MATERNITY/PED 20 - 25
20. A mother who requested discharge 24 hours after a normal vaginal birth calls the nurse the following day. She states she is worried because the baby is having episodes of crying, wants to nurse every 2 hours, and is having irregular breathing, and the temperature under her arm is 95.2°F. What is most important for the nurse to investigate further? a. Crying b. Axillary temperature of 95.2°F c. Irregular respirations d. Feeding every 2 hours
Answer: Axillary temperature 95.2°F Feedback: A low axillary temperature indicates the baby is at risk for cold stress and is an early sign of infection in the newborn. The nurse should obtain more information and either have the infant evaluated or ask the mother to remove some clothing and repeat the temperature. Episodes of crying, irregular respirations, and giving feeding cues every 2 hours are normal for the newborn.
17. The nurse is providing discharge teaching to a mother who is bottle-feeding her baby. Which of the following should the mother be counseled to avoid when reconstituting formula? a. Distilled water b. Tap water c. Filtered tap water d. Spring water
Answer: d. Spring water Feedback: There are no labeling requirements for the mineral content of spring water, so it is best to avoid using it when reconstituting formula. Distilled water has had all minerals removed from it; tap water is subject to analysis and must be safe for consumption by all members of the community, including newborns; and filtered tap water has had it mineral content further reduced by filtration.
9. A nurse is assisting the primary healthcare provider with a forceps-assisted birth. What information from the nurse allows the primary healthcare provider to determine the appropriate time to apply traction? a. When a contraction ends b. The estimated midpoint between contractions c. The current dose of oxytocin d. When a contraction begins
Answer: d. When a contraction begins Feedback: The nurse advises the primary healthcare provider when a contraction is present because traction is applied only with a contraction, not prior to or following a contraction. The current dose of oxytocin does not influence the timing of traction.
2) The newborn at 24 hours of age has a red blood cell (RBC) count of 5.4 million per milliliter. Which entry should the nurse expect to find in the newborn's chart to explain this laboratory value? 1. Cord clamping delayed until pulsation ceased. 2. Infant is breastfed 15 to 20 minutes every 3 hours. 3. CBC drawn from the anterior surface of the left hand. 4. Placental abruption noted to be 80% at time of delivery.
Answer: 1 Explanation: 1. Delayed cord clamping can cause an increase of up to 61%, resulting in a slightly higher-than-average RBC count. 2. Breastfeeding does not impact RBC counts in the first day of life. 3. Venous blood has lower RBC counts than do capillary blood samples. 4. Maternal or fetal blood loss causes hypovolemia and low RBC counts (less than 5.2 million per milliliter).
7) The nurse is teaching a class for new parents. Which statement indicates that additional information is needed? 1. "Car seats are installed the same way in different models of cars. Our friends can show us how to install it." 2. "Genitals of babies look swollen and enlarged at birth as a result of the hormones in the mother's circulation." 3. "We can call the nurse help line any time of day or night if we have questions about our baby after we get home." 4. "Baby girls sometimes have a little bloody mucus in their diapers as a reaction to the high estrogen level in the mother."
Answer: 1 Explanation: 1. Each model of car seat is installed differently in different makes of car. Directions for car seats should be followed carefully. Car dealerships often offer a car seat installation instruction service. 2. This is a true statement and often a concern of parents. 3. Most pediatrician offices, HMOs, hospitals, and physician groups have a nurse line staffed 24 hours a day, 7 days a week to respond to questions and concerns of parents. When this service exists, parents should be made aware of it and provided with the phone number. 4. This is a true statement. Parents might believe there is something wrong if they are not taught about pseudomenstruation.
2) The nurse receives shift change reports on infants born within the last 4 hours. Which newborn should the nurse see first? 1. Term male, grunting respirations 2. 37-week male, respiratory rate 45 3. 8 lb, 1 oz female, pulse 150 4. 39-week female, temperature 97°F
Answer: 1 Explanation: 1. Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly intervention immediately. 2. A normal respiratory rate is 30 to 60 breaths/min. This infant has no unexpected findings. 3. A normal pulse is 110 to 160 beats/min. This infant has no unexpected findings. 4. A normal temperature range is 96.8 to 97.7°F. This infant has no unexpected findings.
8) A client's fetus is estimated to weigh 4500 g (9 lb, 14 oz). Which statement indicates that additional teaching about the size of the baby is needed? 1. "His blood sugars could be high after he is born." 2. "I am at risk for excessive bleeding after delivery." 3. "My perineum could experience trauma during the birth." 4. "His shoulders could get stuck and a collar bone broken."
Answer: 1 Explanation: 1. Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic fetus. 2. Because of the excessive size of the uterus with a macrosomic fetus, uterine atony leading to postpartum hemorrhage is a risk. 3. Perineal trauma due to the large fetus is a possible complication of vaginal delivery of a macrosomic fetus. 4. Shoulder dystocia is more common among large fetuses, and a broken clavicle could result.
11) The nurse manager of the neonatal intensive care unit is preparing a handout for new parents. Which statement should the nurse include? 1. Neonates have a tendency to become dehydrated. 2. Sugar is always present in the urine of a newborn. 3. The kidneys are fully functional by 30 weeks' gestation. 4. Newborns can eliminate excess fluid as quickly as an adult.
Answer: 1 Explanation: 1. Neonates cannot concentrate their urine or pull water back into the vascular volume, and thus can become dehydrated easily. 2. Glucose is not identified as always being present in the urine of a newborn. 3. Full nephron function does not develop until 34 to 36 weeks. 4. Newborns have difficulty eliminating excess fluid because of their relatively low glomerular filtration rate during the first 2 weeks of life.
17) The nurse is instructing a group of new parents about normal newborn behavior. Which attendee's statement indicates that teaching was effective? 1. "My baby will be able to hear very well immediately after birth." 2. "My baby will have difficulty seeing me close up right after delivery." 3. "My baby should be discouraged from sucking on a pacifier if being bottle fed." 4. "My baby should be trained to breastfeed by being encouraged to suck on a pacifier before feedings."
Answer: 1 Explanation: 1. Newborns have very acute hearing immediately after birth. 2. The newborn is nearsighted and has best vision at a distance of 8 to 15 inches. 3. For bottle-fed infants, there is no reason to discourage nonnutritive sucking with a pacifier. 4. Pacifiers should be offered to breastfed infants only after breastfeeding is well established or during prolonged times away from the mother, or when stressful or painful procedures are required.
3) The nurse assesses a sleeping 1-hour-old, 39-weeks' gestation newborn. Which data should cause the nurse the most concern? 1. Respirations 68/min 2. Blood pressure 72/44 mmHg 3. Skin temperature 97.6°F 4. Heart rate 156 beats/min
Answer: 1 Explanation: 1. Normal respiratory rate is 30 to 60 breaths/min. Respirations of 68/min could represent a less-than-expected transition. 2. This blood pressure is within the normal range of 90 to 60/50 to 40 mm Hg. 3. This is within the normal temperature range of 96.8 to 97.7°F. 4. This heart rate is within the normal range of 120 to 160 beats/min.
10) The home care nurse notes jaundice on the skin over the sternum of a 3-day-old infant. What should the nurse explain to the parents about this finding? 1. "The liver of an infant is not fully mature and does not conjugate the bilirubin for excretion." 2. "The yellow color of your baby's skin indicates that you are breastfeeding too often." 3. "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should." 4. "The infant received too many red blood cells after delivery because the cord was not clamped immediately."
Answer: 1 Explanation: 1. Physiologic jaundice is a common occurrence and peaks on day 3 or 4. 2. Frequent feeding will decrease jaundice. 3. Bilirubin binds to the proteins in breast milk and formula for excretion through the bowels. 4. It happens in part because of the red blood cell destruction that infants experience combined with liver immaturity, which leads to less efficient conjugation of bilirubin for excretion.
12) The nurse is instructing the parents of a newborn about the number of wet diapers to expect each day. Which statement by the parents indicates that further education is necessary? 1. "Our baby was born with kidneys that are too small." 2. "Feeding our baby frequently will help the kidneys function." 3. "Kidney function in an infant is very different from in an adult." 4. "A baby's kidneys do not concentrate urine well for several months."
Answer: 1 Explanation: 1. Size of the kidneys is rarely an issue. 2. Frequent feeding helps maintain the fluid volume. 3. The ability to concentrate urine develops by 3 months of age. The inability to concentrate urine due to limited tubular reabsorption and lower glomerular filtration rate are the main differences between kidney function in a newborn and normal adult kidney function. 4. Counting wet diapers indicates urine output in relation to fluid intake.
12) A client at 38 weeks' gestation is diagnosed with oligohydramnios. Which statement indicates that teaching has been effective? 1. "When I go into labor, I should come to the hospital right away." 2. "My gestational diabetes may have caused this problem to develop." 3. "Women with this condition usually go into labor after their due date." 4. "This problem is common and will likely occur with my next pregnancy."
Answer: 1 Explanation: 1. The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid to cushion the umbilical cord. Thus, the client with oligohydramnios should come to the hospital in early labor to detect any fetal intolerance of labor that might develop. 2. Gestational diabetes can lead to polyhydramnios but does not cause oligohydramnios. 3. The risk of fetal demise is increased with oligohydramnios. Labor is usually induced when the client reaches term pregnancy to prevent fetal demise. 4. Oligohydramnios occurs in 1% to 3% of pregnancies. It rarely recurs in subsequent pregnancies.
3) The nurse is making client assignments for the next shift. Which client is most likely to experience a complicated labor pattern? 1. 34-year-old gravida 6 at 39 weeks' gestation with twins 2. 43-year-old gravida 2 at 37 weeks' gestation with hypertension 3. 22-year-old gravida 1 at 23 weeks' gestation with ruptured membranes 4. 30-year-old gravida 3 at 41 weeks' gestation and estimated fetal weight 7 lb, 8 oz
Answer: 1 Explanation: 1. Twins at term will cause overdistention of the uterus, putting the client at risk for development of a hypotonic labor pattern. Her high parity also increases the risk for a hypotonic labor pattern. 2. Hypertension does not impact labor pattern; this client has no risk factors for either hypertonic or hypotonic labor pattern development. 3. Although this client is high-risk, especially for infection, neonatal lung immaturity, and respiratory distress syndrome, this client has no risk factors for an abnormal labor pattern. 4. This client has an average-sized fetus and no risk factors for either hypertonic or hypotonic labor pattern development.
5) The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? 1. "Giving the baby his first bath can really give me a chance to get to know him." 2. "Newborns cannot focus their eyes, so it does not matter how I hold my new baby." 3. "My baby will be very sleepy immediately after birth, so he can go to the nursery." 4. "I should avoid looking directly into the baby's eyes to prevent frightening the baby."
Answer: 1 Explanation: 1. When parents give the first bath with the nurse, the nurse can point out behaviors and characteristics that help the parents understand their infant as unique and can model ways to respond to the baby's behavior. 2. Newborns can focus at a distance of 7-8 inches, the distance from a baby being held to the parent's face. Eye contact is an important aspect of parent-infant attachment and should be promoted, especially in the immediate time after birth. 3. Babies are usually wide awake and alert and responsive in the first few hours after birth. Interacting with the newborn during this first period of reactivity facilitates parent-infant attachment. 4. Eye contact is an important aspect of parent-infant attachment and should be promoted, especially in the immediate time after birth.
13) While eliciting the Moro reflex in a newborn, the nurse notes that only the right arm moves. What should the nurse immediately assess based upon this finding? 1. The clavicle 2. Babinski reflex 3. The rooting reflex 4. Ortolani maneuver
Answer: 1 Explanation: 1. When the Moro reflex is elicited, the newborn will straighten both arms and hands outward while the knees are flexed, then slowly return the arms to the chest, as in an embrace. If this response is not elicited, the nurse will assess the clavicle. If the clavicle is fractured, the response will be demonstrated on the unaffected side only. 2. The Babinski reflex tests for upper neuron abnormalities. 3. The rooting reflex is elicited when the side of the newborn's mouth or cheek is touched. In response, the newborn turns toward that side and opens the lips to suck (if not fed recently). 4. The Ortolani maneuver is an assessment technique that rules out the possibility of congenital hip dysplasia
6) A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice in a 37-hour-old newborn. What information should the nurse gather first? 1. Skin color 2. Fluid intake 3. Bilirubin level 4. Stool characteristics
Answer: 1 Explanation: 1. Yellow coloration of the skin and sclerae is a sign of physiologic jaundice that appears after the first 24 hours postnatally. Inspection of the skin would be the first step in assessing for jaundice. 2. Inadequate fluid intake can predispose an infant toward becoming jaundiced and is best determined by the number of wet diapers per day. 3. Skin color begins to appear yellow once the serum levels of bilirubin are about 4 to 6 mg/dL. 4. The stool characteristic of yellow-brown coloration indicates excretion of bilirubin.
19) A pregnant client is scheduled for a transabdominal cerclage. What teaching information should the nurse prepare for this client? Select all that apply. 1. Cesarean section birth 2. Preoperative laparotomy 3. Potential for hydramnios 4. Risk for abruptio placentae 5. Premature rupture of membranes
Answer: 1, 2 Explanation: 1. Transabdominal cerclage placement typically results in a cesarean section birth. 2. Transabdominal cerclage placement requires a laparotomy for placement and removal. 3. Transabdominal cerclage placement does not increase the risk for hydramnios. 4. Transabdominal cerclage placement does not increase the risk for abruptio placentae. 5. Transabdominal cerclage placement does not increase the risk for premature rupture of
18) The nurse suspects that a newborn needs a complete neurologic examination by a healthcare provider. What finding did the nurse use to make this clinical decision? Select all that apply. 1. Absence of the plantar grasp 2. Absence of the truncal reflex 3. Presence of the stepping reflex 4. Presence of a nonnutritive sucking reflex 5. Presence of bringing the hand to the mouth
Answer: 1, 2 Rationale: 1. Absence of the plantar grasp requires neurologic evaluation. 2. Absence of the Galant (truncal) incurvation reflex requires neurologic evaluation. 3. The stepping reflex is an expected finding. 4. Nonnutritive sucking is an expected reflex. 5. Bringing the hand to the mouth is an expected action.
17) The nurse notes that a newborn has tremor-like movements. For which health problems should this newborn be further assessed? Select all that apply. 1. Seizures 2. Bilirubinemia 3. Hypocalcemia 4. Hypoglycemia 5. Substance withdrawal
Answer: 1, 3, 4, 5 Explanation: 1. Tremors or tremor-like movements must be evaluated to differentiate the tremors from seizures. 2. Bilirubinemia is not identified as causing tremors in a newborn. 3. Tremors may be related to hypocalcemia. 4. Tremors may be related to hypoglycemia. 5. Tremors may be related to substance withdrawal.
17) The nurse is reviewing the medical history of a pregnant client being considered for cervical ripening. Which data indicate that the order for misoprostol (Cytotec) should be reconsidered? Select all that apply. 1. Current fetal heart rate is tachycardic. 2. Client had one cesarean live birth 3 years ago. 3. Uterine contractions are occurring every 2 minutes. 4. Client has 2+ pedal edema and elevated blood pressure. 5. There is a history of placenta previa with one previous pregnancy.
Answer: 1, 2, 3 Explanation: 1. Absolute contraindications for the use of misoprostol include fetal tachycardia. 2. Absolute contraindications for the use of misoprostol include a history of previous cesarean birth. 3. Absolute contraindications for the use of misoprostol include the presence of uterine contractions 3 times in 10 minutes. 4. Evidence of maternal preeclampsia or eclampsia is not an absolute contraindication for the use of misoprostol. 5. Absolute contraindications for the use of misoprostol include the presence of placenta previa, not a history of placenta previa with a previous pregnancy.
16) A client at 40 weeks' gestation is prescribed dinoprostone (Cervidil) for cervical ripening. What should the nurse include when teaching the client about this medication? Select all that apply. 1. Cramping can occur. 2. Uterine irritability is expected. 3. Membrane rupture is a sign of labor. 4. Leakage of the gel should be reported. 5. Strong regular contractions are expected.
Answer: 1, 2, 3 Explanation: 1. Cramping is a common reaction to the medication. 2. Uterine irritability is a common reaction to the medication. 3. Membrane rupture is a sign of labor and not a reaction to the medication. 4. Leakage of the gel is a common reaction that does not need to be reported. 5. Strong regular contractions are a sign of labor and not a reaction to the medication.
20) The nurse notes that a newborn has a dry scalp. What should the nurse include when teaching the parents about the care of this newborn? Select all that apply. 1. Use mild soap. 2. Use baby shampoo. 3. Wash the scalp daily. 4. Apply oil every other day. 5. Rinse the scalp with hot water.
Answer: 1, 2, 3 Explanation: 1. For scalp care the nurse should instruct the parents to shampoo the scalp with mild soap. 2. For scalp care the nurse should instruct the parents to shampoo the scalp with baby shampoo. 3. For scalp care the nurse should instruct the parents to shampoo the scalp and anterior fontanel areas daily. 4. For scalp care the nurse should instruct the parents to avoid the use of oil. 5. Hot water should not be used since this could burn the newborn's delicate tissues and skin.
19) The elderly grandmother of a newborn tells the client that rubbing alcohol should be applied to the cord stump to make it dry and fall off faster. What should the nurse instruct the client about cord care? Select all that apply. 1. Keep the umbilical cord stump clean. 2. Allow the umbilical cord stump to air dry. 3. Fold the diaper down under the cord stump. 4. Notify the healthcare provider if the cord stump appears dark in color. 5. Apply topical antibiotic ointment to the cord stump after each diaper change.
Answer: 1, 2, 3 Explanation: 1. Keeping the umbilical stump clean reduces the chance of infection. 2. Allowing the umbilical stump to air dry reduces the chance of infection. 3. Folding the diaper down under the cord stump prevents contamination of the area. 4. The cord stump will appear dark and dry before falling off. The healthcare provider does not need to be notified. 5. Topical antibiotic ointment does not need to be applied to the cord stump after each diaper change.
13) A pregnant client diagnosed with hydramnios asks for more information about this health problem. What should the nurse include in this teaching? Select all that apply. 1. The exact cause is unknown. 2. It can cause shortness of breath and edema. 3. It can be associated with maternal diabetes. 4. It occurs in large-for-gestational-age infants. 5. It is associated with renal malformation or dysfunction.
Answer: 1, 2, 3 Explanation: 1. The exact cause of hydramnios is unknown. 2. Hydramnios can cause maternal shortness of breath and edema. 3. Hydramnios is associated with maternal diabetes. 4. Hydramnios is not associated with large-for-gestational-age infants. 5. Renal malformation or dysfunction and postmaturity can cause oligohydramnios.
1) Which actions must a nurse perform before weighing the newborn during the admission procedure? Select all that apply. 1. Zero the scale. 2. Clean the scale. 3. Cover the scale. 4. Take the infant's temperature. 5. Wrap the infant tightly in a blanket to prevent heat loss.
Answer: 1, 2, 3 Explanation: 1. This action should be performed to ensure an accurate measurement. 2. This action should be performed to prevent cross infection. 3. This action should be performed to prevent cross infection. 4. This action should be performed after the weight to monitor heat loss. 5. The nurse should remove all clothing and blankets to ensure an accurate measurement. To prevent heat loss, the infant should instead be placed under a radiant warmer.
14) When caring for a client with oligohydramnios, on what should the nurse focus? Select all that apply. 1. Induction is typically scheduled. 2. Early decelerations are more likely. 3. Fetal pulmonary hypoplasia can develop. 4. There is an increased risk of cord compression. 5. Labor progress is often more rapid than average.
Answer: 1, 2, 3, 4 Explanation: 1. As soon as the fetus is term, induction is typically scheduled because the fetus is at an increased risk for intrauterine fetal demise. 2. Decreased amniotic fluid can contribute to fetal head compression, which can manifest itself as early decelerations. 3. Because there is less fluid available for the fetus to use during fetal breathing movements, pulmonary hypoplasia may develop. 4. Less amniotic fluid lessens the cushioning effect, and cord compression is more likely. 5. Labor progress is slower than average due to the decreased fluid volume.
3) The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Select all that apply. 1. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough." 2. "When we change the baby's diaper, we should change any wet clothing or blankets, too." 3. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." 4. "We should make sure that we keep our home air conditioned so the baby does not overheat." 5. "If the baby's body temperature gets too low, he will warm himself up without any shivering."
Answer: 1, 2, 3, 5 Explanation: 1. A neonate with a low body temperature will increase oxygen consumption, which can lead to respiratory distress. 2. Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. 3. Drying a wet baby prevents evaporation, one mechanism of heat loss. 4. Babies need to be kept warm. Cold ambient temperatures will increase the oxygen consumption of a newborn and can lead to respiratory distress. 5. Nonshivering thermogenesis is the mechanism used by newborns to warm themselves
15) A client at 40 weeks' gestation is being considered for cervical ripening. Which criteria should the nurse use to determine the client's success for induction? Select all that apply. 1. Position 2. Effacement 3. Consistency 4. Fetal heart rate 5. Cervical dilatation
Answer: 1, 2, 3, 5 Explanation: 1. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include position. 2. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include effacement. 3. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include consistency. 4. A prelabor scoring system was developed that is helpful to predict the potential success of induction. The fetal heart rate is not a component that is evaluated. 5. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include cervical dilatation.
10) A change in skin color requires further assessment of which physiologic functions? Select all that apply. 1. Hematocrit 2. Oxygenation 3. Glucose levels 4. Blood pressure 5. Bilirubin levels
Answer: 1, 2, 3, 5 Explanation: 1. Changes in skin color may indicate the need for closer assessment of hematocrit. 2. Changes in skin color may indicate the need for closer assessment of cardiopulmonary status. 3. Changes in skin color may indicate the need for closer assessment of glucose. 4. Changes in skin color are not associated with blood pressure. 5. Changes in skin color may indicate the need for closer assessment of bilirubin.
18) The parents of a newborn are concerned that their baby continues to lose weight despite being held and cuddled. What should the nurse tell these parents? Select all that apply. 1. Excessive handling increases caloric use. 2. Permit the newborn to rest quietly when eyelids flutter. 3. Constant handling increases metabolic rate. 4. Gently flick the sole of the foot to stimulate. 5. Avoid stimulating when eye contact is absent.
Answer: 1, 2, 3, 5 Explanation: 1. Excessive handling increases caloric use and causes fatigue, which will affect weight gain. 2. Fluttering eyelids are an indication of fatigue. When this occurs, stimulation should be stopped. 3. Excessive handling increases metabolic rate, which burns more calories. 4. When the infant appears fatigued, stimulation should stop. The parents should wait for the infant to appear alert before stimulating. 5. A subtle cue of fatigue is the loss of eye contact. The infant should be permitted to sleep or rest.
20) A client is recovering from general anesthesia after an emergency cesarean birth. What actions should the nurse take when providing care to this client? Select all that apply. 1. Position on the left side. 2. Observe urine for hematuria. 3. Assess level of anesthesia every 15 minutes. 4. Evaluate perineal pad every 15 minutes for 1 hour. 5. Gently palpate the fundus with vital signs assessment.
Answer: 1, 2, 4, 5 Explanation: 1. If the client has been under general anesthesia, she should be positioned on her side to facilitate drainage of secretions. 2. It is important to observe the urine for a bloody tinge, which could mean surgical trauma to the bladder. 3. Assessment of the level of anesthesia is performed for a client recovering from spinal anesthesia. 4. After a cesarean section, evaluate the dressing and perineal pad every 15 minutes for at least 1 hour. 5. The fundus should be gently palpated to determine whether it is remaining firm.
19) The nurse is assisting in the preparation of a pregnant client in labor for intrauterine resuscitation. For which fetal finding is this intervention indicated? Select all that apply. 1. Prolonged decelerations 2. Persistent late decelerations 3. Last fetal movement 5 minutes ago 4. Fetal heart rate 140 beats per minute 5. Persistent and severe variable decelerations
Answer: 1, 2, 5 Explanation: 1. The presence of prolonged decelerations is a sign of nonreassuring fetal status. Intrauterine resuscitation should be started without delay. 2. The presence of persistent late decelerations is a sign of nonreassuring fetal status. Intrauterine resuscitation should be started without delay. 3. Fetal activity is not used as an indication for intrauterine resuscitation. 4. A fetal heart rate of 140 bpm is within normal limits. 5. The presence of persistent and severe variable decelerations is a sign of monreassuring fetal status. Intrauterine resuscitation should be started without delay.
7) A multigravida client with suspected abruptio placentae is admitted in active labor. Which nursing diagnoses should the nurse identify as appropriate for this client? Select all that apply. 1. Anxiety related to concern for own safety 2. Ineffective Coping related to premature birth 3. Fluid Volume, Risk for Deficit, related to hypovolemia 4. Tissue Perfusion, Risk for Altered, related to blood loss 5. Knowledge Deficit related to lack of information about inherited genetic defects
Answer: 1, 3, 4 Explanation: 1. Abruptio placentae can cause anxiety for both the client and fetus. 2. There is no information regarding the gestational age of this client. The fetus may not be premature. 3. Maternal mortality and perinatal fetal mortality are concerns due to blood loss. 4. Maternal mortality and perinatal fetal mortality are concerns due to hypoxia. 5. Abruptio placentae is a premature separation of the placenta, not a genetic abnormality.
19) A newborn is demonstrating signs of needing comfort and security. What should the nurse instruct the parents about swaddling this infant? Select all that apply. 1. Swaddling should be loose. 2. Swaddling should be done with the arms at the sides. 3. Swaddling helps the newborn control body movements. 4. Swaddling should permit the newborn access to the mouth. 5. Swaddling should be tightly bound around the infant's torso.
Answer: 1, 3, 4 Explanation: 1. Swaddling newborns is a way to provide comfort and security. Blanket swaddling should be loose. 2. Swaddling newborns is a way to provide comfort and security. Tight swaddling with arms at sides is not comforting and may further agitate the infant. 3. Swaddling newborns is a way to provide comfort and security. Swaddling helps the newborn control body movements. 4. Swaddling newborns is a way to provide comfort and security. Blanket swaddling allows the infant easy hand to mouth access to promote self-soothing abilities. 5. Swaddling newborns is a way to provide comfort and security. Tight swaddling is not comforting and may further agitate the infant.
16) The nurse is planning to assess a newborn's neurologic status. Which behaviors should the nurse focus on during this assessment? Select all that apply. 1. Cry 2. Reflexes 3. Alertness 4. Motor activity 5. Resting posture
Answer: 1, 3, 4, 5 Explanation: 1. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include cry. 2. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Reflexes are elicited; not observed. 3. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include the state of alertness. 4. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include motor activity. 5. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include resting posture. Page Ref: 508
13) A pregnant client has not decided on a feeding method for her infant and asks for more information about breastfeeding and formula-feeding. Which client statement indicates that the teaching was successful? 1. "Breastfeeding is more expensive than formula-feeding." 2. "My baby has a lower risk of food allergies if I breastfeed." 3. "Formula-feeding gives the baby protection from infections." 4. "Breast milk cannot be stored; it has to be thrown away after pumping."
Answer: 2 Explanation: 1. Formula must be purchased, and therefore it is expensive. 2. Breast milk provides newborns with immunoglobulins and reduces the risk of food allergies in children. 3. Formula does not provide the baby with protection from infections as breast milk does. 4. Breast milk can be refrigerated or frozen after pumping.
10) The nurse is caring for a client who is a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is most important to take at this time? 1. Perform a Leopold maneuver. 2. Complete a sterile vaginal examination. 3. Obtain an order for pain medication. 4. Assess the odor of the amniotic fluid.
Answer: 2 Explanation: 1. This assessment is not called for at this time. 2. Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated. 3. Pain medication is a low priority at this time. 4. Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority.
13) The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which participant statement indicates that additional information is needed? 1. "Because my hospital is so small and in a rural area, they will not let me attempt a VBAC." 2. "Since the scar on my belly goes down from my navel, I am not a candidate for a VBAC." 3. "The rate of complications from VBAC is lower than the rate of complications from a cesarean." 4. "My first baby was in a breech position, so this pregnancy I can try a VBAC if the baby is head-down."
Answer: 2 Explanation: 1. A repeat cesarean must be able to be performed immediately to safely attempt a VBAC. Many small and rural hospitals do not have surgical and anesthesia staff available at night or on weekends and holidays, and therefore do not allow clients to have a VBAC. 2. Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in deciding if VBAC is advisable. Classic vertical incisions on the uterus have a higher rate of rupture and should not be attempted. 3. The incidence of uterine rupture is 0.5% to 0.9%. Women who have a successful VBAC have lower incidences of infection, less blood loss, fewer blood transfusions, and shorter hospital stays. 4. Nonrepeating conditions such as any nonvertex presentation might make VBAC a viable option as long as this pregnancy is vertex.
16) The new father asks what his baby will experience while sleeping and awake. How should the nurse respond? 1. "Babies have several sleep and alert states. Keep watching and you will notice them." 2. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." 3. "You may have noticed that your child was in an alert awake state for an hour after his birth." 4. "Birth is hard work for babies; it takes them a week or 2 to recover and become more awake."
Answer: 2 Explanation: 1. Although it is true that babies have several sleep and alert states, the wording of this response is condescending and not therapeutic. This is not the best response. 2. This statement is true. Teaching the parents how to detect the two sleep stages helps them tune in to their infant's behavioral states. 3. Although this statement is true, it does not respond to the father's question about sleeping now. 4. Recovery from the birth process only takes a day or 2. During that time, feedings should take place when the baby is in an alert state.
2) The clinical nurse coordinator is reviewing the care of clients who undergo artificial rupture of membranes (AROM) by way of amniotomy with a group of nursing students. Which student statement indicates that the teaching has been effective? 1. "Amniotomy is contraindicated for use in labor augmentation." 2. "For women who undergo artificial rupture of membranes, vaginal examinations should be limited." 3. "Women who undergo artificial rupture of membranes should be advised that they will experience a 'dry birth.'" 4. "In most cases, it is appropriate to assess the fetal heart rate (FHR) right after the artificial rupture of membranes is performed."
Answer: 2 Explanation: 1. Amniotomy is an accepted method of labor augmentation. 2. Following .AROM, because there is now an open pathway for organisms to ascend into the uterus, the number of vaginal examinations must be kept to a minimum to reduce the chance of introducing an infection. 3. Women need to know that amniotic fluid is constantly produced because some women may worry that they will experience a "dry birth." 4. In all cases, the .FHR is assessed just before and immediately after the amniotomy, and the two FHR assessments are compared.
14) A client with cephalopelvic disproportion (CPD) develops tachysystolic labor patterns. Which treatment should the nurse anticipate? 1. Amniotomy 2. Cesarean section 3. Nipple stimulation 4. Oxytocin administration
Answer: 2 Explanation: 1. Amniotomy is used to induce labor; however, a vaginal delivery is unlikely. 2. Cesarean section is the most likely course of action. With CPD, a cesarean birth is indicated, as vaginal delivery cannot be performed. 3. Nipple stimulation is used to induce labor; however, a vaginal delivery is unlikely. 4. Oxytocin is used to induce labor; however, a vaginal delivery is unlikely.
5) The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? 1. Antibiotics decrease the incidence of hyperbilirubinemia. 2. Total bilirubin is the sum of the direct and indirect levels. 3. Conjugated bilirubin is eliminated in the conjugated state. 4. Unconjugated bilirubin is neurotoxic and cannot cross the placenta.
Answer: 2 Explanation: 1. Because of the role of gut bacteria in converting conjugated bilirubin into urobilinogen, neonates who have been administered antibiotics have an increased incidence of hyperbilirubinemia. 2. This is true. Conjugated bilirubin is also referred to as direct, while unconjugated bilirubin is also referred to as indirect. 3. Conjugated bilirubin can be transformed back into unconjugated bilirubin prior to excretion by β-glucuronidase enzyme if gut bacteria have not transformed it into urobilinogen. 4. Unconjugated bilirubin is neurotoxic but crosses the placenta during fetal life for the maternal gastrointestinal system to conjugate and excrete.
3) A pregnant client is diagnosed with cervical insufficiency. How should the nurse expect this client to explain symptoms of this condition? 1. "I've been having contractions every 4 hours." 2. "I'm not having any pain and I do not feel any contractions." 3. "My cervical pain has gotten much worse over the past 2 days." 4. "I'm not having any pain, but my contractions are getting stronger."
Answer: 2 Explanation: 1. Contractions are not associated with cervical insufficiency. 2. Cervical insufficiency is painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix. 3. Cervical pain is not a manifestation of cervical insufficiency. 4. Contractions are not associated with cervical insufficiency.
14) A client who delivered a day ago has chosen to breastfeed her infant. Which observation best indicates that the client understands breastfeeding? 1. The infant is crying when brought to the breast. 2. The client takes off her gown to achieve skin-to-skin contact. 3. The infant is held so that the nipple is accessed by turning the head. 4. The client puts the infant to breast when the baby is asleep to help wake the baby up.
Answer: 2 Explanation: 1. Crying is a late cue of hunger. Newborns should be put to breast when they begin rooting, lip-smacking, or tongue-thrusting behaviors. 2. Skin-to-skin contact creates tactile sensations that increase the sucking of newborns. 3. The infant should be held in a "tummy-to-tummy" position so that the head does not have to turn to find the nipple and access the breast. 4. Breastfeeding is more successful if the infant is in the alert-awake state when put to breast. Putting a newborn to breast is not likely to wake the infant up to feed.
1) The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching? 1. "If I have bleeding in the third trimester of my next pregnancy, I might rupture membranes again." 2. "If I want to become pregnant again, I will have to plan on being on bed rest for the whole pregnancy." 3. "If I develop a urinary tract infection in my next pregnancy, I might rupture membranes early again." 4. "If I were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured."
Answer: 2 Explanation: 1. Second- and third-trimester bleeding increases the risk for PPROM. 2. There is no evidence indicating that bed rest in a subsequent pregnancy decreases the risk for PPROM. 3. A urinary tract infection (UTI) increases the risk for PPROM. 4. Multifetal gestation increases the risk for PPROM.
9) The membranes of a client in labor have spontaneously ruptured and the fluid is meconium stained. The fetal heart tones are 100 to 105. Which nursing action is most important? 1. Notify the surgical team of an impending cesarean. 2. Change the client's position from Fowler to left lateral. 3. Insert a Foley catheter with the assistance of another nurse. 4. Decrease the IV of lactated Ringer solution to 50 mL/hour.
Answer: 2 Explanation: 1. The decision to go to cesarean birth is a medical decision. The nurse may not make medical decisions. 2. Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal bradycardia is present. Left lateral position increases uterine blood flow. 3. If a cesarean is needed, a Foley catheter will be needed. But at this time, this is a low priority. 4. Increasing IV fluids will facilitate uterine blood flow and fetal oxygenation if the client is hypotensive. Decreasing the IV rate will not improve fetal heart tones.
9) A postpartum client calls the nursery to report that her 3-day-old newborn has passed a bright green stool. How should the nurse respond to the client? 1. "Your newborn has diarrhea." 2. "This is a normal occurrence." 3. "There may be a possible food allergy." 4. "Take your newborn to the pediatrician."
Answer: 2 Explanation: 1. The green color of stool is not characterized as diarrhea, but is a transitional stool that consists of part meconium and part fecal material. 2. By the third day of life, the newborn's stools appear brown to green in color. 3. The green color of stool is not due to food allergies. 4. It is not necessary for the client to take her newborn to the pediatrician.
4) Which information is least likely recorded as a part of the initial newborn assessment? 1. Presence or absence of meconium-stained fluid 2. Blood draw for phenylketonuria (PKU) screening 3. Resuscitative measures required in the birthing area 4. Parents' desires regarding circumcision for a male infant
Answer: 2 Explanation: 1. The labor and birth record, including the presence or absence of meconium-stained fluid, should be recorded as part of the newborn assessment. 2. Blood is often drawn for laboratory testing, which should be recorded. However, blood draws for PKU screening must occur more than 24 hours after birth. 3. The condition of the newborn, including resuscitative measures required in the birthing area, should be recorded as part of the newborn assessment. 4. Parent-newborn attachment information, including the parents' desires regarding care, should be noted during the newborn assessment.
17) The nurse is assisting a mother to bottle-feed her newborn, who has been crying. What should the nurse instruct the client to do before feeding the infant? 1. Offer a pacifier. 2. Burp the newborn. 3. Unwrap the newborn. 4. Stroke the newborn's spine and feet.
Answer: 2 Explanation: 1. The newborn's cries are indicative of an issue; a pacifier would not solve the problem. 2. If a newborn has been crying prior to feeding, air might have been swallowed; therefore, the newborn should be burped before feeding. Time should be taken to calm the newborn prior to feeding. 3. Unwrapping the newborn stimulates the newborn. 4. Stroking the spine and feet stimulates the newborn.
5) A primiparous client is at 42 weeks' gestation. What order should the nurse question? 1. Begin non-stress test now. 2. Return to the clinic in 1 week. 3. Obtain biophysical profile today. 4. Schedule labor induction for tomorrow.
Answer: 2 Explanation: 1. The non-stress test is a commonly used assessment for the postterm fetus. 2. A postterm pregnancy is high risk. Fetal assessments must be obtained to verify fetal well-being or the need for delivery via induction or cesarean. One week is too long a time period between assessments. 3. A biophysical profile is a commonly used assessment for the postterm fetus. 4. Labor induction is likely to occur with postterm pregnancies because the aging placenta becomes less efficient at transporting oxygen and nutrients and because the risk of fetal macrosomia increases with length of gestation.
1) The nursing instructor is demonstrating a newborn assessment using the Ballard gestational assessment tool. Which assessment should be performed after the first hour of birth? 1. Scarf sign 2. Arm recoil 3. Popliteal angle 4. Square window sign
Answer: 2 Explanation: 1. The scarf sign is elicited by placing the newborn supine and drawing an arm across the chest toward the newborn's opposite shoulder until resistance is met. A preterm infant's elbow will cross the midline of the chest, whereas a full-term infant's elbow will not cross midline. 2. Recoil time is slower in fatigued newborns. Therefore, arm recoil is best elicited after the first hour of birth so the newborn can recover from the stress of birth. 3. The popliteal angle (degree of knee flexion) is determined with the newborn flat on the back. The thigh is flexed on the abdomen and chest, and the nurse places the index finger of the other hand behind the newborn's ankle to extend the lower leg until resistance is met. The angle formed is then measured. Results vary from no resistance in the very immature newborn to an 80-degree angle in the term newborn. 4. The square window sign is elicited by gently flexing the newborn's hand toward the ventral forearm until resistance is felt. The angle formed at the wrist is measured.
7) The nurse manager observes care being provided by a graduate nurse who is caring for a client undergoing a forceps delivery. Which action requires intervention? 1. Bladder is emptied using a straight catheter. 2. The client is instructed to push between contractions. 3. Fetal heart tones are consistently between 110 and 115. 4. Regional anesthesia is administered via pudendal block.
Answer: 2 Explanation: 1. The urinary bladder is emptied to prevent the full bladder from impeding descent of the fetal head. 2. The client should only push during contractions, not between contractions. 3. These are normal fetal heart tones. No intervention is needed. 4. Regional anesthesia is important to facilitate application of the forceps and cooperation with pushing efforts.
10) The risk management nurse is reviewing labor and delivery statistics over the last 2 years in an effort to decrease costs of maternity care. What finding contributes to increased healthcare costs in clients undergoing cesarean birth by request? 1. Prolonged anemia, requiring blood transfusions every few months 2. Increased abnormal placenta implantation in subsequent pregnancies 3. Decreased use of general anesthesia with greater use of epidural anesthesia 4. Coordination of career projects of both partners leading to increased income
Answer: 2 Explanation: 1. This is not a complication of cesarean birth by request. 2. Placenta implantation problems are more common after cesarean birth and increase healthcare costs because of the high-risk care and testing required. 3. Which anesthesia method is used is not a significant factor in healthcare costs of cesarean birth by request. The need for anesthesia, use of the operating suite, equipment use, personnel, and other factors are more responsible for greater costs of cesarean birth compared with vaginal birth. 4. The income of the couple does not affect healthcare costs directly.
14) The mother of a 2-day-old infant newly diagnosed with sepsis asks why she could not detect the symptoms. What should the nurse reply to this mother? 1. "Your mothering skills will improve with time. You should take the newborn class." 2. "Newborns have immature immune function at birth, and illness is very hard to detect." 3. "Your baby did not get enough active acquired immunity from you during the pregnancy." 4. "The immunity your baby gets in utero does not start to function until 4 to 8 weeks of age."
Answer: 2 Explanation: 1. This response does not address the physiology of neonatal infection and is not therapeutic because it is blaming. 2. The immune system of a newborn lacks response to pyrogens and presents a limited inflammatory response; thus, the signs and symptoms of infection are often subtle and nonspecific in the newborn. 3. The mother develops active acquired immunity, which is passed to the newborn transplacentally as passive acquired immunity. This immunity is to the illnesses and infections she has had or been immunized against. 4. The passive acquired immunity a newborn receives from its mother is effective at birth and lasts from 4 weeks to 8 months, depending on the specific antibody.
8) A client experiencing a difficult labor has a vacuum extraction birth. What is expected with this type of delivery? 1. The head is delivered after eight pulls during contractions. 2. The location of the vacuum is apparent on the fetal scalp after birth. 3. A bruise is present on the occiput that does not cross the suture line. 4. Positive pressure is applied by the vacuum extraction during contractions.
Answer: 2 Explanation: 1. Use of the vacuum extraction for eight contractions is too many and can create damage to the fetal head. If fetal descent does not occur with the first two pulls, the procedure should be discontinued, and cesarean birth should take place. 2. Caput in the shape of the vacuum cup is usually present immediately after birth and resolves in 2 to 3 days. 3. This is a cephalohematoma and is a complication of vacuum extraction birth. 4. Negative pressure is suction, which is needed to use the vacuum extractor to facilitate birth.
12) The nurse is preparing a client with cephalopelvic disproportion (CPD) for an immediate cesarean birth. What is the last assessment that the nurse should make before the client is draped for surgery? 1. Vaginal examination 2. Fetal heart tones 3. Maternal temperature 4. Maternal urine output
Answer: 2 Explanation: 1. Vaginal examination is unnecessary when CPD is present. 2. Fetal heart tones are assessed just prior to the start of surgery because the supine position can lead to fetal hypoxia. 3. Maternal temperature is monitored by anesthesia personnel. 4. Maternal urine output is not significant at this point.
16) The multiparous client at 33 weeks has experienced an intrauterine fetal demise. What finding requires immediate intervention? 1. Temperature 99°F 2. Fibrinogen level 50 mg/dL 3. Platelet count 210,000/cmm 4. Family refusing fetal autopsy
Answer: 2 Explanation: 1. Women with intrauterine fetal demise can demonstrate signs of an infection; however, this temperature is not high enough to indicate this problem. 2. Intrauterine fetal demise can cause disseminated intravascular coagulopathy (DIC); the normal fibrinogen level is 200 to 400 mg/dL. This is a very low fibrinogen level and indicates that the client is in DIC. 3. Intrauterine fetal demise can lead to disseminated intravascular coagulopathy (DIC), but this is a normal platelet count. 4. Some religious traditions prohibit autopsy. Disseminated intravascular coagulopathy (DIC) is a higher priority.
12) Which statement by a breastfeeding class participant indicates that teaching was effective? Select all that apply. 1. "Breastfeeding is worthwhile, even if it costs more overall." 2. "Breastfed infants get more skin-to-skin contact and sleep better." 3. "Breastfed infants have fewer digestive and respiratory illnesses." 4. "Breastfeeding raises the level of a hormone that makes me feel good." 5. "Breastfeeding is complex and difficult, and I probably will not succeed."
Answer: 2, 3, 4 Explanation: 1. Breastfeeding actually costs substantially less than formula feeding, even considering the need for increased calcium and protein intake during lactation. 2. This is a true statement. Newborns are very responsive to touch, and it is vital for the infant's emotional well-being. The tactile stimulation associated with breastfeeding can communicate warmth, closeness, comfort, and the opportunity to learn each other's behavioral cues and needs. 3. This is a true statement. Reduced infections are due to immunologic properties in breast milk and to the fact that breastfed infants are not put to bed with a bottle, a practice known to increase ear infections. 4. Every time an infant suckles, the prolactin level doubles; prolactin creates feelings of euphoria and relaxation. 5. Although there is skill involved in getting a baby to nurse successfully and coordinating the infant's efforts with the maternal efforts, breastfeeding is not perceived as being difficult by the majority of women who attempt to do so.
21) The nurse is caring for a client who delivered a 38 weeks' gestation stillborn fetus. What should the nurse do to support the client at this time? Select all that apply. 1. Remove the fetus from the room. 2. Clean the fetus and wrap in a blanket. 3. Ask the client if she would like to hold the baby. 4. Instruct on postdelivery care to be completed in the home. 5. Ask if other family members would like to spend time with the baby.
Answer: 2, 3, 4 Explanation: 1. The fetus should not be removed from the room unless the client asks that the fetus be removed. 2. The fetus should be bathed/cleansed and wrapped in a blanket in preparation for viewing. 3. The client should be asked her preference for viewing and holding the baby. 4. It is inappropriate for the nurse to instruct the client on home care needed after delivery at this time. The client and family are having a highly emotional experience which should not be ignored. 5. Oftentimes other family members will be present and they should be asked of their desire to spend time with the baby.
17) The nurse is caring for the newborn of a client who received magnesium sulfate for preterm labor. Which fetal effects should the nurse attribute to the client's medication treatment? Select all that apply. 1. Flushing 2. Lethargy 3. Hypotonia 4. Poor sucking reflex 5. Respiratory depression
Answer: 2, 3, 5 Explanation: 1. Flushing is a maternal adverse effect of magnesium sulfate. 2. Fetal side effects of magnesium sulfate may include lethargy that persists for 1 or 2 days following birth. 3. Fetal side effects of magnesium sulfate may include hypotonia that persists for 1 or 2 days following birth. 4. Poor sucking reflex is not an adverse effect of magnesium sulfate. 5. Respiratory depression in the newborn can also occur after maternal magnesium sulfate.
18) A pregnant client receiving oxytocin for labor induction begins demonstrating adverse effects of the medication. In which order should the nurse provide care to this client? 1. Notify the healthcare provider. 2. Discontinue the oxytocin infusion. 3. Position the client onto the left side. 4. Infuse prescribed intravenous fluids. 5. Administer oxygen 8 to 10 L per tight face mask.
Answer: 2, 4, 3, 5, 1 Explanation: 1. After applying oxygen the healthcare provider should be notified. 2. Nursing management of adverse effects begins by discontinuing the IV oxytocin infusion. 3. After intravenous fluids are started, the client should be turned onto the side. 4. After the oxytocin infusion is discontinued, the primary intravenous solution should be opened up for immediate infusion. 5. After positioning on the side, oxygen by tight face mask at 8 to 10 L/min should be administered. Page Ref: 453
21) During a postpartum home visit the nurse reinforces the importance of holding the infant and having tummy time periodically through the day with the new mother. What did the nurse observe that indicated the mother needed additional teaching? Select all that apply. 1. Rapid respiratory rate 2. Weak gross motor skills 3. Crusted nasal secretions 4. Positional plagiocephaly 5. Sluggish upper body strength
Answer: 2, 4, 5 Explanation: 1. Because most newborns are nose breathers for the first few months of life, the nasal passages must be kept clear and clean of secretions. A rapid respiratory rate could indicate that the nasal passages are occluded. Instruction about the bulb syringe should be reinforced at this time. 2. Tummy time enhances gross motor skills. 3. Crusted nasal secretions indicate that the mother needs additional information on the use of the bulb syringe. 4. Positional plagiocephaly, or flat head syndrome, occurs when the infant spends too much time in the supine position. The infant needs to be held or placed for tummy time more often. 5. Tummy time enhances upper body strength.
14) A client in the midst of labor and delivery of twins is being considered for a podalic version. What should the nurse assess in order for this version to be considered? Select all that apply. 1. Previous cesarean birth 2. Second fetus does not descend 3. Premature rupture of membranes 4. Presence of third-trimester bleeding 5. Second fetus heart rate nonreassuring
Answer: 2, 5 Explanation: 1. A previous cesarean birth is a contraindication for a version. 2. A podalic version is used only with the second fetus during a vaginal twin birth and only if the twin does not descend readily. 3. Premature rupture of membranes is a contraindication for a version. 4. Presence of third-trimester bleeding is a contraindication for a version. 5. A podalic version is used only with the second fetus during a vaginal twin birth and only if the heart rate is nonreassuring.
2) A client who is pregnant with her first child has been laboring for 14 hours with very minimal progress. Cervical dilatation and effacement are slow, and the nurse is unable to verify engagement of the presenting fetal part. What condition should the nurse suspect may be affecting the client's labor? 1. Prolapsed cord 2. Placenta accreta 3. Cephalopelvic disproportion (CPD) 4. Occiput anterior (OA) fetal position
Answer: 3 Explanation: 1. A prolapsed cord is an umbilical cord that precedes the fetal presenting part. Fetal bradycardia is a critical indicator of prolapsed cord. 2. Placenta accreta, in which the chorionic villi attach directly to the uterine myometrium, is associated with maternal hemorrhage and failed placental separation after birth. 3. The nurse should suspect CPD when labor is prolonged, cervical dilatation and effacement are slow, and engagement of the presenting part is delayed. 4. The occiput anterior (OA) fetal position is amenable to delivery and would not represent a barrier to labor.
6) A multiparous client at term is in active labor with intact membranes. A Leopold maneuver indicates the fetus is in a transverse lie with a shoulder presentation. What healthcare provider order is most important? 1. Artificially rupture membranes. 2. Apply internal fetal scalp electrode. 3. Alert the surgical team of urgent cesarean. 4. Monitor maternal blood pressure every 15 minutes.
Answer: 3 Explanation: 1. Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord. 2. An internal fetal scalp electrode cannot be applied until membranes have ruptured. Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord. 3. This is the highest priority because of the transverse lie and the risk of fetal hypoxia secondary to prolapsed cord if the membranes rupture. 4. The fetus is at risk for hypoxia secondary to prolapsed cord if the membranes rupture. The maternal blood pressure is less important than getting the cesarean under way.
8) A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? 1. "I cannot believe he can already digest fats, carbohydrates, and proteins." 2. "It is amazing that his whole digestive tract moves things along at birth." 3. "Incredibly, his stomach capacity is already a cupful when he was born." 4. "He will lose some weight but then miraculously regain it by about 10 days."
Answer: 3 Explanation: 1. At birth, neonates can digest fats, simple carbohydrates, and proteins. 2. Gastric emptying and intestinal peristalsis occur during in utero life; the first bowel movement usually occurs in the first day of life. 3. A newborn's stomach capacity is only 50 to 60 mL; overfeeding of bottle-fed infants tends to cause regurgitation and abdominal discomfort, exhibited by crying. 4. Neonates lose 5% to 10 % of their birth weight in the first days after life, especially if they are breastfed. They should have regained the lost weight and should be back to their birth weight by 10 days of age.
15) The mother of a newborn with iron deficiency anemia asks if breastfeeding or using a formula high in iron is better for the baby. How should the nurse respond? 1. Breastfeeding, because breast milk has higher levels of iron compared to formula 2. Formula-feeding, because formula has higher levels of iron compared to breast milk 3. Breastfeeding, because although breast milk has lower levels of iron compared to formula, it is more easily absorbed by the infant 4. Formula-feeding, because although formula has lower levels of iron compared to breast milk, it is more easily absorbed by the infant
Answer: 3 Explanation: 1. Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed if possible. 2. Although formula is iron enriched, the concentration of the nutrient may not be consistent. 3. Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed if possible. 4. Although formula is iron enriched, it is not necessarily more easily absorbed by the infant.
6) The nurse attempts to take the vital sign of the newborn, but the newborn is crying. What intervention would be appropriate? 1. Taking the vital signs 2. Waiting until the newborn stops crying 3. Placing a gloved finger in the newborn's mouth 4. Swaddling the newborn with several warm blankets in an attempt to calm the newborn
Answer: 3 Explanation: 1. Crying will increase heart rate and respiratory rate, so vitals should not be taken when the newborn is crying. 2. Assessment of vitals needs to be done at regularly timed intervals, so waiting until the newborn stops crying might be too long of a delay. 3. To soothe a newborn during assessment or other procedures, place a gloved finger into the newborn's mouth. 4. Swaddling an infant with warm blankets can cause the infant to become overheated and increase restlessness.
11) The client is instructing a client recovering from a classic uterine incision for a cesarean birth. Which statement indicates that the client understands implications for future pregnancies that are secondary to this type of incision? 1. "I can only have one more baby." 2. "The next time I have a baby, I can try to deliver vaginally." 3. "Every time I have a baby, I will have to have a cesarean delivery." 4. "The risk of rupturing my uterus is too high for me to have any more babies."
Answer: 3 Explanation: 1. Future pregnancies are not limited to one. 2. Attempting a vaginal birth is contraindicated, and future births will be planned cesareans. 3. A classic uterine incision is made in the upper uterine segment and holds an increased risk of rupture in subsequent pregnancy, labor, and birth. 4. Future pregnancies are not prohibited.
4) The nurse has received end of shift report in the high-risk maternity unit. Which client should the nurse see first? 1. 35 weeks' gestation with grade 1 abruptio placentae in labor who has a strong urge to push 2. 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations 3. 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement 4. 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously
Answer: 3 Explanation: 1. Grade 1 abruptio placentae creates slight vaginal bleeding. The urge to push indicates that delivery is near. This client is not the highest priority. 2. Late decelerations are an abnormal finding, but put only the fetus at risk. This client is not the highest priority. 3. Bleeding with a placenta previa is a complication that can be life threatening to both the mother and baby. This client is the highest priority. 4. Although pregnancy-induced hypertension increases the risk for developing abruptio placentae, there is no indication that this client is experiencing this complication. This client is not the highest priority.
4) The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement indicates that further information is required? 1. "I can take ibuprofen (Motrin) when my perineum starts to hurt." 2. "Soaking in the tub will help my mediolateral episiotomy to heal." 3. "The tear I have through my rectum is unrelated to my episiotomy." 4. "Because I have a midline episiotomy, I should keep my perineum clean."
Answer: 3 Explanation: 1. Healing episiotomies can be very painful, and pain medication should be provided for clients experiencing pain. 2. Warm tub baths are helpful to facilitate both comfort and healing of an episiotomy. 3. This statement is incorrect. Midline episiotomies tend to tear posteriorly toward the rectum. 4. When a client has an episiotomy, perineal hygiene is important to prevent infection and facilitate healing.
5) A client who received a mediolateral episiotomy to facilitate vacuum extraction birth asks what kind of episiotomy was performed. How should the nurse explain the location of the episiotomy? 1. "It goes straight back toward your rectum." 2. "It is from your vagina toward the urethra." 3. "It is cut diagonally away from your vagina." 4. "It extends from your vagina into your rectum."
Answer: 3 Explanation: 1. Midline episiotomy is straight back from the vagina toward the rectum. 2. Episiotomies are not cut anteriorly toward the urethra. 3. Mediolateral episiotomy is angled from the vaginal opening toward the buttock. 4. Extension into the rectum is a fourth-degree laceration.
12) The nurse is assessing newborns in the nursery. Which assessment finding places a newborn at risk for developing physiologic jaundice? 1. Molding 2. Mongolian spots 3. Cephalohematoma 4. Telangiectatic nevi
Answer: 3 Explanation: 1. Molding is caused by overriding of the cranial bones. 2. Mongolian spots are macular areas of bluish black pigmentation on the dorsal area of the buttocks. 3. A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. The red blood cells present in the cephalohematoma begin to break down, which can lead to an increase in bilirubin levels in the blood. 4. Telangiectatic nevi are pale pink or red spots found on the eyelids, nose, lower occipital bone, or nape of the neck.
9) The home health nurse is visiting the home of a client who is 18 weeks pregnant with twins. Which nursing action is most important? 1. Assess the client's blood pressure in the upper right arm. 2. Collect a cervicovaginal fetal fibronectin (fFN) specimen. 3. Teach the client about foods that are good sources of protein. 4. Determine whether the pregnancy is a result of infertility treatment.
Answer: 3 Explanation: 1. Preeclampsia is not diagnosed until the 20th week of gestation. This client is only at 18 weeks. Further, blood pressure can be assessed in either arm when the client is in a sitting position; in a side-lying position, the blood pressure should be assessed in the upper arm. 2. Preterm labor is not diagnosed until 20 weeks. This client is only at 18 weeks. Fetal fibronectin (fFN) testing is not indicated at this time. 3. A diet containing 3500 kcal (minimum) and 175 g protein is recommended for a client with normal-weight twins. Teaching about protein sources facilitates adequate fetal growth. 4. Although the incidence of multifetal pregnancy is higher in pregnancies resulting from infertility treatment than in those that are spontaneous pregnancies, the cause of the multifetal pregnancy does not impact nursing care.
6) A client recovering from delivery asks for another ice pack to place on the site of a midline episiotomy. How should the nurse respond to this request? 1. "I will get you one right away." 2. "You only need to use one ice pack." 3. "You need to leave it off for at least 20 minutes and then reapply." 4. "I will bring you an extra so that you can change it when you are ready."
Answer: 3 Explanation: 1. Providing an additional ice pack before 20 minutes have passed would increase the perineal edema. 2. More than one ice pack must be used in order to apply ice for 20 minutes on, followed by 20 minutes off. 3. Optimal effects from the use of an ice pack occur when it is applied for 20 to 30 minutes and then removed for at least 20 minutes before being reapplied. 4. An ice pack that is provided now for use in 20 minutes would be melted before being used.
13) A client who delivered 30 minutes ago is being prepared for manual removal of the placenta. What should the nurse complete as a priority? 1. Bottle-feed the infant. 2. Send the placenta to pathology. 3. Start an IV of lactated Ringer solution. 4. Apply antiembolism stockings.
Answer: 3 Explanation: 1. The client's partner or family member, or a nursery nurse, can feed the infant. The client is at risk for excessive blood loss due to retained placenta, and preparation for manual removal of the placenta is a higher priority at this time. 2. The placenta might be sent to pathology after it is removed, but preparing the client for manual removal of the placenta now is a higher priority. 3. The client undergoing manual removal of the placenta will need either IV sedation or general anesthesia. An IV is necessary. 4. Antiembolism stockings are used after major surgery that leads to immobility, thus increasing the risk of embolism. However, antiembolism stockings are not needed for this client because manual removal of the placenta is not major surgery and does not lead to postprocedure immobility.
11) A client pregnant with twins asks if the pregnancy will be uncomplicated. How should the nurse respond to this client? 1. "The perinatal mortality rate for monoamniotic siblings is 50%." 2. "Twins are less likely to have complications than are singleton births." 3. "Spontaneously conceived twins are less likely to develop complications." 4. "Primiparous women pregnant with twins are less likely to develop complications."
Answer: 3 Explanation: 1. The perinatal mortality rate for monoamniotic siblings is 10% to 32%. 2. Twins are more likely to have complications than are singleton births. 3. This is true. Spontaneously conceived twins are less likely to develop complications. 4. Primiparous women with twin pregnancies are more likely to develop complications.
11) The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. How should the nurse interpret this finding? 1. Prematurity 2. Facial paralysis 3. A normal position 4. A possible chromosomal abnormality
Answer: 3 Explanation: 1. The top of the ear (pinna) should be parallel to the outer and inner canthus of the eye in the normal newborn. 2. The top of the ear (pinna) should be parallel to the outer and inner canthus of the eye in the normal newborn. 3. The top of the ear (pinna) should be parallel to the outer and inner canthus of the eye in the normal newborn. 4. Low-set ears could indicate a chromosomal abnormality.
9) A client experiencing a difficult labor is going to have vacuum extraction to facilitate delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance? 1. "The baby's head might have a bruise from the vacuum cup." 2. "The vacuum will be applied for a total of 10 minutes or less." 3. "I can stop pushing and just rest if the vacuum extractor is used." 4. "A small cup will be put onto the baby's head, and a gentle suction will be applied."
Answer: 3 Explanation: 1. The vacuum extractor might leave a bruise on the scalp where the device is placed. 2. The vacuum extractor is applied to the scalp for up to 10 minutes total. 3. Vacuum extraction is an assistive delivery, and the client must continue with pushing efforts to accomplish the birth. 4. The vacuum extractor is a small cup-shaped device that is applied to the scalp.
8) A pregnant client is diagnosed with central abruptio placentae. What can the nurse infer about the client's condition? 1. The slight separation of the client's placenta from the uterine wall will not produce any bleeding. 2. The total separation of the client's placenta from the uterine wall will lead to massive hemorrhage. 3. Blood is trapped between the client's placenta and the uterine wall, and there may be concealed bleeding. 4. Blood is passing between the fetal membranes and the client's uterine wall, which will lead to some vaginal bleeding.
Answer: 3 Explanation: 1. This describes a marginal placenta separation, grade 1. 2. With complete separation, there is total separation of the placenta from the uterine wall, and massive bleeding ensues. 3. With the central type of placental separation, blood is trapped between the placenta and uterine wall with concealed bleeding. 4. This describes a marginal placenta separation, grade 1.
1) The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? 1. Mean blood pressure 55 mmHg 2. Pulse rate 145, systolic murmur heard 3. Pauses in respiration lasting 30 seconds 4. Respiratory rate 60, crackles present bilaterally
Answer: 3 Explanation: 1. This is a normal finding in an infant at 1 hour of life. 2. This pulse rate is normal. Systolic murmurs are very unlikely to indicate serious pathology and are usually caused by incomplete closure of the ductus arteriosus or foramen ovale. 3. Pauses in respirations greater than 20 seconds are considered episodes of apnea and require further intervention. 4. This respiratory rate is normal; crackles are commonly heard in the first few hours after birth as the infant reabsorbs the fluid in the lungs that was present at birth.
10) The nurse is counseling a newly pregnant gravida 1 at 8 weeks' gestation with twins about the need for increased caloric intake. What should the nurse emphasize as being the minimum recommended intake? 1. 2500 kcal and 120 g protein 2. 3000 kcal and 150 g protein 3. 3500 kcal and 175 g protein 4. 4000 kcal and 190 g protein
Answer: 3 Explanation: 1. This is less than recommended for a twin-gestation pregnancy. 2. This is less than recommended for a twin-gestation pregnancy. 3. This is the recommended caloric and protein intake in a twin-gestation pregnancy. 4. This is recommended if the twins are underweight.
3) The nurse notes the presence of a cephalohematoma on the head of a newborn. What did the nurse use to make this clinical determination? Select all that apply. 1. The head appears asymmetric. 2. The mass overrides the suture line. 3. The mass appears only on one side of the head. 4. The mass appeared on the second day after birth. 5. The mass appears larger when the newborn cries.
Answer: 3, 4 Explanation: 1. Molding causes the head to appear asymmetric; this is due to the overriding of cranial bones during labor and birth. 2. Cephalohematomas do not cross the suture lines. 3. Cephalohematomas can be unilateral or bilateral. 4. A cephalohematoma can appear between the first and second day after birth. 5. A cephalohematoma does not increase in size when the newborn cries.
8) A new mother is concerned because the anterior fontanelle swells when the newborn cries. What normal findings should the nurse include when teaching the new mother about this concern? Select all that apply. 1. The fontanelles might bulge. 2. The fontanelles might be depressed. 3. The fontanelles can swell with crying. 4. The fontanelles can pulsate with the heartbeat. 5. The fontanelles can swell when stool is passed.
Answer: 3, 4, 5 Explanation: 1. Bulging fontanelles signify increased intracranial pressure. 2. Depressed fontanelles indicate dehydration. 3. Newborn fontanelles can swell when the newborn cries. 4. Newborn fontanelles can pulsate with the heartbeat. 5. Newborn fontanelles can swell when the newborn passes a stool.
12) A client with a suspected small pelvis is dilated at 6 cm. The fetus has an estimated weight of 4200 g (9 lb, 4 oz). What is the most important action for the client at this time? 1. Encourage oral fluids and carbohydrate intake. 2. Assess the cervix for change every 8 hours. 3. Inform the couple that labor might be prolonged. 4. Assist the client to squat during the second stage.
Answer: 4 Explanation: 1. A client with a large fetus and a small pelvis has a higher-than-average chance of needing a cesarean section. This client should either be given only clear liquids or be NPO to reduce the risk of aspiration should a cesarean section need to be performed. 2. The cervix is normally assessed when the client's labor status appears to have changed, or in order to determine whether cervical change is taking place. The cervix would be assessed more frequently if a client was in the active phase of labor and cephalopelvic disproportion was a risk. Every 8 hours is too far apart. 3. Although it is true that labor with a large fetus and a small pelvis could be prolonged, informing the couple of this fact is a psychosocial intervention. Physiologic interventions are a higher priority. 4. Squatting increases the diameter of the pelvic outlet and might facilitate vaginal birth when cephalopelvic disproportion is a risk.
15) For delivery, a client received a midline episiotomy, which extended into a third-degree laceration. What should the nurse include when explaining the location of the episiotomy to the client? 1. "Up near your urethra." 2. "Into the muscle layer." 3. "Through your rectal mucosa." 4. "Through your rectal sphincter."
Answer: 4 Explanation: 1. A periurethral laceration is near the urethra. 2. A first-degree laceration involves only the skin. A second-degree laceration involves skin and muscle. 3. A fourth-degree laceration is through the rectal mucosa. 4. A third-degree laceration includes the rectal sphincter.
11) A new adolescent mother is concerned about being able to properly care for the newborn at home because her mother thinks she is too young. What should the nurse say to this client? 1. "You are very young, and parenting will be a challenge for you." 2. "Your mother was probably right. Be very careful with your baby." 3. "Mothers have instincts that kick in when they get their babies home." 4. "We can give the baby's bath together. I'll help you learn how to do it."
Answer: 4 Explanation: 1. Although this statement is true, it does not teach the client anything or increase her confidence in being able to care for her infant. 2. This statement is very judgmental and does not teach the client anything or increase her confidence in being able to care for her infant. 3. Maternal instincts might indeed exist, but this client has expressed a specific fear about being a safe mother. It is best to work with her to teach her skills and increase her confidence. 4. This response is best because it both teaches the new mother skills she does not have and increases her confidence.
2) The clinical instructor reviews postoperative care of cerclage with a group of nursing students. Which student statement indicates the need for further information? 1. "Sometimes cerclage can be performed on an outclient basis." 2. "If cerclage is performed emergently, the client will usually be hospitalized for at least 5 days." 3. "After 37 weeks' gestation, the client's cerclage may be cut in order to allow for vaginal delivery." 4. "If the client's amniotic sac is bulging, the cerclage is contraindicated and the procedure cannot be performed."
Answer: 4 Explanation: 1. An uncomplicated elective cerclage may be done as an outclient. 2. An emergency cerclage requires hospitalization for 5 to 7 days or longer. 3. After 37 completed weeks' gestation, the suture may be cut and vaginal birth permitted, or the suture may be left in place and a cesarean birth performed. 4. Decompression of a bulging amniotic sac is not a contraindication to cerclage; rather, the amniotic sac must be decompressed immediately before the procedure.
15) Nursing students describe actions while practicing physical assessment of a newborn using a model. Which nursing student's statement indicates the need for further teaching? 1. "I auscultated the infant's heart tones for 1 minute." 2. "I palpated peripheral pulses in all the newborn's extremities." 3. "I obtained a higher blood pressure on the legs than on the arms." 4. "I obtained the infant's heart rate by observing the cardiac monitor."
Answer: 4 Explanation: 1. Apical pulse rates should be obtained by auscultation for a full minute, preferably when the newborn is asleep. 2. Peripheral pulses of all extremities should also be evaluated to detect any inequalities or unusual characteristics. 3. Blood pressure in the lower extremities is usually higher than that in the upper extremities. 4. Physical assessment of the newborn's heart rate requires auscultation of the apical pulse for a full minute.
6) The nurse is not familiar with the cultural background of new parents who have recently immigrated to the United States. What statement is best? 1. "You appear to be Muslim. Do you want your son to be circumcised?" 2. "Let me explain how newborn care takes place here in the United States." 3. "Your baby is a U.S. citizen. You must be very happy about that." 4. "Could you explain what your preferences are regarding child care?"
Answer: 4 Explanation: 1. Avoid making assumptions about clients based on appearance. It is much better to respectfully ask questions regarding preferences and practices. 2. The nurse should not assume the family does not understand the U.S. healthcare system. It is much better to respectfully ask questions regarding preferences and practices. 3. This is an assumption often based on the false idea that people from other countries only come to have their babies in the United States so they will be citizens and therefore eligible for federal aid. It is much better to respectfully ask questions regarding preferences and practices. 4. Sensitive, nonjudgmental exploration of the family's cultural beliefs regarding newborn care allows the nurse to gain valuable knowledge that will be applied when planning culturally competent care.
6) A client at 30 weeks' gestation is experiencing painless late vaginal bleeding. What should the nurse expect in the management of this client? 1. Assessing blood pressure every 2 hours 2. Evaluating the fetal heart rate with an internal monitor 3. Limiting vaginal examinations to only one per 24-hour period 4. Monitoring for blood loss, pain, and uterine contractibility
Answer: 4 Explanation: 1. Blood pressure measurements every 2 hours are unnecessary. They can be done on a routine basis or prn. 2. Fetal heart rate monitoring will be done with an external fetal monitor. The placenta is covering the cervical os, and therefore the fetal scalp cannot be accessed to apply an internal monitor. 3. Vaginal examinations are contraindicated because the examination can stimulate bleeding. 4. Blood loss, pain, and uterine contractibility need to be assessed for client comfort and safety.
4) The nurse is planning the care of a 1-day-old infant. Which intervention would protect the newborn from heat loss by convection? 1. Drying the newborn thoroughly 2. Prewarming the examination table 3. Removing wet linens from the isolette 4. Placing the newborn away from air currents
Answer: 4 Explanation: 1. Drying the newborn thoroughly immediately after birth or after a bath will prevent heat loss by evaporation. 2. Prewarming the examination table reduces heat loss by conduction. 3. Removing wet linens that are not in direct contact with the newborn from the isolette reduces heat loss by radiation. 4. Placing the newborn away from air currents reduces heat loss by convection.
13) The nurse notes that a 1-day-old infant's immunoglobulin M (IgM) antibodies are elevated. Which is the least likely cause for this elevation? 1. Placental leakage 2. Intrauterine exposure to syphilis 3. Intrauterine exposure to TORCH (toxoplasmosis, rubella, cytomegalovirus, herpesvirus hominis type 2 infection) syndrome 4. Maternal-fetal transfer of IgM while in utero
Answer: 4 Explanation: 1. Elevated levels of IgM at birth may indicate placental leaks. 2. Elevations in IgM may be due to newborn exposure to an intrauterine infection such as syphilis. 3. Elevations in IgM at birth may be due to newborn exposure to an intrauterine infection such as TORCH syndrome. 4. Because IgM does not normally cross the placenta, most or all of it is produced by the fetus beginning at 10 to 15 weeks' gestation.
5) A mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? 1. "Your baby must be dehydrated." 2. "Bring your infant to the clinic immediately." 3. "This is due to overriding of the cranial bones during labor." 4. "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth."
Answer: 4 Explanation: 1. Fontanelles can be depressed when the infant is dehydrated. 2. The posterior fontanelle closes within 8 to 12 weeks. This is a normal finding at 16 weeks, and does not require emergency evaluation. 3. Overriding of the cranial bones is referred to as molding, and will diminish within a few days following birth. 4. This is a normal finding at 16 weeks. The posterior fontanelle closes within 8 to 12 weeks.
15) For which reason should the nurse suspect hydramnios in a pregnant client? 1. The client is pregnant with twins. 2. The quadruple screen comes back positive. 3. There is less amniotic fluid than normal for gestation. 4. The fundal height increases disproportionately to the gestation.
Answer: 4 Explanation: 1. Hydramnios is not suspected simply by virtue of a twin gestation. 2. A quadruple screen is not used to determine hydramnios. 3. Hydramnios occurs when there is more amniotic fluid than normal for gestation. 4. The increased amount of amniotic fluid will increase the fundal height disproportionately to the gestation.
3) A client at 39 weeks' gestation being prepared for labor induction feels as though the baby has "flipped." What action should the nurse take? 1. Evaluate fetal maturity. 2. Administer dinoprostone (Cervidil) vaginal gel. 3. Implement continuous electronic fetal monitoring (EFM). 4. Notify the healthcare provider that the client feels as though the baby has changed position.
Answer: 4 Explanation: 1. Malpresentation, such as breech, is a relative contraindication to induction of labor. Before proceeding with preparation for induction of labor, the client will require additional evaluation by the healthcare provider before proceeding. 2. Dinoprostone (Cervidil) is used to facilitate cervical ripening, which might be premature since the fetal position needs to be evaluated before proceeding with the induction. 3. EFM will not provide enough information regarding the position of the fetus. 4. Because malpresentation, such as breech, is a relative contraindication to induction of labor, the client will require additional evaluation by the healthcare provider before proceeding. Page Ref: 452
4) During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. How should the nurse document this finding? 1. Nevus flammeus 2. Nevus vasculosus 3. A Mongolian spot 4. Telangiectatic nevi
Answer: 4 Explanation: 1. Nevus flammeus (port-wine stain), a capillary angioma, is located directly below the epidermis. 2. Nevus vasculosus (strawberry mark) is a capillary hemangioma. 3. Mongolian spots are macular areas of bluish black pigmentation on the dorsal area of the buttocks. 4. Telangiectatic nevi (stork bites) are pale pink or red spots that appear on the eyelids, nose, lower occipital bone, or the nape of the neck.
7) What should the nurse anticipate the labor pattern for a fetal occiput posterior position to be? 1. Precipitous 2. Rapid during transition 3. Shorter than average during the latent phase 4. Prolonged with regard to the overall length of labor
Answer: 4 Explanation: 1. Overall labor is often prolonged, not precipitous. 2. Overall labor is often prolonged, not more rapid. 3. Overall labor is often prolonged, not shorter. 4. The malposition does not allow the smallest diameter of the fetal head to come down the birth canal, and this can prolong the overall length of labor.
4) A client at 39 weeks' gestation was assessed 2 hours ago as being 3 cm dilated, 40% effaced, and +1 station and experienced contractions every 5 minutes with duration 40 seconds and intensity 50 mmHg. Currently, the client is 4 cm dilated, 40% effaced, and +1 station with frequency of contractions every 3 minutes with 40 to 50 seconds' duration with intensity of 40 mmHg. What action should the nurse make a priority at this time? 1. Start oxygen at 8 L/min. 2. Give terbutaline to stop the preterm labor. 3. Have anesthesia provider give the client an epidural. 4. Begin oxytocin after assessing for cephalopelvic disproportion (CPD).
Answer: 4 Explanation: 1. Oxygen will not hurt, but it is not the priority. 2. Terbutaline would not be recommended. The contraction pattern is incoordinate, but they need to be enhanced, not stopped. 3. An epidural will not change the incoordinate contraction pattern. 4. The client is having hypertonic contractions. The presence of CPD can prolong labor, so it is important to rule this out. Oxytocin (Pitocin) can create a more productive labor pattern by strengthening the contractions.
11) The charge nurse is reviewing charting completed on clients in the maternal-child triage unit. Which entry requires immediate intervention? 1. Multipara at 32 weeks: "Oligohydramnios per ultrasound secondary to fetal renal agenesis." 2. Primipara at 41 weeks: "Client reports leaking clear fluid from her vagina for 7 hours." 3. Primipara at 24 weeks diagnosed with polyhydramnios: "Client reporting shortness of breath." 4. Multipara at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, −2 station, up to walk in hallway."
Answer: 4 Explanation: 1. Renal agenesis will lead to oligohydramnios because of the lack of fetal urine production. This client will be grieving but is not experiencing physical complications. 2. Leakage of clear fluid is normal; leaking for several hours can lead to oligohydramnios, which in turn can lead to variable decelerations. This client might be experiencing a complication, but it is a lower priority than the client with the possibility of a prolapsed cord. 3. Although this client is uncomfortable, shortness of breath often accompanies polyhydramnios. It can require removal of some amniotic fluid through amniocentesis to facilitate comfort, but this is not a life-threatening emergency. 4. Active labor in a preterm multipara with the presenting part high in the pelvis is at high risk for prolapse of the cord when the membranes rupture. This client should be on bed rest until the membranes rupture and the presenting part has descended well into the pelvis. This client is at the highest risk for physical complication (cord prolapse) and therefore is the highest priority.
15) The nurse explains normal newborn behavior to new parents who are concerned about the baby's desire to be held. Which statement indicates that teaching has been effective? 1. "Some babies are easier to deal with than others." 2. "Our baby spends more time in the active alert phase." 3. "We are lucky to have a baby with a calm disposition." 4. "Cuddliness is a social behavior that some babies have."
Answer: 4 Explanation: 1. Saying a baby is easier or more difficult to deal with is a judgment, not an assessment. 2. The active alert phase of the sleep-wake cycle is characterized by motor activity. 3. Describing an infant as having a calm disposition is a judgment, not an assessment. 4. Cuddliness or social behaviors refers to the newborn's need for, and response to, being held.
2) Before the nurse begins to dry the newborn off after birth, which assessment finding should be documented to ensure an accurate gestational rating on the Ballard gestational assessment tool? 1. Size of the areolae 2. Creases on the sole 3. Body surface temperature 4. Amount and area of vernix coverage
Answer: 4 Explanation: 1. Size of the areolae is not affected by drying of the newborn. 2. Creases on the sole are not affected by drying of the newborn. 3. Body surface temperature is not part of the Ballard gestational assessment tool. 4. Drying the baby after birth will disturb the vernix and potentially alter the score when using the Ballard gestational assessment tool. The nurse first should document the amount and coverage of the vernix before drying the newborn.
7) The nurse is assessing a newborn's musculoskeletal status. How should the nurse assess for clubfoot? 1. Stimulate the sole of the foot 2. Adduct the foot and listen for a click 3. Extend the foot and observe for pain 4. Move the foot to midline and determine resistance
Answer: 4 Explanation: 1. Stimulating the sole of the foot will elicit the plantar grasp reflex, and is not an appropriate assessment for clubfoot. 2. Adducting the foot and listening for a click is not an assessment that is done. 3. Extending the foot and observing for pain will not determine or rule out clubfoot. 4. Clubfoot is suspected when the foot will not turn to a midline position or align readily.
14) The nurse wants to demonstrate to a new family their infant's individuality. Which assessment tool should the nurse use? 1. Ortolani maneuver 2. Ballard Maturity Scale 3. Dubowitz Gestational Age Scale 4. Brazelton Neonatal Behavioral Assessment Scale
Answer: 4 Explanation: 1. The Ortolani maneuver is an assessment technique that rules out the possibility of congenital hip dysplasia. 2. The Ballard Maturity Scale is a tool that assesses external physical characteristics and neurologic or neuromuscular development. 3. The Dubowitz Gestational Age Scale is a tool that assesses external physical characteristics and neurologic or neuromuscular development. 4. The Brazelton Neonatal Behavioral Assessment Scale assesses the newborn's state changes, temperament, and individual behavior patterns.
9) The nurse is making an initial assessment of a newborn. Which data would be considered normal? 1. Chest circumference 30 cm, head circumference 29 cm 2. Chest circumference 38 cm, head circumference 31.5 cm 3. Chest circumference 32.5 cm, head circumference 38 cm 4. Chest circumference 31.5 cm, head circumference 33.5 cm
Answer: 4 Explanation: 1. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. 2. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. 3. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. 4. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth
10) A new parent asks why the baby appears to be occasionally cross-eyed. When should the nurse instruct the parent that this finding will resolve? 1. 1 year 2. 2 weeks 3. 2 months 4. 4 months
Answer: 4 Explanation: 1. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. This will gradually regress in 3 to 4 months. 2. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. This will gradually regress in 3 to 4 months. 3. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. This will gradually regress in 3 to 4 months. 4. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. This will gradually regress in 3 to 4 months. Page Ref: 503
9) The nurse is assessing a 2-day-old male infant that has been circumcised. Which finding requires immediate intervention? 1. The umbilical cord clamp has been removed. 2. The mother is ready to breastfeed on demand. 3. The infant maintains temperature when wrapped in a blanket. 4. The infant has had a dry diaper since the circumcision procedure.
Answer: 4 Explanation: 1. The umbilical cord clamp should be removed between 24 and 48 hours after birth to reduce the chance of tension injury to the area. 2. This is a positive action that represents the mother's readiness to care for her infant at home. 3. The infant should be able to maintain body temperature without the presence of the radiant warmer. 4. If the infant has not voided since the circumcision procedure, further assessment should be done to determine if a penile injury and/or edema is preventing urinary flow.
1) After a lengthy labor and delivery, a client suddenly complains of chest pain and dyspnea. The client is cyanotic, has tachycardia and blood pressure decreased to 78/36 mmHg. Based on these assessment findings, which health problem is the client experiencing? 1. Infection 2. Placenta accreta 3. Hypertensive crisis 4. Amniotic fluid embolus
Answer: 4 Explanation: 1. These are not manifestations of an infection. 2. Placenta accreta occurs when the chorionic villi attach directly to the uterine myometrium. The major complications of placenta accreta include maternal hemorrhage and failure of the placenta to separate following birth of the infant. 3. The client is hypotensive. 4. Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis. The condition may progress to hemorrhage, shock, and death.
1) The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the client's chart requires immediate intervention? 1. "Multipara, transverse lie." 2. "Primipara failed ECV last week." 3. "Primipara, frank breech ballotable." 4. "Multipara, 32 weeks, complete breech."
Answer: 4 Explanation: 1. This client has no contraindication to ECV. 2. Although this client is less likely to have a successful ECV this week if it were unsuccessful last week, there is no contraindication to attempting the procedure. 3. This client has no contraindication to ECV. 4. ECV is not attempted until 36 weeks. This client is too early in her pregnancy for ECV.
8) An infant weighing 8 lb, 4 oz at birth weighs 7 lb, 15 oz 3 days later. What should the nurse explain to the parents about this change in the newborn's weight? 1. "This weight loss is unusual." 2. "This weight loss is less than expected." 3. "This weight loss is excessive." 4. "This weight loss is within normal limits."
Answer: 4 Explanation: 1. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5% to 10% in term newborns. 2. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5% to 10% in term newborns. 3. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5% to 10% in term newborns. 4. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5% to 10% in term newborns.
7) The nurse is reviewing the medical records of several newborns. Which infant requires immediate intervention? 1. 24-hour-old term male with total bilirubin level of 2 2. 3-day-old term bottle-fed female with bilirubin of 11 3. 2-week-old postterm breastfed male with bilirubin of 10 4. 12-hour-old preterm female exhibiting icterus and lethargy
Answer: 4 Explanation: 1. Total bilirubin levels under 3 are expected in the first 24 hours of life. 2. Physiologic jaundice peaks between days 3 and 5; a total bilirubin level of 11 is not treated with phototherapy, regardless of feeding method. 3. Breast milk jaundice peaks at 2 to 3 weeks of age and commonly presents with a total bilirubin level of 5 to 10. 4. Jaundice is an indication of hyperbilirubinemia and is not an expected finding in the first day of life. Lethargy can be a sign of kernicterus developing. Preterm infants are more likely to develop jaundice.
5) The nurse is planning an educational program about disseminated intravascular coagulation (DIC) in pregnancy. What risk factors should the nurse include about this health problem? Select all that apply. 1. Multiparity 2. Preterm labor 3. Diabetes mellitus 4. Abruptio placentae 5. Prolonged retention of a fetus after demise
Answer: 4, 5 Explanation: 1. Multiparity does not cause the same release of thromboplastin that triggers DIC. 2. Preterm labor does not cause the same release of thromboplastin that triggers DIC. 3. Diabetes does not cause the same release of thromboplastin that triggers DIC. 4. Abruptio placentae leaves intrauterine arteries open and bleeding. This results in release of thromboplastin into the maternal blood supply and triggers the development of DIC. 5. In prolonged retention of the fetus after demise, thromboplastin is released from the degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC.
16) The nurse is assisting a new mother to breastfeed. In which order should the nurse review the steps with the mother? 1. Bring the newborn to the breast. 2. The newborn opens mouth wide. 3. Tickle the newborn's lips with the nipple. 4. Have the newborn face the mother tummy-to-tummy. 5. Position the newborn so the newborn's nose is at level of the nipple.
Answer: 5, 4, 1, 3, 2 Explanation: 1. The newborn should then be brought to the breast. 2. The newborn then opens the mouth wide to latch on. 3. The newborn's lips should be tickled with the mother's nipple. 4. The newborn should be placed tummy-to-tummy. 5. The infant's nose should be at the level of the mother's nipple.
6. What are appropriate nursing actions for facilitating family-newborn attachment? (Select all that apply.) a. Take the newborn to the nursery for periods of sleep. b. Assist with an interactive bath. c. Take the newborn to the nursery for IV antibiotic therapy. d. Encourage sibling visitation whenever possible.
Answer: b. Assist with an interactive bath; d. Encourage sibling visitation whenever possible. Feedback: Rooming in and family visits are encouraged at all times to promote attachment. Even in the instance of IV antibiotic therapy, the newborn may still stay with the family in the hospital room.
6. Which is true of a 38-weeks'-gestation newborn when testing for head lag? a. The nurse should see total head lag. b. The newborn holds the head in front of the body lines. c. The newborn can support her head momentarily. d. The newborn lifts her head momentarily while both legs lift off the table top momentarily.
Answer: c. The newborn can support her head momentarily. Feedback: Total lag is common in newborns up to 34 weeks' gestation, whereas postterm newborns (42-plus weeks) hold their heads in front of their body lines. Full-term newborns can support their heads momentarily.
11. The nurse is examining an infant at 1 hour of life and notes a small, flat, pink lesion between the eyebrows that becomes more pronounced with crying. This should be documented as a(n): a. Nevus flammeus. b. Nevus vasculosus. c. Erythema toxicum. d. Telangiectatic nevus.
Answer: Telangiectatic nevus. Feedback: A telangiectatic nevus, or stork bite, is a flat, pink lesion, usually on the head and face, that is present at birth and may darken with crying. It is benign and disappears spontaneously in the first few years of life. A nevus flammeus is a red-to-purple area of dense capillaries that does not fade with time. A nevus vasculosus, or strawberry mark, is a raised red lesion that may increase in size over time. Erythema toxicum is 1-3mm erythematous papules, similar to an insect bite, possibly related to irritation from clothing.
14. The nurse is evaluating a new mother's understanding of successful breastfeeding. Which of the new mother's statements indicates a need for further instruction? a. "I should be breastfeeding my baby a maximum of seven times in 24 hours." b. "Once I'm making enough milk, I will probably be able to hear my baby swallowing." c. "My breasts will feel less firm after I breastfeed my baby." d. "Five days after my baby is born, she should be producing at least six wet diapers each day."
Answer: a. "I should be breastfeeding my baby a maximum of seven times in 24 hours." Feedback: This is an incorrect statement. The newborn generally feeds every 1.5 to 3 hours around the clock, about 8 to 12 feedings per day.
7. A nurse is caring for a client during an amnioinfusion. Which fetal heart rate (FHR) pattern would be an expected outcome of a successful amnioinfusion? a. A decrease in variable decelerations b. FHR rate of 100-110 beats per minute c. An increase in variable decelerations d. FHR rate of 160-180 beats per minute
Answer: a. A decrease in variable decelerations Feedback: Variable decelerations should decrease, not increase, following an amnioinfusion, because the fluid buffers the cord from being compressed. There should be no bradycardia or tachycardia.
2. What would be considered an abnormal finding upon the initial physical assessment of the newborn? a. A two-vessel cord b. APGARs of 8 at 1 minute and 9 at 5 minutes c. Newborn required suctioning of the mouth and nares immediately after delivery. d. Loud, continued crying
Answer: a. A two-vessel cord Feedback: A two-vessel clamped umbilical cord is the only abnormal physical finding listed. A two-vessel cord can indicate anomalies of the renal system. The cord should have three vessels.
9. Which of the following physical assessment findings indicates a need for further evaluation? a. Absence of the rooting reflex b. Hypertonia c. Brisk knee jerk d. Plantar flexion
Answer: a. Absence of the rooting reflex Feedback: Absence or delayed disappearance of reflexes will always be a concern and a reason to refer for developmental screening. Newborns tend to have more hypertonia than hypotonia. Hypotonia would be a definite need for a referral. Brisk knee jerk and plantar flexion should be found upon exam of the newborn.
1. A client born at 27 weeks' gestation develops grunting, nasal flaring, and decreased oxygenation. Based on the client's gestational age, there is more than likely a deficiency in surfactant. Surfactant is critical for: a. Alveolar stability. b. Development of the bronchi or bronchioles in the lungs. c. Preventing the exchange of oxygen and carbon dioxide. d. Absorption and reabsorption of additional lung secretions.
Answer: a. Alveolar stability. Feedback: Surfactant prevents the alveoli from completely collapsing with each expiration, thus promoting lung expansion. Other options are important for inspiratory and expiratory cycles, but are not pertinent in the discussion of functioning alveoli of the lung.
8. The nurse is conducting an intake interview for a new prenatal client. A review of her records and self-reported history reveals she is a G6P1132 and the current pregnancy was diagnosed as a twin gestation in the emergency department the week before. What significant risk should be taken into account in the care of this client? a. Cervical insufficiency b. Postterm pregnancy c. Placenta previa d. Placental abruption
Answer: a. Cervical insufficiency Feedback: Twin gestation, prier preterm delivery, and multiple prior pregnancy losses are risk factors for cervical insufficiency. Multiple gestations are more likely to be delivered preterm. Prior uterine surgery and uterine abnormalities are risk factors for placenta previa. Hypertension, trauma, and drug use are risk factors for abruption.
11. A prenatal client has been scheduled for induction of labor and tells the nurse she does not understand why her cervix needs to be softened with misoprostol. She asks, "Won't it be faster if we just start the Pitocin?" Which explanation from the nurse would be most accurate? a. Cervical ripening decreases the likelihood of failed induction. b. It is advisable to decline cervical ripening because it does not improve outcomes. c. Softening of the cervix does not occur in normal labor, but is required for induction. d. Misoprostol is the only effective method of cervical ripening.
Answer: a. Cervical ripening decreases the likelihood of failed induction. Feedback: Cervical ripening decreases the duration of induction, Pitocin administration, and the incidence of failed induction. It is an evidenced-based intervention that clients should be encouraged to consider when indicated. Softening of the cervix normally occurs in late pregnancy or early labor. There are several other methods of cervical ripening, including Cervidil and intracervical balloon catheters.
7. What symptoms would indicate respiratory distress in the newborn? (Select all that apply.) a. Changes in color or activity b. Grunting c. Facial grimacing d. Chest retractions
Answer: a. Changes in color or activity, b. Grunting, c. Facial grimacing d. Chest retractions Feedback: All are correct. The nurse must take extra care to teach parents how to recognize hallmarks of newborn respiratory distress and how to respond immediately to signs of respiratory problems. The parents learn to observe changes in color or activity, grunting or sighing sounds with breathing, rapid breathing with chest retractions, or facial grimacing.
5. Before giving a newborn the first sponge bath, the nurse must first: a. Check the temperature. b. Decrease room lighting. c. Weigh the baby. d. Check capillary refill.
Answer: a. Check the temperature. Feedback: The nurse must make sure the newborn can maintain an adequate body temperature before exposing him to heat loss through evaporation. Decreasing room temperature increases heat loss. Weight is done daily to assess hydration status and is unrelated to bathing. Capillary refill is not an assessment performed on newborns, because peripheral circulation may not be established for 48 hours.
2. A nurse is admitting a laboring client with a breech presentation. Which complication occurs more frequently in the setting of breech presentation? a. Cord prolapse b. Neonatal hypoglycemia c. Respiratory distress d. Retained placenta
Answer: a. Cord prolapse Feedback: Cord prolapse occurs more readily in breech presentations because the breech does not fill the pelvic inlet or become as well applied to the cervix as the head. Neonatal hypoglycemia occurs more frequently in the setting of maternal diabetes. Respiratory distress occurs more frequently with nonreassuring FHR tracings in labor and infection. Grand multiparity, uterine over distention, and prior uterine surgery are risk factors for retained placenta.
6. A neonate whose mother declined prenatal ultrasounds is admitted to the special care nursery. His estimated gestational age by LMP was 42 weeks and 2 days. His 5-minute Apgar score was 6 and the nurse notes his skin is loose and peeling. This infant is likely to be affected by: a. Dysmaturity syndrome. b. Brachial plexus palsy. c. Hypoxia. d. Sepsis.
Answer: a. Dysmaturity syndrome. Feedback: Dysmaturity syndrome occurs in postterm infants who lost weight at the end of the pregnancy due to placental insufficiency. Brachial plexus palsy is a complication of shoulder dystocia. Hypoxia and sepsis are evidenced by abnormal respirations, color, and heart rate.
5. Which is the best explanation of how to elicit the "square window sign"? a. Flex the newborn's hand to the ventral forearm until resistance is felt. Measure the angle formed at the wrist. b. Measure flexion of the elbow and extension of the arms at the newborn's side for 5 seconds, then release them. c. The thigh is flexed on the abdomen/chest and the nurse places the index finger of the other hand behind the newborn's ankle to extend the lower leg until resistance is met. The angle formed is measured. d. Draw an arm across the chest toward the newborn's opposite shoulder until resistance is met.
Answer: a. Flex the newborn's hand to the ventral forearm until resistance is felt. Measure the angle formed at the wrist. Feedback: The square window sign is elicited by gently flexing the newborn's hand toward the ventral forearm until resistance is felt. The angle formed at the wrist is measured. Other options listed elicit other neuromuscular reflexes/signs.
11. The benefits of breast milk include: (Select all that apply.) a. Immunologic benefits. b. Nutritional benefits. c. Economic benefits. d. Psychosocial benefits.
Answer: a. Immunologic benefits; b. Nutritional benefits; c. Economic benefits; d. Psychosocial benefits. Feedback: All answers are correct. Immunologic advantages of breastfeeding include varying degrees of protection from respiratory and gastrointestinal infections, otitis media, meningitis, sepsis, and allergies. Breast milk provides newborns with minerals in more appropriate doses than formula does. The concentration of iron in breast milk is much lower than that in prepared formula, it is much more readily and fully absorbed, and it appears sufficient to meet the infant's iron needs for the first 6 months. All components are delivered to the infant in an unchanged form. Economic benefits include cost of formula versus supplies for breastfeeding, such as pump supplies and liners. It is much more expensive to utilize formula. Psychosocial advantages are associated with maternal-infant attachment. Oxytocin is released, and this hormone coincides with more mood responses and increased feelings of maternal well-being.
9. Clinical manifestations that indicate a newborn may be experiencing overheating include: a. Increased heart rate, increased blood pressure, and increased restlessness. b. Decreased blood pressure and lethargy. c. Increased respiratory rate, perspiration over forehead and torso, and decreased blood pressure. d. Increased heart rate, increased blood pressure, decreased oxygen consumption.
Answer: a. Increased heart rate, increased blood pressure, and increased restlessness. Feedback: Newborns may respond to overheating with increased restlessness and, eventually, perspiration. Many newborns initially cannot perspire, so they increase their respiratory and heart rates, which increases oxygen consumption.
8. A newborn has developed physiologic jaundice and hyperbilirubinemia. Which of the following supportive measures would be most effective at helping to decrease bilirubin levels? a. Give the baby a bottle of water. b. Place the baby under a radiant warmer. c. Assist with and facilitate frequent breastfeeding. d. Make the newborn NPO.
Answer: c: Assist with and facilitate frequent breastfeeding. Feedback: Colostrum in the mother's breasts during the first few postpartum days has a laxative effect. Bilirubin is eliminated through stool. Infants should not be given bottles of water. Placing the baby under a radiant warmer decreases heat loss by convection but does not directly affect bilirubin levels.
3. The nurse is preparing to assist with administration of amnioinfusion (AI). Which of the following nursing interventions is most appropriate? a. Obtain a solution of warmed, sterile normal saline. b. Monitor the fetal heart rate through intermittent electronic fetal monitoring (EFM). c. Ensure that fluids infused into the uterus are not expelled. d. Increase the rate of oxytocin infusion.
Answer: a. Obtain a solution of warmed, sterile normal saline. Feedback: Warmed normal saline is used in amnioinfusion. Amnioinfusion is most often used to improve decelerations in the fetal heart rate, so continuous electronic monitoring should be maintained. The nurse should ensure comparable amounts of fluid are instilled and expelled from uterus to prevent overdistention from retained fluid. Increases in the rate of oxytocin are not related to amnioinfusion, and should only be done in the presence of reassuring fetal status.
4. Regarding vaginal birth after cesarean (VBAC), which of the following statements is true? a. Misoprostol is contraindicated in women attempting a VBAC. b. After one successful VBAC, there remains an increased risk of neonatal and maternal complications in subsequent attempts. c. Research shows no significant correlation between maternal weight and successful VBAC. d. Healthcare costs are considerably higher for women who have a VBAC than for those who have a repeat cesarean birth.
Answer: a. Prostaglandin agents are contraindicated in women attempting a VBAC. Feedback: Misoprostol is contraindicated in women attempting a VBAC. After one successful VBAC, the risk of neonatal and maternal complications decreases in subsequent attempts. Research does show a significant correlation between maternal weight and successful VBAC. Healthcare costs are considerably lower for women who have a VBAC than for those who have a repeat cesarean birth.
6. Which of the following may cause convection heat loss in the newborn? a. Removal from an incubator for procedures b. Placing cold objects, such as ice, onto the radiant warmer bed c. Inadequate drying d. Using a cold stethoscope
Answer: a. Removal from an incubator for procedures Feedback: Convection is defined as loss of heat from the warm body surface to the cooler air currents. The other options are examples of radiation, evaporation, and conduction.
18. A newborn continually falls asleep at the breast. Which intervention is appropriate when promoting effective breastfeeding by this infant? a. Removing all newborn coverings except a diaper b. Increasing the room temperature c. Minimizing tactile stimulation d. Avoiding speaking to the baby
Answer: a. Removing all newborn coverings except a diaper Feedback: All newborn coverings except a diaper should be removed. The room temperature should not be increased; tactile stimulation should not be minimized; and speaking to the baby should be encouraged.
8. A nurse is reviewing the charts of four clients in the birthing unit. Which client has an increased risk for an episiotomy? a. The client with repetitive FHR decelerations in the second stage b. The client with a fetus in an occiput-anterior position c. The client with abruptio placentae d. The client with gestational hypertension
Answer: a. The client with repetitive FHR decelerations in the second stage Feedback: A client with repetitive FHR decelerations is at increased risk for having an episiotomy. Allowing time for the perineum to stretch may place the fetus at risk for asphyxia. A client with abruptio placentae is only at increased risk for episiotomy if it results in decelerations in the second stage. Gestational hypertension is not a risk factor in having an episiotomy.
1. Which statement best describes the newborn's transition to extrauterine life? a. The risk of mortality and morbidity is statistically high during this period. b. Due to frequent monitoring of the newborn, it is difficult to bond with parents during this period. c. The procedure for estimating gestational age done on each newborn is a rigorous exam, and difficult for the newborn to tolerate. d. Because of stimulation, both tactile and auditory, by family members and healthcare professionals, the newborn is unable to rest, and depletion of the immune system occurs.
Answer: a. The risk of mortality and morbidity is statistically high during this period. Feedback: The first 24 hours are significant because mortality and morbidity are statistically high during the transition period. The monitoring should not be too frequent to allow for attachment; the gestational age exam does not take too much time, and newborns generally do well with the exam; and the immune system will not be depleted by simple stimulation of the family members that have undergone all communicable disease screenings.
12. The nurse is assisting a mother with perineal care on the postpartum floor. The birth record indicates she had a second-degree, midline episiotomy the day before. The mother asks, "When will this stop hurting?" What is the nurse's best response? a." The pain should be gone by tomorrow." b. "It might be painful for several weeks." c. "Episiotomy usually results some degree of permanent discomfort." d. "You might have an infection. It's not normal to still be experiencing pain."
Answer: b. "It might be painful for several weeks." Feedback: The episiotomy site may be painful for several weeks. It is normal for the client to be experiencing pain the day after the procedure. This is not a sign of infection. If the repair was done by a skilled practitioner and healing proceeds normally, the client should not suffer from long-term discomfort.
1. The nurse is caring for a client who is not in labor but has been diagnosed with ruptured membranes at 30 weeks' gestation. For what intervention should the nurse prepare? a. Induction of labor b. Administration of magnesium sulfate c. Digital vaginal examination d. Amnioinfusion
Answer: b. Administration of magnesium sulfate Feedback: Magnesium sulfate is indicated for the prevention of infant neurological impairment anytime preterm delivery is expected. Induction of labor will only be done if the risks of complications such as infection outweigh the benefits of continuing the pregnancy. Digital vaginal examination increases the risk of infection in cases of prolonged rupture of membranes. Amnioinfusion is only indicated when there is evidence of cord compression.
5. The nurse is caring for a prenatal client at 38 weeks' gestation whose ultrasound reveals polyhydramnios. She complains of shortness of breath and has 2+ pitting edema in her lower extremities. The nurse anticipates preparation for: a. Delivery by cesarean. b. Amniocentesis. c. Intravenous antibiotics. d. Amnioinfusion.
Answer: b. Amniocentesis. Feedback: Amniocentesis would draw fluid off and provide relief in a client with excess amniotic fluid. A cesarean section delivery is contraindicated, because it could be dangerous to give anesthesia to a client with respiratory distress. Intravenous antibiotics would not be indicated, as it has not been established that the client has an infection. Amnioinfusion (instilling fluid into the uterus) is inappropriate for a client with excess amniotic fluid.
11. The nurse attends the birth of a healthy, term baby at 7:15 p.m. The mother has expressed a desire to breastfeed. When is the best time to assist her with the baby's first feeding? a. Immediately, before the cord is cut b. Between 7:45 and 8 p.m. c. After 2 hours, when recovery is over and she is settled in a postpartum bed d. Any time before the baby receives any bottles or artificial nipples
Answer: b. Between 7:45 and 8 p.m. Feedback: The first period of reactivity in the newborn occurs between 30 minutes and 1 hour after birth. The baby will be in a quiet, alert state at this time, which is ideal for feeding. Breastfeeding may be initiated immediately if the mother wishes but is likely to be disrupted by the necessary assessments of mother and baby that occur immediately after birth. After the first period of reactivity, the baby is likely to enter a sleep phase where it will be difficulty to arouse and have little interest in sucking.
19. Which is the most appropriate method for defrosting breast milk? a. Defrost under hot running water. b. Dispense a plastic container of breast milk in a glass of warm water. c. Defrost in boiling water. d. Microwave on medium heat.
Answer: b. Dispense a plastic container of breast milk in a glass of warm water. Feedback: Frozen milk can be thawed by initially running cool water over the container, then gradually adding warm water until the milk is thawed. Breast milk should not be defrosted under hot running water or in boiling water. Breast milk should never be microwaved. Uneven heating patterns may alter the composition of the milk and can create hot spots that can burn the infant's mouth.
4. The nurse is assessing for descent of the testes in a full-term newborn. The nurse is unable to locate the testes in the scrotal sac. What would be an appropriate intervention for this finding? a. Assess hourly until the testes descend into the scrotal sac. b. Document findings and explain to parents that this will be evaluated again before discharge and at each health supervision visit until the testes are palpable in the scrotal sac. c. Make newborn NPO in preparation for surgery. d. Note that there is an absence of rugae on the scrotum, indicating testicular development is not mature.
Answer: b. Document findings and explain to parents that this will be evaluated again before discharge and at each health supervision visit until the testes are palpable in the scrotal sac. Feedback: Undescended testes can be a common finding upon physical exam of the newborn. Reassure parents that the newborn will be evaluated frequently and followed closely even after discharge from the hospital. This condition does not require hourly monitoring, a surgical emergency, or assessment of rugae for an accurate diagnosis.
6. A nurse is planning an educational seminar on medical vs. complementary and alternative methods of cervical ripening. The nurse teaches that the medical method uses: a. Blue/black cohosh herbs. b. Misoprostol (Cytotec). c. Evening primrose oil. d. Sexual intercourse.
Answer: b. Misoprostol (Cytotec). Feedback: Misoprostol (Cytotec) is used in the medical model of care for cervical ripening, whereas blue/black cohosh herbs, primrose oil, and sexual intercourse are considered complementary and alternative methods.
2. A nurse in the birthing unit is caring for a client following an amniotomy. What is an appropriate nursing intervention? a. Assess cervical dilation every 2 hours. b. Monitor temperature every 2 hours. c. Increase the rate of the IV maintenance fluid. d. Replace expelled amniotic fluid every 1-2 hours.
Answer: b. Monitor temperature every 2 hours. Feedback: Due to an increased risk of infection, the nurse should monitor temperature every 2 hours following an amniotomy. Vaginal exams are kept to a minimum to decrease the chance of infection. Increasing the rate of IV fluid is not indicated. Replacing expelled amniotic fluid every 1-2 hours is unnecessary, as amniotic fluid is constantly produced.
12. A breastfeeding client is concerned that her milk supply has begun to diminish. What is the most appropriate intervention for the client to assist in increasing milk supply? a. Supplement the newborn with formula until milk supply equals demand. b. Place the newborn to breast whenever possible to increase milk production. c. Increase nutritional intake, with more calories from fruits and/or vegetables. d. Use a pacifier between feedings to stimulate the suck reflex.
Answer: b. Place the newborn to breast whenever possible to increase milk production. Feedback: Putting the newborn to breast to feed or suckle will stimulate milk ducts and production of milk. As the newborn is put to breast frequently, the supply will catch up with the demand if the client is well hydrated. The client should not supplement formula; an increase in calories from fruits and/or vegetables is beneficial, but does not assist in increasing milk production; and use of a pacifier also will not assist in increasing milk production.
5. To create a neutral thermal environment for a newborn immediately after delivery, the nurse should consider: a. Deep suction every hour while under the radiant warmer bed. b. Providing care and assessments while the infant is skin-to-skin on the mother's chest. c. Placing the newborn with the extremities extended and relaxed under the radiant warmer bed. d. Placing the newborn with the extremities extended and relaxed, and placing a hat over the newborn's head.
Answer: b. Providing care and assessments while the infant is skin-to-skin on the mother's chest. Feedback: A newborn should never be suctioned hourly. Maintaining skin-to-skin contact on the mother's chest under a dry blanket eliminates heat loss through all of the possible routes. The newborn should be placed in a flexed position to decrease exposed surface tension, decreasing the amount of heat lost. A hat is one way to help the infant reduce heat loss by convection but is not as effective as skin-to-skin contact with the mother.
1. A nurse is preparing a prenatal client with a breech presentation for an external cephalic version (ECV). What condition must be met prior to this procedure? a. Mild labor contractions b. 34 weeks gestational age c. Reactive nonstress test d. Fetal breech must be engaged in the pelvis.
Answer: b. Reactive nonstress test Feedback: The fetus must be more than 36 weeks' gestation, with a reactive nonstress test, and not engaged in the pelvis.
7. Upon physical examination, the nurse notes the liver of a newborn is palpable 2-3 cm below the right costal margin. The nurse recognizes this finding and should consider which of the following? a. Notifying the primary healthcare provider b. Recognizing this as a normal physical finding c. Requesting liver enzyme testing d. Checking the results of the newborn neonatal screen
Answer: b. Recognizing this as a normal physical finding Feedback: In the newborn, the liver is palpable 2-3 cm below the right costal margin. It is relatively large and occupies 40% of the abdominal cavity. This is a completely normal finding.
10. The nurse educator is creating an in-service for student nurses who are completing their mother-baby clinical rotation. When discussing misoprostol (Cytotec), which of the following components is incorrect and should be omitted from the educational content? a. The initial dosage of misoprostol for induction is 50 mcg. b. The safe dosing interval is 3-6 hours. c. Pitocin should not be administered less than 4 hours after the last misoprostol dose. d. Misoprostol should only be administered where uterine activity can be monitored continuously if needed.
Answer: b. Recurrent administration of misoprostol should exceed dosing intervals of more than 3-6 hours Feedback: The initial dosage of misoprostol for induction is 25 mcg. Recurrent administration of misoprostol should be at intervals of 3-6 hours. Pitocin should not be administered less than 4 hours after the last misoprostol dose. Misoprostol should only be administered where uterine activity and fetal well-being can be monitored continuously if needed.
12. The nurse weighs a breastfed infant delivered by cesarean at about 48 hours of life. The weight is 3348 g. The documented birth weight was 3600 g. The previous shift report states the infant is nursing well. What is the most appropriate nursing action? a. Supplement the baby with 2 oz of formula. b. Review the feeding record, counsel the mother as needed, and repeat the weight the next day. c. Have the mother pump her breasts and measure the output. d. Notify the primary healthcare provider.
Answer: b. Review the feeding record, counsel the mother as needed, and repeat the weight the next day. Feedback: This baby has lost 7% of its weight in the first 48 hours of life, which is below the 10% upper limit of normal weight loss. Watchful waiting and confirmation of the mother's understanding of infant feeding are appropriate. Supplementation would be indicated if the baby experienced another 3% weight loss. Pumping the breasts does not provide reliable information on the baby's intake. The primary healthcare provider should be notified if the baby is 10% below birth weight.
5. A nurse is caring for a client with an oxytocin infusion. What is the correct nursing action prior to increasing the oxytocin rate? a. Assess cervical dilation. b. Review the fetal monitor tracing. c. Evaluate the need for analgesia. d. Assess maternal temperature.
Answer: b. Review the fetal monitor tracing. Feedback: Assessing the fetal heart tracing is crucial for establishing fetal well-being and contraction pattern before increasing the oxytocin rate is crucial when caring for a client with an oxytocin infusion. Assessing cervical dilation and the need for analgesia should be done as clinically indicated and is unrelated to the oxytocin rate. Contractions pattern, not cervical dilation, determines the need to increase the rate. Maternal temperature is not affected by oxytocin infusion.
1. A newborn is born at 38 weeks' gestation weighing 2250 grams. Which is the most appropriate nursing diagnosis? a. Ineffective Airway Clearance b. Risk for Altered Body Temperature c. Acute Pain d. Altered Nutrition: More than Body Requirements
Answer: b. Risk for Altered Body Temperature Feedback: This newborn is small for gestational age and is experiencing heat loss due to low birth weight. It is a priority of the nurse to ensure a neutral thermal environment. No information is given to indicate the other nursing diagnoses would be priorities.
3. It is estimated that the newborn is slightly over 42 weeks' gestation according to an ultrasound performed in the first trimester of the pregnancy. What is the highest-priority nursing diagnosis for the newborn during delivery? a. Altered Health Maintenance b. Risk for Injury c. Altered Tissue Perfusion d. Altered Nutrition: More than Body Requirements
Answer: b. Risk for Injury Feedback: An infant estimated to be at 42 weeks' gestation obviously will be larger in size, making Risk for Injury the highest-priority nursing diagnosis listed. The other nursing diagnoses may be considered, but a nurse would need more information to make one of these a priority nursing diagnosis
15. A client is postoperative day 3 from a cesarean birth. What breastfeeding position is generally the most appropriate? a. Sitting up with the newborn resting on the mother's lap b. Side-lying with a pillow behind the back and one between the legs c. Leaning forward toward the newborn's mouth, with the newborn lying on the lap d. Football hold
Answer: b. Side-lying with a pillow behind the back and one between the legs Feedback: The mother who has had a cesarean birth needs support so that the infant does not rest on her abdomen for long periods. When the mother is breastfeeding, she is more comfortable lying on her side with a pillow behind her back and one between her legs. The football hold is also an option, but should be a second choice for a mother recovering from a cesarean section.
3. The nurse is assessing a client receiving magnesium for neuroprotection in the setting of preterm rupture of membranes at 25 weeks' gestation. Which finding should be reported to the primary healthcare provider? a. Maternal complaints of muscle weakness b. Temperature of 100.6°F c. Blood pressure 90/50 d. Minimal FHR variability
Answer: b. Temperature of 100.6°F Feedback: Elevation of the maternal temperature in the presence of ruptured membranes may be a sign of chorioamnionitis. Maternal complaints of muscle weakness and minimal FHR variability are benign side effects of magnesium. A maternal blood pressure of 90/50 in the second trimester is a normal finding.
10. The nurse is called to a postpartum room by a mother who is worried about her baby's irregular breathing. What is the best explanation the nurse can give? a. "Notify the nurse whenever you see that, because infants can develop respiratory distress very quickly." b. "You can assume the baby is fine unless he is lethargic." c. "Irregular breathing and pauses up to 20 seconds are normal for a newborn." d. "Irregular breathing is normal as long as the total is at least 20 breaths per minute."
Answer: c. "Irregular breathing and pauses up to 20 seconds are normal for a newborn." Feedback: Periodic breathing is normal in newborns. Pauses in breathing are not considered apnea unless they last longer than 20 seconds. Periodic breathing does not indicate impending respiratory distress. The respiratory rate should be at least 30 breaths per minute.
2. The nurse is discussing betamethasone's effects on fetal lung maturity with a group of students. Which statement by a student demonstrates understanding of the effects of betamethasone? a. "It prevents delivery until the lungs are mature." b. "It increases capillary permeability in the lungs" c. "It alters the oxygen-carrying capacity of fetal hemoglobin." d. "It promotes surfactant production in the alveoli."
Answer: d. "It promotes surfactant production in the alveoli." Feedback: Respiratory problems in the preterm infant result from inability to expand the alveoli in the lungs because there is not yet enough surfactant to prevent their walls from sticking to one another. Administration of betamethasone to the mother promotes the production of surfactant.
16. A Vietnamese client has just delivered and has stated she would like to breastfeed. What is the nurse's best response to the client's comment, "I do not want to breastfeed until my milk supply is well established"? a. "Colostrum can considerably build your newborn's immune system. Would you like to reconsider?" b. "I think it is best to ensure a strong milk supply immediately. Putting your newborn to breast right now will assist with that." c. "What are your thoughts and preferences about breastfeeding? I would like to help you with this process any way that I can." d. "Here is some information about breastfeeding and current research that discusses the benefits. Please take some time to read this and I will be back to discuss this with you."
Answer: c. "What are your thoughts and preferences about breastfeeding? I would like to help you with this process any way that I can." Feedback: The nurse needs to be culturally sensitive to this comment. The nurse should first ask what the client's cultural views are and proceed from there. In the Vietnamese culture, colostrum is not offered to the newborn and breastfeeding begins only after the milk flow is established.
3. The nurse is caring for a laboring client with a known history of cocaine abuse. What complication is most likely for this client? a. Placenta previa b. Prolapsed cord c. Abruptio placentae d. Polyhydramnios
Answer: c. Abruptio placentae Feedback: Abruptio placentae is the most likely complication for a client with a known history of cocaine abuse. This is because cocaine causes severe uteroplacental vasoconstriction and regional hypertension, which causes the placenta to separate from the uterine wall. Placenta previa may be a complication for women with multiple prior cesarean births. Prolapsed cord may be a complication with hydramnios, a small fetus, and a breech presentation. Polyhydramnios may be a complication of women with diabetes.
3. To assist the nurse in providing comprehensive care, which subjective data are pertinent to document? a. Height/weight/Body Mass Index b. Gestational examination results c. Available support system d. Newborn screening results
Answer: c. Available support system Feedback: Available support system is the only subjective data information provided. Height/weight/Body Mass Index, gestational examination results, and newborn screening results all are objective assessment data.
8. Which is the preferred method of taking a newborn's temperature? a. Rectal b. Tympanic c. Axillary d. Oral
Answer: c. Axillary Feedback: Axillary temperatures are the preferred method and are considered to be a close estimation of the rectal temperature. The thermometer must be in place for at least 3 minutes, unless an electronic thermometer is used. Rectal is not suggested, except in severe cases of trauma; the newborn's ear canals are too small to receive an accurate reading from a tympanic thermometer; and the newborn is unable to hold the thermometer under the tongue to receive an accurate reading.
4. A routine hematocrit level is drawn on a newborn immediately after delivery and is found to be 60%. What may have contributed to this relatively high hematocrit level? a. Congenital heart defect b. Leukocytosis c. Delayed cord clamping d. Hypovolemia
Answer: c. Delayed cord clamping Feedback: Blood volume increases with delayed cord clamping; this increase is reflected by a hematocrit level that is at the upper limit or normal. Congenital heart defects, leukocytosis, and hypovolemia are not related at all to high hematocrit levels.
8. What is the most appropriate nursing action when signs of fatigue occur in the newborn, such as loss of eye contact, decreased muscle tension, and closure of the eyelids? a. Increase IV fluids. b. Administer sedation medications. c. Discourage parent tactile stimulation. d. Administer blow by oxygen.
Answer: c. Discourage parent tactile stimulation. Feedback: Excessive handling and tactile stimulation can cause an increase in the newborn's metabolic rate and caloric use, and can cause fatigue.
7. A client is diagnosed with preterm labor at 28 weeks' gestation. She asks the nurse what is going to happen to her baby if she is born now. The nurse's responses are based on the knowledge that the most significant problems for this infant will be associated with: a. Low birth weight. b. Feeding problems. c. Lung maturity. d. Skeletal injuries.
Answer: c. Lung maturity. Feedback: Inability to ventilate the lungs and achieve gas exchange is the most significant risk for preterm infants. Low birth weight and feeding problems cannot be addressed until the infant is adequately oxygenated and are compounded by hypoxia and acidemia. Preterm infants are a higher risk for birth trauma but this is not as significant as inability to breathe.
5. The nurse is assuming care of a woman whose baby was stillborn at term. Which nursing action is most appropriate? a. Restrict visitors. b. Avoid mentioning the baby. c. Offer her photographs of the baby. d. Stay at the bedside continuously.
Answer: c. Offer her photographs of the baby. Feedback: Most parents prefer to have photographs of the baby and regret not accepting if they decline when they are offered. Not mentioning the baby denies the reality of what has happened to the mother and makes her feel isolated. She should be encouraged to talk about the baby if she desires. Restriction of visitors and having staff at the bedside should be done according to the mother's individual needs and preferences.
1. The nurse is caring for a client at 40 weeks' gestation who is has been experiencing prolonged labor. The nurse-midwife estimates the fetal weight at 4600 g. Which complication will the nurse anticipate at the birth? a. Occiput posterior delivery b. Meconium aspiration c. Shoulder dystocia d. Neonatal sepsis
Answer: c. Shoulder dystocia Feedback: A fetal weight of 4500 g or more is macrosomia. Macrosomia is a significant risk factor for shoulder dystocia. Occiput posterior delivery increases the risk of maternal lacerations. The presence of meconium-stained amniotic fluid increases the risk of meconium aspiration. Prolonged rupture of membranes and maternal infection increase the risk of neonatal sepsis.
2. Which rationale best describes the intervention of suctioning a baby's mouth and nares immediately after delivery? a. Suctioning decreases intrathoracic pressure, decreasing the respiratory rate to 30-60 breaths per minute. b. Suctioning assists with increasing the pulmonary vascular resistance in the lungs, resulting in a decrease in blood flow to the pulmonary bed. c. Suctioning removes fluid that remains in the respiratory passages, facilitating adequate movement of air. d. Suctioning assists with the opening of the glottis, creating negative intrathoracic pressure.
Answer: c. Suctioning removes fluid that remains in the respiratory passages, facilitating adequate movement of air. Feedback: It is stated that 80-110 ml remains in the respiratory passages that must be removed to permit adequate movement of air. Suctioning increases intrathoracic pressure, decreases pulmonary vascular resistance, and creates a positive intrathoracic pressure.
7. The nurse weighs a newborn who is 1 day old. It is noted that the newborn has lost 10 grams from the previous day. Which responses from the nurse to the parents are appropriate? a. "This is acceptable, and your newborn more than likely will continue to lose close to 20% of the birth weight over the next few days, but then regain it by 2 weeks." b. "I am concerned about the weight loss, and feel the physician should be notified." c. "This will be very alarming if your baby continues to lose weight over the next 2 days. We will watch closely." d. "We will continue to monitor closely, but it is expected that each baby will lose weight as fluids shift within a few days after delivery."
Answer: d. "We will continue to monitor closely, but it is expected that each baby will lose weight as fluids shift within a few days after delivery." Feedback: During the initial newborn period (first 3-4 days), there is a physiologic weight loss of about 5% to 10% for term newborns because of fluid shifts. There is no apparent reason to notify the primary healthcare provider; this type of weight loss is considered normal, even over the next 2 days.
4. A frequent blood glucose test may be indicated for which newborn? a. A newborn with increased temperature and increased heart rate b. A newborn that is inconsolable c. A newborn with suspected hypothyroidism d. A newborn that is large for gestational age
Answer: d. A newborn that is large for gestational age Feedback: A blood glucose evaluation should be performed on at-risk newborns, or as clinically indicated (such as for small-for-gestational-age or large-for-gestational-age infants, or if the newborn is jittery).
4. The nurse is performing a pelvic exam on a laboring client and discovers a loop of cord in the vagina. What is the initial nursing action? a. Administer oxygen at 5 L per minute. b. Call the primary healthcare provider or nurse-midwife. c. Place the client in a side-lying position. d. Apply upward pressure on the presenting part
Answer: d. Apply upward pressure to the presenting part. Feedback: The initial action is pressure to the presenting part in order to elevate it off of the cord, should the nurse discover a loop of cord in the vagina. Administering oxygen at 5 L per minute, calling the primary healthcare provider or nurse-midwife, and placing the client in a side-lying position are appropriate actions but not the initial nursing action.
6. The nurse is assessing a prenatal client diagnosed with possible placenta previa. What signs and symptoms should the nurse expect this client to demonstrate? a. Dark red vaginal bleeding b. Severe abdominal pain c. Absence of fetal heart sounds d. Bright red vaginal bleeding
Answer: d. Bright red vaginal bleeding Feedback: Bright red vaginal bleeding is a sign that a prenatal client has possible placenta previa. Severe abdominal pain, possible absence of fetal heart sounds, and dark red vaginal bleeding are true of abruptio placentae.
9. What is the best rationale for removing the cord clamp within 24 hours? a. It decreases the risk for infection. b. Waiting longer than 24 hours will make the clamp difficult to remove. c. To reassess the number of vessels found within the cord d. It decreases the chance of tension injury to the area.
Answer: d. It decreases the chance of tension injury to the area. Feedback: The umbilical cord is assessed for signs of bleeding or infection. Removal of the cord clamp within 24 hours reduces the chance of tension injury to the area.
10. What rationale supports drawing the newborn screen after 24 hours from the time of delivery? a. Hemoglobinopathies are most evident at 24-36 hours of life. b. There is overdiagnosis of congenital adrenal hyperplasia if drawn before 24 hours of life. c. Cystic fibrosis is not apparent in the blood of the newborn until 24 hours postdelivery. d. It is well documented that there is a decrease in sensitivity of the screening if obtained before 24 hours of life, resulting in underdiagnosing of PKU.
Answer: d. It is well documented that there is a decrease in sensitivity of the screening if obtained before 24 hours of life, resulting in underdiagnosing of PKU. Feedback: It is noted that there can be decreased sensitivity to testing if the screening is drawn before 24 hours of life.
3. Which objective data best indicates that the ductus arteriosus of a newborn has not closed? a. Rapid heart rates between 180 and 220 beats per minute b. Low blood pressure and blood pressure means c. Temperature instability ranging from 36.5°C to 38.5°C d. Labile oxygen saturations with occasional apnea/bradycardia episodes
Answer: d. Labile oxygen saturations with occasional apnea/bradycardia spells Feedback: Closing of the ductus arteriosus does not directly affect heart rate, blood pressure, or body temperature. It does affect shunting of the blood, causing unstable oxygen saturations and resulting in possible apneic and bradycardic episodes.
13. Which is a true medical contraindication to breastfeeding? a. Pregnant mother b. Multiple births c. The father wants to be involved in feeding the newborn. d. Management of newborn galactosemia
Answer: d. Management of newborn galactosemia Feedback: Management of newborn galactosemia is a true medical contraindication to breastfeeding. A pregnant mother; multiple births; and the father wanting to be involved in feeding the newborn are not true medical contraindications.
2. A newborn appears large for gestational age, while a lower score for neurological maturation is noted on gestational exam. Which answer best explains this outcome? a. Maternal preeclampsia b. Maternal analgesia and anesthesia c. Maternal hypertension d. Maternal diabetes
Answer: d. Maternal diabetes Feedback: Maternal diabetes accelerates fetal growth, but retards maturation. Maternal hypertension retards physical growth and speeds maturation. Maternal analgesia causes respiratory depression. Maternal preeclampsia causes active muscle tone and edema.
10. What is the most appropriate nursing action for a newborn demonstrating acrocyanosis? a. Administer IV fluids. b. Suction vigorously. c. Place in the Trendelenburg position. d. Swaddle in blankets.
Answer: d. Swaddle in blankets. Feedback: Acrocyanosis is caused by poor peripheral circulation and is a normal finding in the first 2 days of life. Administering IV fluids is not indicated; suction is not indicated in this scenario; and the Trendelenburg position will not assist with better perfusion. Keeping the hands and feet warm will increase perfusion to the periphery.
4. The nurse is caring for a third-trimester prenatal client admitted with bright red, painless vaginal bleeding. What nursing intervention is not recommended? a. Intravenous fluids with lactated Ringer's b. Assessment of the fetal heart rate with continuous monitoring c. Application of a pulse oximeter d. Vaginal exams
Answer: d. Vaginal exams Feedback: Vaginal exams are contraindicated on a client with placenta previa. This is due to the increased risk of perforating the placenta. Nursing management may include intravenous fluids with lactated Ringer's, assessment of the fetal heart rate, and monitoring vital signs, contractions, bleeding, and fetal heart rate.