MCN Exam 2 EAQ

The nurse gives a NG feeding to a preterm male infant. As the mother watched she asks. "Would it hurt my baby to suck on a pacifier during the feeding? How would the nurse best respond.

"sucking on a pacifier during tube feedings may help him associate sucking with food so that he'll adjust better to oral feedings"

A PCP examines an 11 month old infant and suspects anemia. Which questions would the primary health care provider most likely ask the mother.

- "Do you use 2% cows milk?" - "Do you use whole cows milk?" - "Do you use alternative milk products?"

Which deviations from the normal range would make the nurse suspect that there might be a problem during the physical assessment of a newborn infant?

- An expiratory grunt - A persistent heart rate of 180 or more - apneic epidodes that last longer than 20 seconds

a client expresses a desire to breastfeed her late preterm infant, who is being cared for in the NICU. How would the nurse respond to this client?

- Buy supporting the clients decision and explaining that her infant may not be able to finish breastfeeding because of exhaustion

A client asks about the difference between cows milk and breast milk. The nurse would respond that cows milk differs from human milk in that it contains which?

- More protein, more calcium and fewer carbs

An infant born at 36 weeks' gestation weighs 4 lb 3 oz and has apgar scores of 7 and 9. Which nursing actions will be performed upon the infants admission to the nursery?

- Recording the neonates vital signs - Evaluation of the neonates health status - Keeping the neonates body warm

the nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth?

- foramen ovale - ductus arteriosus

On the second postpartum day a client mentions that her nipples are becoming sore from beast feeding. Which is the nurses initial action in response to this information?

Assess her breastfeeding technique to identify possible causes.

a client who has had a c section has been having difficulty breastfeeding for 2 days and now asks the nurse to bring her a bottle of formula. which would be the nurses initial reaction?

Assessing the clients breastfeeding technique

A client expresses a desire to breastfeed her preterm neonate, who is in the NICU. How would the nurse respond to the mothers request of wanting to pump her breasts until her baby is ready to breastfeed?

By supporting the clients decision and explaining that the infant may lie close to her breast for nippling as desired.

Hydramnios is diagnosed in a primigravida at 35 wks gestation. for which condition would the nurse assess the newborn?

Esophageal atresia

which action would the nurse take before birth when meconium staining is present?

Gather equipment for neonatal resuscitation

The nurse must continually assess a preterm infants temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant has which limitation?

Has a limited supply of brown fat available to provide heat

Which condition is detected by an alpha feto protien test?

Neural tube defects

How would the nurse respond to a primigravida who says " its so fast, is that normal?" when first hearing the fetal heartbeat of 150 bpm?

Normal range for fetal HR at 12 weeks gestation is 120-180 bpm

Which nursing intervention would the nurse provide to prevent heat loss in the neonate immediately after birth?

Putting the naked newborn on the mothers bare chest.

A newborn is diagnosed as having NAS after exhibiting jitteriness, irritability, and a shill cry. Which is the priority nursing care?

Reducing environmental stimuli to promote relaxation

Because preterm infants are at risk for respiratory distress syndrome, immediate nursing intervention is required when a preterm infant exhibits which sign?

Supraventricular retractions

Which intervention would the nurse plan for the breastfeeding client with a diagnosis of mastitis?

Teach her to empty her breasts frequently

Which parent education would the nurse provide as rationale for gavage feeding in an infant with CHF?

The eneregy that would have been expended on suckling is conserved

After her babys birth a client wishes to begin breastfeeding as soon as possible. How can the nurse best assist the client at this time?

Touching the infants cheek adjacent to the nipple to elicit the rooting reflex.

Two days after being discharged a new mother calls the clinic stating that she is not sure that her baby is receiving enough breast milk. Which information would indicate that the infant is being fed adequately?

Voids four times before 2 pm

Which sign does not reflect opioid drug withdrawal in neonates?

hypoactivity

Which is a neonatal effect of maternal smoking during pregnancy?

low birth weight

The nurse is caring for preterm infants with respiratory distress in the NICU. Which is the priority nursing actions?

maintaining a high humidity environment to promote gas exchange

five minutes after birth a newborn infant is given an apgar score of 8. twelve hours later the newborn becomes hyperactive and jittery, sneezes frequently and has difficulty swallowing. which would the nurse suspect is the cause of these clinical findings.

opioid drug withdrawal

The nurse assess a newborn and observes central cyanosis. Which type of congenital heart defect usually results in central cyanosis?

shunting of blood from left to right

Which parent education would the nurse provide for an infant who is restarting bottle feedings after surgery for hypertrophic pyloric stenosis?

start with small, frequent feedings

A client delivered an infant at 11pm yesterday after a labor of 14 hrs. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks the nursery staff to take the baby back to the nursery because she has not had a shower yet. One hr later the nurse returns with the infant. Again, the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks if the baby be picked up so she can take a nap. Which behavior pattern is the new mother demonstrating?

taking in