Maternity and newborn
Pain should be regularly assessed in all newborns. If the infant is displaying physiologic or behavioral cues that indicate pain, then measures should be taken to manage the pain. Which interventions are examples of nonpharmacologic pain management techniques? (Select all that apply.) Select one or more: a. Nonnutritive sucking b. Swaddling c. Acetaminophen d. Sucrose e. Skin-to-skin contact with the mother
A B D E
*Painful nipples are a major reason why women stop breastfeeding. A primary intervention to decrease nipple irritation is: Select one: a. Teaching proper techniques for latching-on and releasing of suction b. Applying hot compresses to breast prior to feeding c. Instructing woman to express colostrum or milk at the end of the feeding session and rub it on her nipples d. Air drying nipples for 10 minutes at the end of the feeding session
A
A mother is changing the diaper of her newborn son and notices that his scrotum appears large and swollen. The client is concerned. What is the bestresponse from the nurse? Select one: a. "A large scrotum and swelling indicate a hydrocele, which is a common finding in male newborns." b. "Your baby might have testicular cancer." c. "I don't know, but I'm sure it is nothing." d. "Your baby's urine is backing up into his scrotum."
A
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? Select one: a. The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth. b. The nurse should immediately notify the pediatrician for this emergency situation. c. If this baby was born vaginally, then a pneumothorax could be indicated. d. The neonate must have aspirated surfactant.
A
A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation for administration of Vitamin K to the infant, the nurse will explain to the parents that an injection of this medication: Select one: a. Influences the activation of coagulation factors to prevent delayed clotting and hemorrhagic disease b. Prevents high levels of unconjugated bilirubin in the newborn's blood c. Prevents the excessive loss of RBCs d. Aids the liver in regulation of blood glucose
A
An infant admitted to the newborn nursery has a blood glucose level of 55 mg/dL. Which of the following actions should the nurse perform at this time? Select one: a. Provide the baby with routine feedings. b. Assess the baby's blood pressure. c. Place the baby under the infant warmer. d. Monitor the baby's urinary output.
A
An infant boy was delivered minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. When should the Apgar assessment be performed? Select one: a. At least twice, 1 minute and 5 minutes after birth b. Every 15 minutes during the newborn's first hour after birth c. Once by the obstetrician, just after the birth d. Only if the newborn is in obvious distress
A
The nurse is advising parents of a full-term neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select one: a. Put the car seat facing forward only after the baby reaches 20 pounds. b. The infant car seat should be placed facing the rear seat in the front seat of the car. c. Car seats are recommended only when traveling longer distances from home; holding the infant is safe for short trips d. It is safe to leave an infant in a car seat alone as long as the windows are down at least 1 inch.
A
The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)? Select one: a. 120 to 160 b. 80 to 100 c. 100 to 120 d. 150 to 180
A
The nurse is teaching a client with preterm premature rupture of membranes (PPROM) regarding self-care activities. Which activities should the nurse include in her teaching? Select one: a. Do not engage in sexual activity. b. Tampons are safe to use to absorb the leaking amniotic fluid. c. Taking frequent tub baths is safe. d. Report a temperature higher than 40° C.
A
The nurse is teaching the parents of a female baby how to change a baby's diapers. Which of the following should be included in the teaching? Select one: a. Always wipe the perineum from front to back. b. Use an antibiotic ointment at the first sign of diaper rash c. Put powder on the buttocks every time the baby stools. d. Weigh every diaper in order to assess for hydration.
A
To accurately measure the neonate's head, the nurse places the measuring tape around the head: Select one: a. Just above the ears and eyebrows b. Middle of the ear and over the eyes c. Middle of the ear and over the bridge of the nose d. Just below the ears and over the upper lip
A
Under which circumstance should the nurse immediately alert the pediatric provider? Select one: a. Infant is dusky and turns cyanotic when crying. b. Acrocyanosis is present 1 hour after childbirth. c. The infant's blood glucose level is 45 mg/dl. d. The infant goes into a deep sleep 1 hour after childbirth.
A
What is the most critical physiologic change required of the newborn after birth? Select one: a. Initiation and maintenance of respirations Correct b. Full function of the immune defense system c. Maintenance of a stable temperature d. Closure of fetal shunts in the circulatory system
A
Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? Select one: a. Babinski b. Stepping c. Tonic Neck d. Plantar grasp
A
The perinatal nurse observed the pediatrician completing the Ballard Maturational Score (BMS). The maturity components used with this assessment are (select all that apply): Select one or more: a. Physical b. Behavioral c. Reflexive d. Neuromuscular
A D
The nurse is about to elicit the rooting reflex on a newborn baby. Which of the following responses should the nurse expect to see? Select one: a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.
A (An infant exhibits Rooting reflex when the neonate turns his head toward the direction of the stimulus and opens his mouth. Choice 2 is the Babinski reflex; Choice 3 is the Startle or Moro reflex; Choice 4 is the Tonic Neck reflex)
The nursery nurse notes the presence of diffuse edema on a baby girl's head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edema has disappeared. The nurse documents the following condition in the infant's chart. Select one: a. Caput succedaneum b. Cephalhematoma c. Subperiosteal hemorrhage d. Epstein pearls
A (Caput succedaneum is localized soft tissue edema of the scalp; feels spongy; may cross suture lines; results from prolonged pressure of the head against the maternal cervix during labor; resolves within the first week of life.)
A mother of a 10-day-old infant calls the clinic and reports that her baby is having loose, green stools. The mother is breastfeeding her infant. Which of the following is the best nursing action? Select one: a. Instruct the woman to bring her infant to the clinic. b. Instruct the woman to decrease the amount of feeding for 24 hours and to call if the stools continue to be loose. c. Explain that this is a normal stool pattern. d. Instruct the woman to eat a bland diet for the next 24 hours and call back if the stools continue to be loose and green.
A (Instruct parents to notify the health care provider if stools are runny and green and/or if newborn/infant has less than 6 wet diapers per day.)
Which of the following breath sounds are normal to hear in the neonate during the first few hours postbirth? Select one: a. Scattered crackles b. Wheezes c. Stridor d. Grunting
A (Scattered crackles may be detected during the first few hours after birth due to retained amniotic fluid. Persistent crackles, wheezes, stridor, grunting, paradoxical breathing, decreased breath sounds, and/or prolonged periods of apnea are signs of respiratory distress. Decreased or absent breath sounds are often related to meconium aspiration or pneumothorax.)
Which of the following breath sounds are normal to hear in the neonate during the first few hours postbirth? Select one: a. Scattered crackles b. Wheezes c. Stridor d. Grunting
A (Scattered crackles may be detected during the first few hours after birth due to retained amniotic fluid. Persistent crackles, wheezes, stridor, grunting, paradoxical breathing, decreased breath sounds, and/or prolonged periods of apnea are signs of respiratory distress. Decreased or absent breath sounds are often related to meconium aspiration or pneumothorax.)
A first-time mother informs her nurse that she is concerned about infant abduction. The nurse should explain to the parents which of the following? (Select all that apply.) Select one or more: a. Do not allow a person without proper unit specific hospital ID to take their baby. b. Encourage parents to accompany any person who removes their infant from the hospital room c. Instruct parents not to leave their newborn unattended at any time d. Inform parents that ID bands with matching identification numbers are placed on the parents and infant at birth to ensure identification of the correct infant with the correct parents
A B C D
General skin care for full-term infants includes which of the following? (Select all that apply.) Select one or more: a. Avoid daily bathing with soap. b. Use a cleanser with a neutral pH. c. Avoid fragrant soaps. d. Apply petrolatum-based ointments sparingly to dry skin, but avoid head and face.
A B C D (It is not necessary to bathe an infant daily. Daily bathing with soap can cause dry skin in the infant. The cleanser should be of neutral pH and free of additives such as fragrances that could be irritants.)
*Heat loss through radiation can be reduced by: (Select all that apply). a. Removing wet blankets used to dry the infant after birth from the crib b. Placing a stocking cap on the neonate's head and placing in a crib c. Providing skin-to-skin contact with the mother and covering both with a warm blanket when the room temperature is cool d. Placing crib near a warm wall
A B C D (double check)
During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. What are these four essential factors? Select one or more: a. Thermal b. Mechanical c. Sensory d. Psychologic e. Chemical
A B C E
A healthy, full-term baby boy is scheduled for a circumcision. Nursing actions prior to the procedure include which of the following? (Select all that apply.) Select one or more: a. Obtain written consent from the parents b. Administer acetaminophen PO 1 hour before procedure per provider order. c. Feed the neonate glucose water 30 minutes before the procedure. d. Verify that the neonate has voided
A B D (Nursing actions include obtaining written consent, administering acetaminophen as per provider order, and ensuring the neonate has voided; neonate should not eat 2-3 hours prior to the procedure to avoid risk of vomiting and aspiration)
The nurse is teaching the parents of a healthy newborn about infant safety. Which of the following should be included in the teaching plan? (Select all that apply). Select one or more: a. Water temperature for the infant's bath should be 100.4 degrees F. b. Do not cook while holding an infant c. Cover electrical outlets d. Remove strings from infant sleepwear, bedding, and pacifiers to prevent strangulation.
ALL (double check)
*A nurse is performing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for congenital dislocation of the hip? Select one: a. Grasp the inner aspects of the baby's calves with thumbs and forefingers. b. Gently abduct the baby's thighs listening for clicks at the joints. c. Palpate the baby's patellae to assess for subluxation of the bones. d. Dorsiflex the baby's feet.
B
A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? Select one: a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life c. Physiologic jaundice is also known as breast milk jaundice. d. Physiologic jaundice is caused by blood incompatibilities between the mother and the infant blood types.
B
A perinatal nurse assesses a term newborn for respiratory functioning. The nurse knows that which of the following conditions is normal for newborns? Select one: a. A respiratory rate of 60 to 80 breaths per minute b. A breathing pattern that is often shallow, diaphragmatic, and irregular c. Periodic episodes of apnea d. Retractions of the chest wall
B
A primiparous woman is watching her newborn sleep. She wants him to wake up and respond to her. The mother asks the nurse how much he will sleep every day. What is an appropriate response by the nurse? Select one: a. "He is being stubborn by not waking up when you want him to. You should try to keep him awake during the daytime so that he will sleep through the night." b. "The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing." c. "He will only wake up to be fed, and you should not bother him between feedings." d. "He will probably follow your same sleep and wake patterns, and you can expect him to be awake soon."
B
A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the client place the infant to her breast within 15 minutes after birth. The nurse is aware that the initiation of breastfeeding is most effective during the first 30 minutes after birth. What is the correct term for this phase of alertness? Select one: a. Second period of reactivity b. First period of reactivity c. Transition period d. Organizational stage
B
An infant boy was delivered minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. When should the Apgar assessment be performed? Select one: a. Only if the newborn is in obvious distress b. At least twice, 1 minute and 5 minutes after birth c. Once by the obstetrician, just after the birth d. Every 15 minutes during the newborn's first hour after birth
B
As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Based on the most recent evidence, which information is incorrect and should be discussed with parents? Select one: a. Avoid loose bedding, water beds, and beanbag chairs. b. Place the infant on his or her abdomen to sleep. c. Prevent exposure to people with upper respiratory tract infections. d. Keep the infant away from secondhand smoke.
B
At 1 minute after birth a nurse assesses an infant and notes a heart rate of 80 beats per minute, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. Which Apgar score does the nurse calculate based upon these observations and signs? Select one: a. 6 b. 5 c. 7 d. 4
B
Early this morning, an infant boy was circumcised using the PlastiBell method. Based on the nurse's evaluation, when will the infant be ready for discharge? Select one: a. When yellow exudate forms over the glans b. When the infant voids c. When the bleeding completely stops d. When the PlastiBell plastic rim (bell) falls off
B
The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)? Select one: a. 80 to 100 b. 120 to 160 c. 150 to 180 d. 100 to 120
B
The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients? Select one: a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b. If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks. c. Hearing screening is now mandated by federal law. d. Federal law prohibits newborn genetic testing without parental consent.
B
The nurse is using the New Ballard Scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? Select one: a. Faint red marks on the soles of the feet b. Flexed posture c. Smooth, pink skin with visible veins d. Abundant lanugo
B
The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. What information provided by the nurse would be most useful to these new parents? Select one: a. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." b. "Infants can track their parents' eyes and can distinguish patterns; they prefer complex patterns." c. "Infants can see very little until approximately 3 months of age." d. "It's important to shield the newborn's eyes. Overhead lights help them see better."
B
What is one of the initial signs and symptoms of puerperal infection in the postpartum client? Select one: a. Pain with voiding b. Temperature of 38° C (100.4° F) or higher on 2 successive days c. Profuse vaginal lochia with ambulation d. Fatigue continuing for longer than 1 week
B
What is the primary nursing responsibility when caring for a client who is experiencing an obstetric hemorrhage associated with uterine atony? Select one: a. Preparing the woman for surgical intervention b. Performing fundal massage c. Establishing venous access d. Catheterizing the bladder
B
What marks on a baby's skin may indicate an underlying problem that requires notification of a physician? Select one: a. Telangiectatic nevi on the nose or nape of the neck b. Petechiae scattered over the infant's body c. Erythema toxicum neonatorum anywhere on the body d. Mongolian spots on the back
B
Which information about variations in the infant's blood counts is important for the nurse to explain to the new parents? Select one: a. Platelet counts are higher in the newborn than in adults for the first few months. b. An early high white blood cell (WBC) count is normal at birth and should rapidly decrease. c. Even a modest vitamin K deficiency means a problem with the blood's ability to properly clot. d. A somewhat lower-than-expected red blood cell count could be the result of a delay in clamping the umbilical cord.
B
Which intervention by the nurse would reduce the risk of abduction of the newborn from the hospital? Select one: a. Restricting the amount of time infants are out of the nursery b. Applying an electronic and identification bracelet to the mother and the infant c. Carrying the infant when transporting him or her in the halls d. Instructing the mother not to give her infant to anyone except the one nurse assigned to her that day
B
Which intervention can nurses use to prevent evaporative heat loss in the newborn? Select one: a. Placing the baby away from the outside walls and windows b. Drying the baby after birth, and wrapping the baby in a dry blanket c. Warming the stethoscope and the nurse's hands before touching the baby d. Keeping the baby out of drafts and away from air conditioners
B
A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions would be appropriate for the nurse to delegate to the CNA? Select one: a. Admit a newly delivered baby to the nursery. b. Bathe and weigh a 3-hour-old baby. c. Provide discharge teaching to the mother of a 4-day-old baby. d. Interpret a bilirubin level reported by the laboratory.
B (Assessment and education are within the scope of practice of an RN; CNAs may perform basic skills under the supervision of the RN.)
A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions would be appropriate for the nurse to delegate to the CNA? Select one: a. Admit a newly delivered baby to the nursery. b. Bathe and weigh a 3-hour-old baby. c. Provide discharge teaching to the mother of a 4-day-old baby. d. Interpret a bilirubin level reported by the laboratory.
B (Assessment and education are within the scope of practice of an RN; CNAs may perform basic skills under the supervision of the RN.)
During the assessment of the newborn at 3 hours of age, the perinatal nurse documents the presence on the infant's scalp of a unilateral, well-defined mass which does not cross the suture lines. The mother's chart indicates a prolonged labor with use of a vacuum extractor. The RN identifies this finding as: Select one: a. Caput succedaneum b. Cephalohematoma c. Molding d. Intraventricular hemorrhage
B (Cephalohematoma is hematoma formation between the periosteum and skull with unilateral swelling. It appears within a few hours of birth and can increase in size over the next few days. It has a well-defined outline and does not cross suture lines.)
The nurse assesses that a full-term neonate's temperature is 97.1°F (36.2°C). The first nursing action is to: Select one: a. Turn up the heat in the room. b. Place the neonate on the mother's chest with a warm blanket over the mother and baby. c. Take the neonate to the nursery and place in a radiant warmer. d. Notify the neonate's primary provider.
B (Preventative nursing actions to prevent cold stress include skin-to-skin contact with the mother withe a warm blanket over both.)
Typical signs of abusive head trauma (AHT, also known as Shaken Baby Syndrome) include which of the following? (Select all that apply.) Select one or more: a. Broken clavicle b. Poor feeding c. Vomiting d. Breathing problems
B C D
Women who are obese are at risk for several complications during pregnancy and birth. Which of these would the nurse anticipate with an obese client? (Select all that apply.) Select one or more: a. Breech presentation b. Hypertension c. Thromboembolism d. Cesarean birth e. Wound infection
B C D E
The "Period of Purple Crying" is a program developed to educate new parents about infant crying and the dangers of shaking a baby. Each letter in the acronym "PURPLE" represents a key concept of this program. Which concepts are accurate? (Select all that apply.) Select one or more: a. L: extremely loud b. U: unexpected c. R: baby is resting at last d. P: peak of crying and painful expression e. E: evening
B D E (P: peak of crying and painful expression, U: unexpected, E: evening)
*The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks' gestation with no birth trauma. The nurse's findings include the following parameters: heart rate 136 beats per minute; respiratory rate 64 breaths per minute; temperature 98.2°F (36.8°C); length 49.5 cm; and weight 3500 g. The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate consultation with the baby's health-care provider? Select one: a. Respiratory rate b. Presence of a heart murmur c. Absent bowel sounds d. Weight
C
*The nurse is teaching the parents of a 1-day-old baby how to give their baby a bath. Which of the following actions should be included? Select one: a. Clean the eye from the outer aspect to the inner aspect. b. Keep the door of the room open to allow for ventilation. c. Gather all supplies before beginning the bath. d. Bathe daily with warm soapy water.
C
*Which component of the sensory system is the least mature at birth? Select one: a. Smell b. Hearing c. Vision d. Taste
C
*While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive _____ reflex. Select one: a. tonic neck b. Babinski c. Moro d. glabellar
C
A client at 39 weeks of gestation has been admitted for an external version. Which intervention would the nurse anticipate the provider to order? Select one: a. Foley catheter b. Local anesthetic c. Tocolytic drug d. Contraction stress test (CST)
C
A new father wants to know what medication was put into his infant's eyes and why it is needed. How does the nurse explain the purpose of the erythromycin (Ilotycin) ophthalmic ointment? Select one: a. This ointment prevents the infant's eyelids from sticking together and helps the infant see. b. Erythromycin (Ilotycin) ophthalmic ointment destroys an infectious exudate caused by Staphylococcus that could make the infant blind. c. This ophthalmic ointment prevents gonorrheal infection of the infant's eyes, potentially acquired from the birth canal. d. Erythromycin (Ilotycin) prevents potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes.
C
A new mother notices what appears to be bruising over her newborn's buttocks. She asks the nurse if the baby has been injured in some way. The nurse explains that this is: Select one: a. Erythema Toxicum b. Jaundice c. Mongolian spots d. Milia
C
Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? Select one: a. The baby with respirations 52, oxygen saturation 98% b. The baby with Apgar 9/9, weight 2960 grams c. The baby with temperature 96.3°F, length 17 inches d. The baby with glucose 60 mg/dL, heart rate 132
C
The exact cause of preterm labor is unknown but believed to be multifactorial. Infection is thought to be a major factor in many preterm labors. Which type of infection has not been linked to preterm birth? Select one: a. Periodontal b. Urinary tract c. Viral d. Cervical
C
The nurse is circulating during a cesarean birth of a preterm infant. The obstetrician requests that cord clamping be delayed. What is the rationale for this directive? Select one: a. To decrease total blood volume b. To reduce the risk for jaundice c. To reduce the risk of intraventricular hemorrhage d. To improve the ability to fight infection
C
Which is the most accurate description of PPD without psychotic features? Select one: a. Condition that is more common among older Caucasian women because they have higher expectations b. Condition that disappears without outside help c. Distinguishable by irritability d. Postpartum baby blues requiring the woman to visit with a counselor or psychologist
C
Which of the following statements indicates that a new mother needs additional teaching? Select one: a. "I need to supervise my cat when she is in the same room as my baby." b. "I will place my baby on her back when she is sleeping." c. "I will not leave my baby on an elevated flat surface after she is able to turn over on her own." d. "I have asked my husband to install safety latches on the lower cabinets."
C
Which statement related to cephalopelvic disproportion (CPD) is the least accurate? Select one: a. CPD can be related to either fetal size or fetal position. b. The fetus cannot be born vaginally. c. CPD can be accurately predicted d. Causes of CPD may have maternal or fetal origins.
C
Which of the following statements indicates that a new mother needs additional teaching? Select one: a. "I need to supervise my cat when she is in the same room as my baby." b. "I will place my baby on her back when she is sleeping." c. "I will not leave my baby on an elevated flat surface after she is able to turn over on her own." d. "I have asked my husband to install safety latches on the lower cabinets."
C (Infants should never be left unattended on an elevated flat surface)
One of the following neonates is at highest risk for cold stress: Select one: a. LGA neonate at 38 weeks gestation b. AGA neonate at 37 weeks gestation c. SGA neonate at 33 weeks gestation d. SGA neonate at 40 weeks gestation
C (Risk factors for cold stress include prematurity, small for gestational age (SGA); hypoglycemia, prolonged resuscitation efforts, sepsis, neurological/endocrine/cardiorespiratory problems)
During labor induction with oxytocin, the fetal heart rate baseline is in the 140s with moderate variability. Contraction frequency is assessed to be every 2-3 minutes with duration of 60 seconds, of moderate strength to palpation. Based on this assessment, the nurse should take which action? Select one: a. Increase oxytocin infusion rate per provider's protocol. b. Stop oxytocin infusion immediately. c. Maintain present oxytocin infusion rate and continue to assess. d. Decrease oxytocin infusion rate by 2 mU/min and report to provider.
C (The goal of oxytocin use in labor is to establish uterine contraction patterns that promote cervical dilation of about 1 cm/hr once in active labor. The lowest possible dose should be used to achieve labor progress. Generally, the labor pattern should be 3 UCs in 10 minutes, lasting 40-60 seconds with an intensity of 25-75 mm/HG with IUPC and resting tone <20 mm HG with 1 minute between each UC. The labor pattern described above is appropriate and no increase or decrease in oxytocin infusion rate is indicated.)
A nurse is providing discharge teaching to the parents of a 2-day-old neonate. Which of the following information should be included in the discharge teaching on umbilical cord care? Select one: a. Cleanse the cord twice a day with hydrogen peroxide. b. Remove the cord with sterile tweezers if the cord does not fall off by 10 days of age. c. Call the provider if greenish discharge appears. d. Cover the cord with sterile dressing until it falls off.
C (The umbilical cord is clamped at birth and the clamp is removed after 24 hours of life. The cord falls off and the site heals within 2 weeks. The diaper is placed below the cord to facilitate drying. Parents should be instructed to contact the provider if there is bleeding from the cord site, foul-smelling drainage, redness, or fever. Follow institutional guidelines for cord cleaning; generally, the cord is left alone except when soiled with stool or urine - wipe clean with plain water and allow to dry.)
A nurse is providing discharge teaching to the parents of a 2-day-old neonate. Which of the following information should be included in the discharge teaching on umbilical cord care? Select one: a. Cleanse the cord twice a day with hydrogen peroxide. b. Remove the cord with sterile tweezers if the cord does not fall off by 10 days of age. c. Call the provider if greenish discharge appears. d. Cover the cord with sterile dressing until it falls off.
C (The umbilical cord is clamped at birth and the clamp is removed after 24 hours of life. The cord falls off and the site heals within 2 weeks. The diaper is placed below the cord to facilitate drying. Parents should be instructed to contact the provider if there is bleeding from the cord site, foul-smelling drainage, redness, or fever. Follow institutional guidelines for cord cleaning; generally, the cord is left alone except when soiled with stool or urine - wipe clean with plain water and allow to dry.)
Heat loss through radiation can be reduced by: (Select all that apply). Select one or more: a. Removing wet blankets used to dry the infant after birth from the crib b. Placing a stocking cap on the neonate's head and placing in a crib c. Providing skin-to-skin contact with the mother and covering both with a warm blanket when the room temperature is cool d. Placing crib near a warm wall
C D (double check)
*If the newborn has excess secretions, the mouth and nasal passages can be easily cleared with a bulb syringe. How should the nurse instruct the parents on the use of this instrument? Select one: a. Insert the compressed bulb into the center of the mouth. b. Avoid suctioning the nares. c. Remove the bulb syringe from the crib when finished. d. Suction the mouth first.
D
A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on high. The nurse instructs the mother that the fan should not be directed toward the newborn and that the newborn should be wrapped in a blanket. The mother asks why. How would the nurse respond? Select one: a. "Your baby will easily get cold stressed and needs to be bundled up at all times." b. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." c. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." d. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him."
D
A primigravida at 40 weeks of gestation is having uterine contractions every 1½ to 2 minutes and states that they are very painful. Her cervix is dilated 2 cm and has not changed in 3 hours. The woman is crying and wants an epidural. What is the likely status of this woman's labor? Select one: a. She is experiencing precipitous labor. b. She is exhibiting hypotonic uterine dysfunction. c. She is experiencing a normal latent stage. d. She is exhibiting hypertonic uterine dysfunction
D
Instructions to a mother of an uncircumcised male infant should include which of the following? Select one: a. Instruct her to use a cotton swab to clean under the foreskin. b. Instruct her to clean the penis by retracting the foreskin. c. Instruct her to clean the penis with alcohol. d. Instruct her not to retract the foreskin.
D
Screening for critical congenital heart disease (CCHD) was added to the uniform screening panel in 2011. The nurse has explained this testing to the new mother. Which action by the nurse related to this test is correct? Select one: a. Screening is performed when the infant is 12 hours of age. b. Oxygen (O2) is measured in both hands and in the right foot. c. Testing is performed with an electrocardiogram. d. A passing result is an O2 saturation of ≥95%.
D
The nurse caring for a newborn checks the record to note clinical findings that occurred before her shift. Which finding related to the renal system would be of increased significance and require further action? Select one: a. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days. b. Breastfed infants will likely void more often during the first days after birth. c. Brick dust or blood on a diaper is always cause to notify the physician. d. The pediatrician should be notified if the newborn has not voided in 24 hours
D
The nurse is completing a physical examination of the newborn 24 hours after birth. Which component of the evaluation is correct? Select one: a. Once often neglected, blood pressure is now routinely checked. b. When the nurse listens to the neonate's heart, the S1 and S2 sounds can be heard; the S1 sound is somewhat higher in pitch and sharper than the S2 sound. c. The parents are excused to reduce their normal anxiety. d. The nurse can gauge the neonate's maturity level by assessing his or her general appearance.
D
What is the primary rationale for nurses wearing gloves when handling the newborn? Select one: a. Because the nurse has the primary responsibility for the baby during the first 2 hours b. As part of the Apgar protocol c. To protect the baby from infection d. To protect the nurse from contamination by the newborn
D
When assessing the apical pulse (point of maximal impulse: PMI) of the neonate, the stethoscope should be placed at the: Select one: a. First or second intercostal space B. Fifth intercostal space c. Third intercostal space d. Fourth intercostal space
D
Which cardiovascular changes cause the foramen ovale to close at birth? Select one: a. Increased pressure in the right atrium b. Decreased blood flow to the left ventricle c. Changes in the hepatic blood flow d. Increased pressure in the left atrium
D
Which condition is considered a medical emergency that requires immediate treatment? Select one: a. ITP b. Hypotonic uterus c. Uterine atony d. Inversion of the uterus
D
Which explanation will assist the parents in their decision on whether they should circumcise their son? Select one: a. The infant will likely be alert and hungry shortly after the procedure. b. American Academy of Pediatrics (AAP) recommends that all male newborns be routinely circumcised. c. Circumcision is rarely painful, and any discomfort can be managed without medication. d. The circumcision procedure has pros and cons during the prenatal period.
D
What is the rationale for evaluating the plantar crease within a few hours of birth? Select one: a. Heel sticks may be required. b. Creases will be less prominent after 24 hours. c. Newborn has to be footprinted. d. As the skin dries, the creases will become more prominent.
D (This helps the nurse better evaluate for physical maturity)
A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in the baby as a result? Select one: a. Skin color is dusky. b. Vital signs are labile. c. Glucose levels are subnormal. d. Circumcision site oozes blood.
D (Vitamin K activates coagulation factors which prevent delayed clotting and hemorrhagic disease)
The nurse assessing a newborn for heat loss is aware that nonshivering thermogenesis utilizes the newborn's stores of brown adipose tissue (BAT) to provide heat in the cold-stressed newborn. Select one: True False
True
Endometritis is an infection that usually starts at the placental site. Select one: True False
True (Endometritis is an infection of the endometrium that usually starts at the placental site and spreads to encompass the entire endometrium.)
