrome (NAS) after exhibiting jitteriness, irritability, and a shrill cry. What is the priority nursing care? 1 Administering an opioid antagonist 2 Limiting fluid intake to inhibit vomiting 3 Assessing for age-appropriate developmental level 4 Reducing environmental stimuli to promote relaxation
Reducing environmental stimuli to promote relaxation The addicted neonate is very sensitive to lights, noise, and surrounding activities; the infant must be kept calm and comfortable to reduce overreaction to stimuli. Morphine or other opioids are administered to those infants who have loose stools and other gastrointestinal problems resulting from withdrawal. Some of these infants need tranquilizers or sedatives to minimize the effects of withdrawal. Fluid intake must be increased to prevent dehydration in the infant who vomits. Assessment for developmental status is not the priority; physical needs take precedence. An opioid antagonist would lower the seizure threshold and is contraindicated in this clinical situation.
The nurse is planning care for a client with postpartum psychosis. Which priority intervention should the nurse plan to implement? 1 Teaching the client about normal newborn care 2 Ensuring adequate bonding time with the infant 3 Giving the client time and space to express her feelings 4 Referring the client to a psychiatric health care provider as prescribed
Referring the client to a psychiatric health care provider as prescribed. Assessment and management of postpartum psychosis are beyond the scope of a maternity nurse, and a mother who experiences this condition must be referred to a specialist for comprehensive therapy. Women with signs of postpartum psychosis need immediate medical attention to prevent suicide or infanticide. In light of this psychiatric emergency condition it would not be appropriate to plan bonding time for the client and infant, teach her about normal newborn care, or allow expression of her feelings.
What is the most common complication for which a nurse must monitor preterm infants? 1 Hemorrhage 2 Brain damage 3 Respiratory distress 4 Aspiration of mucus
Respiratory distress Immaturity of the respiratory tract in preterm infants is evidenced by a lack of functional alveoli, smaller lumina with increased possibility of collapse of the respiratory passages, weakness of respiratory musculature, and insufficient calcification of the bony thorax, leading to respiratory distress. Hemorrhage is not a common occurrence at the time of birth unless trauma has occurred. Brain damage is not a primary concern unless severe hypoxia occurred during labor; it is difficult to diagnose at this time. Aspiration of mucus may be a problem, but generally the air passageway is suctioned as needed.
The transmission of which microorganism that causes maternal mastitis is minimized by frequent handwashing by nursing staff members? 1 Escherichia coli 2 Group B Streptococcus 3 Staphylococcus aureus 4 Chlamydia trachomatis
Staphylococcus aureus Staphylococcus aureus is a resident organism of the skin; it is the causative agent of 95% of the infections that result in maternal mastitis. Escherichia coli is found in the lower intestinal tract; it is not associated with mastitis. Group B Streptococcus rarely causes mastitis. Chlamydia trachomatis can cause neonatal pneumonia and conjunctivitis, not mastitis.
During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? 1 Stimulating crying 2 Suctioning the airway 3 Using an Ambu bag with oxygen support 4 Placing the infant in the reverse Trendelenburg position
Suctioning the airway Suctioning must be done to minimize the possibility of the aspiration of meconium into the lungs. If the newborn cries before being suctioned, meconium may be aspirated. If the newborn is bagged, any meconium present will be forced into the lungs. If the newborn is positioned in reverse Trendelenburg, meconium may be aspirated.
After being shown to the parents, a preterm male newborn weighing 3 lb 15 oz (1500 g) is moved to the neonatal intensive care unit. What should the nurse's plan for parental visits include? 1 Taking them to visit their son as soon as possible 2 Securing a prescription for them to be allowed to visit their son 3 Determining whether their son's condition is satisfactory before taking them to see him 4 Discouraging them from being involved with their son until his prognosis is established
Taking them to visit their son as soon as possible The development of attachment between parents and infant is an important psychological goal and should be facilitated. The decision to visit is the nurse's responsibility and does not require a practitioner's permission. It is important for parents to develop a relationship with the ill newborn even if the prognosis is unfavorable.
A client arrives at the clinic with swollen, tender breasts and flulike symptoms. A diagnosis of mastitis is made. What does the nurse plan to do? 1 Help her wean the infant gradually. 2 Teach her to empty her breasts frequently. 3 Review breastfeeding techniques with her. 4 Send a sample of her milk to the laboratory for testing.
Teach her to empty her breasts frequently. Emptying the breasts limits engorgement because engorgement causes pressure and tenderness in an already tender area. Breastfeeding should be continued; it is not only unnecessary but also unwise to remove the infant from breastfeeding. Suckling keeps the breasts empty, limits engorgement, and reduces pain. Learning is difficult when the client is in pain; this may be done eventually, after the client has some relief from pain. The milk culture may be negative because the infection may be limited to the connective tissue of the breast.
The nurse is caring for a preterm infant in the neonatal intensive care unit. What early sign of neonatal sepsis should the nurse report to the health care provider? 1 Flat anterior fontanel 2 Increased temperature 3 Temperature instability 4 Brisk capillary refill time
Temperature instability In the neonate, early signs of infection are often subtle and can be indicators of other conditions. There may be temperature instability, respiratory problems, and changes in feeding habits or behavior. Early signs of sepsis in the neonate include full anterior fontanels (not flat) and prolonged capillary refill time (not brisk). Increased temperature or hyperthermia is a rare early sign of sepsis in the neonate.
A client who has had a postpartum hemorrhage is to receive 1 unit of packed red blood cells (RBCs). The nurse manager observes a staff nurse administering the packed RBCs without wearing gloves. What does the nurse manager conclude? 1 The client does not have an infection. 2 The donor blood is free of bloodborne pathogens. 3 The nurse should have worn gloves for self-protection. 4 The nurse was skilled enough to prevent exposure to the blood.
The nurse should have worn gloves for self-protection. The Centers for Disease Control and Prevention (CDC) recommends that gloves be worn when there is the potential for contact with blood or other body fluids. Even if the client does not have an infection, gloves are always worn when exposure to blood or other body fluids is a possibility. All blood is considered potentially infectious. Nurses are required to take precautions that limit exposure; gloves must be worn.
A postpartum nurse is providing care to four maternal/infant couplets. After receiving handoff report from the off-going nurse, which client will the nurse see first? 1 The term infant with a heart rate of 158 beats/min 1 hour after birth 2 The mother who has saturated one peripad over the 4 hours since delivery 3 The mother with a white blood cell count of 12,500/mm3 24 hours after delivery 4 The term infant with a transcutaneous bilirubin reading of 8.6 mg/dL 12 hours after birth
The term infant with a transcutaneous bilirubin reading of 8.6 mg/dL 12 hours after birth The appearance of jaundice during the first 24 hours of life or persistence beyond the ages delineated usually indicates a potential pathologic process that requires further investigation. The white blood cell count increase is normal after birth, possibly a result of to stress and tissue trauma during the birthing process. The acceptable range for the newborn heart rate is 110 to 160 beats/min. Saturating more than one pad per hour with lochia rubra is a matter of concern because it is less than the acceptable limit.
Phototherapy is prescribed for a preterm neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effect of the phototherapy? 1 Covering the trunk to prevent hypothermia 2 Using shields on the eyes to protect them from the light 3 Massaging vitamin E oil into the skin to minimize drying 4 Turning after each feeding to reduce exposure of each surface area
Using shields on the eyes to protect them from the light The lights used for phototherapy can damage the infant's eyes, and eye shields are standard equipment. Maximal effectiveness is achieved when the infant's entire skin surface is exposed to the light. Vitamin E oil massage is contraindicated because it can cause burns and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless of feeding times so that all body surfaces are exposed to the light and no single body surface is overexposed.
A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13 oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The client complains, "This pain in my vagina and rectum is excruciating, and my vagina feels so full and heavy." What does the nurse suspect as the cause of the pain? 1 Full bladder 2 Vaginal hematoma 3 Infected episiotomy 4 Enlarged hemorrhoid
Vaginal hematoma
A pregnant client with iron-deficiency anemia is prescribed iron supplements daily. To help the client increase iron absorption, the nurse should suggest that the client eat foods high in: 1 Vitamin C 2 Fat content 3 Water content 4 Vitamin B complex
Vitamin C Vitamin C aids the absorption of iron. Fat content, water content, and vitamin B complex are all unrelated to the absorption of iron. Study Tip: Rest is essential to the body and brain for good performance; think of it as recharging the battery. A run-down battery provides only substandard performance. For most students, it is better to spend 7 hours sleeping and 3 hours studying than to cut sleep to 6 hours and study 4 hours. The improvement in the rested mind's efficiency will balance out the difference in the time spent studying. Knowing your natural body rhythms is necessary when it comes to determining the amount of sleep needed for personal learning efficiency.
