Nursing 404 Exam 2 NClex

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting-go b. Taking-in c. Taking-on d. Taking-hold

ANS: A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. In the taking-in phase, the mother is primarily focused on her own needs. There is no taking-on phase of maternal adjustment. During the taking-hold phase, the mother assumes responsibility for her own care and shifts her attention to the infant.

Which clinical findings are early signs of hypoglycemia in the newborn? (Select all that apply.) a. Jitteriness b. Poor feeding c. Respiratory difficulty d. An increase in temperature e. A capillary refill of 2 seconds

ANS: A, B, C Early signs of hypoglycemia include jitteriness and other central nervous system signs and signs of respiratory difficulty, a decrease in temperature, and poor feeding. A capillary refill of 2 seconds is a normal finding in the newborn.

2. Which organs are nonfunctional during fetal life? a. Eyes and ears b. Lungs and liver c. Kidneys and adrenals d. Gastrointestinal system

ANS: B Conduction occurs when the infant comes in contact with cold objects. Radiation is the transfer of heat to a cooler object that is not in direct contact with the infant. Convection occurs when heat is transferred to the air surrounding the infant. Evaporation can occur during birth or bathing as a result of wet linens or clothes, or insensible heat loss.

When assessing the A of the acronym REEDA, the nurse should evaluate the a. skin color. b. degree of edema. c. edges of the episiotomy. d. episiotomy for discharge.

ANS: C In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other letters of the acronym refer to other components of wound assessment: R = redness, E = edema, E = ecchymosis, and D = drainage.

A reported hematocrit level for a newborn delivered by vaginal birth is 75%. Based on this lab value, which complication is the newborn least likely to develop? a. Hypoglycemia b. Respiratory distress c. Infection d. Jaundice

ANS: C The presence of polycythemia as indicated by this lab result could result in the infant being at risk to develop hypoglycemia, respiratory distress, and jaundice. Possible infection would be unrelated to this diagnostic value.

1. The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? a. Negative Barlow test b. Equal knee heights c. Negative Ortolani sign d. Thigh and gluteal creases are asymmetric

ANS: D Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. If the hip is dislocated, the knee on the affected side will be lower. A positive Ortolani sign yields a clunking sensation and indicates a dislocated femoral head moving into the acetabulum. During a positive Barlow test, the examiner can feel the femoral head move out of the acetabulum

To promote bonding and attachment immediately after birth, which action should the nurse take? a. Assist the mother in feeding her baby. b. Allow the mother quiet time with her infant. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in assuming an en face position with her newborn.

ANS: D Assisting the mother in assuming an en face position with her newborn will support the bonding process. After birth is a good time to initiate breastfeeding, but first the mother needs time to explore the new infant and begin the bonding process. The mother should be given as much privacy as possible; however, nursing assessments must still be continued during this critical time. The mother has just delivered and is more focused on the infant; she will not be receptive to teaching at this time.

Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is optimal for the newborn? a. Deltoid muscle b. Gluteal muscle c. Rectus femoris muscle d. Vastus lateralis muscle

ANS: D The vastus lateralis muscle is located away from the sciatic nerve and femoral blood vessels. Gluteal muscles are not used until a child has been walking for at least 1 year to develop these muscles. The rectus femoris is used only if absolutely necessary because this muscle is located closer to the sciatic nerve and blood vessels, which poses a greater danger. The deltoid is not a recommended site for newborn injections.

In the newborn nursery, you are reviewing the maternal medication list to ascertain if there is any significant risk to the newborn. Which medications would pose a potential risk to the newborn in terms of clotting ability? (Select all that apply.) a. Carbamazepine b. Phenytoin (Dilantin) c. Phenobarbital d. INH (Isoniazid) e. Prenatal vitamins with iron

ANS: A, B, C, D Carbamazepine, phenytoin (Dilantin), phenobarbital, and isoniazid (INH) when taken by the mother can affect the newborn's clotting ability. Anticonvulsant usage can cause bleeding problems. Prenatal vitamins with added iron should have no effect on the newborn's clotting ability.

3. Infants who develop cephalohematoma are at increased risk for: a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.

ANS: B Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalohematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas.

The infant's heat loss immediately at birth is predominantly from a. radiation. b. conduction. c. convection. d. evaporation.

ANS: D Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Radiation occurs with the transfer of heat to a cooler object that is not in direct contact with the infant. Conduction occurs when the infant comes into contact with a cold surface. The crib should be preheated to prevent this from occurring. Convection occurs when heat is transferred to the air surrounding the infant.

A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital 5 days after her son was circumcised. She is very concerned. Which response by the nurse is most appropriate? a. The yellow crust should not be removed. b. This yellow crust is an early sign of infection. c. Discontinue the use of petroleum jelly to the tip of the penis. d. After circumcision, the diaper should be changed frequently and fastened snugly.

ANS: A Crusting is a normal part of healing. The normal yellowish exudate that forms over the site should be differentiated from the purulent drainage of infection. The only contraindication for petroleum jelly is the use of a PlastiBell device. The diaper should be fastened loosely to prevent rubbing or pressure on the incision site.

Which newborn assessment finding requires the nurse to take immediate action? a. Glucose level of 40 mg/dL b. Axillary temperature of 37°C (98.6°F) c. Mild yellow tinge to skin at 32 hours of age d. Mild inflammation of conjunctiva after eye prophylaxis

ANS: A A glucose level of 40 mg/dL requires an action. The nurse should follow agency policy and health care provider orders regarding feeding infants with low glucose levels. A common practice is to feed the newborn breast milk or formula if the glucose screening reveals a level of 40 to 45 mg/dL or less to prevent further depletion of glucose. Infants with severe hypoglycemia may need intravenous feedings to provide glucose more rapidly. A normal temperature for a newborn is 36.5 to 37.5°C (97.7 to 99.5°F). Mild jaundice at 32 hours of age is physiologic jaundice and does not need an action by the nurse, just further monitoring. Some infants develop a mild inflammation a few hours after prophylactic eye treatment.

The nurse is performing the initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system? a. Respiratory b. Cardiovascular c. Gastrointestinal d. Musculoskeletal

ANS: A Tachypnea, a respiratory rate of more than 60 breaths per minute, is the most common sign of respiratory distress. Retractions occur when the soft tissue around the bones of the chest is drawn in with the effort of pulling air into the lungs. Xiphoid (substernal) retractions occur when the area under the sternum retracts each time the infant inhales. When the muscles between the ribs are drawn in so that each rib is outlined, intercostal retractions are present. A reflex widening of the nostrils occurs when the infant is receiving insufficient oxygen. Nasal flaring helps decrease airway resistance and increase the amount of air entering the lungs.

2. Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Stepping c. Tonic neck d. Plantar grasp

ANS: A The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The stepping reflex occurs when infants are held upright, with their heel touching a solid surface, and the infant appears to be walking. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infant's toes curl over the nurse's finger.

The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding? a. Depress the tip of the nose. b. Stroke the outer aspect of the foot. c. Place a finger in the palm of the hand. d. Rotate the hips in an upward and outward direction.

ANS: A The nurse assesses for jaundice at least every 8 to 12 hours and is particularly watchful when infants are at increased risk for hyperbilirubinemia. Jaundice is identified by pressing the infant's skin over a firm surface, such as the end of the nose or the sternum. The skin blanches as the blood is pressed out of the tissues, making it easier to see the yellow color that remains. Jaundice is more obvious when the nurse assesses in natural light. Jaundice begins at the head and moves down the body, and the areas of the body involved should be documented. Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL. The Babinski reflex is assessed by stroking the outer aspect of the foot. The grasp reflex is determined by placing a finger in the newborn's palm. The Barlow and Ortolani tests are methods of assessing for hip instability in the newborn period. Both legs should abduct equally in normal infants. Abducting the affected hip may be difficult. A hip click may be felt or heard but is usually normal and is different from the clunk of hip dysplasia when the femoral head moves in the hip socket.

During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant? a. Formal b. Informal c. Personal d. Anticipatory

ANS: A A major task of the formal stage of role attainment is getting acquainted with the infant. The informal stage begins once the parents have learned appropriate responses to their infant's cues. The personal stage is attained when parents feel a sense of harmony in their role. The anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes

Which situation would require the administration of Rho(D) immune globulin? a. Mother Rh-negative, baby Rh-positive b. Mother Rh-negative, baby Rh-negative c. Mother Rh-positive, baby Rh-positive d. Mother Rh-positive, baby Rh-negative

ANS: A An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's.

If the patient's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take? a. Document the finding. b. Inform the health care provider. c. Begin antibiotic therapy immediately. d. Have the laboratory draw blood for reanalysis.

ANS: A An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding. There is no reason to alert the health care provider. Antibiotics are not needed because the elevated WBCs are caused by the stress of labor and not an infectious process. There is no need for reassessment as it is expected for the WBCs to be elevated.

Which anticipatory guidance action by the nurse makes role transition to parenthood easier? a. Helps the new parents identify resources. b. Recommends employing babysitters frequently. c. Tells the parents about the realities of parenthood. d. Offers a home phone number and tells parents to call if they have a question.

ANS: A Available resources within the community can assist the parents in role transition. Some parents may not be able to afford babysitters. Also, this removes them from the parenthood role. Each adult sees parenthood in a different light. They cannot be compared. Searching out resources for the parents is an important task; however, the nurse should not give her personal number to patients.

A new father calls the nurse's station stating that his wife, who delivered last week, is happy one minute and crying the next. He states, "She was never like this before the baby was born." How should the nurse best respond? a. Reassure him that this behavior is normal. b. Advise him to get immediate psychological help for her. c. Tell him to ignore the mood swings because they will go away. d. Instruct him in the signs, symptoms, and duration of postpartum blues.

ANS: A Before providing further instructions, inform family members of the fact that postpartum blues are a normal process to allay anxieties and increase receptiveness to learning. Postpartum blues are a normal process that is short-lived; no medical intervention is needed. Telling him to ignore the moods blocks communication and may belittle the husband's concerns. Patient teaching is important; however, his anxieties need to be allayed before he will be receptive to teaching

The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which action is most appropriate for the nurse to take at this time? a. Hand the baby to the woman. b. Explain "taking-in" to the woman. c. Offer to hand the baby to the woman. d. No action, because this situation is perfectly acceptable.

ANS: A During the taking-in phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. She learns best during the taking-hold phase. The woman is dependent and passive at this stage and may have difficulty making a decision. This is expected behavior during the taking-in phase; however, interventions that facilitate infant bonding can be taken

The nurse is evaluating a newborn's circumcision 30 minutes after the procedure. The nurse notes excessive bleeding coming from the circumcised area. Which priority intervention should the nurse implement at this time? a. Apply pressure to the site. b. Continue to observe for another 30 minutes. c. Apply the diaper tightly over the circumcised area. d. Apply petroleum jelly to the site with a small piece of gauze.

ANS: A If excessive bleeding occurs after a circumcision, pressure is applied to the site. The nurse notifies the physician, who may apply Gelfoam or epinephrine or suture the small blood vessels. A small amount of blood loss may be significant in an infant, who has a small total blood volume. Continuing to observe could mean additional blood loss. Applying the diaper tightly will not stop the bleeding. Petroleum jelly is applied to keep the diaper from sticking to the circumcised area. It will not stop the bleeding.

An infant at 39 weeks' gestation was just delivered; included in the protocol for a term infant is an initial blood glucose assessment. The nurse obtains the blood sample and the reading is 58 mg/dL. What is the priority nursing action based upon this reading? a. Document the finding in the newborn's chart. b. Double-wrap the newborn under a warming unit. c. Feed the newborn a 10% dextrose solution. d. Notify the neonatal intensive care unit (NICU) of the pending admission.

ANS: A In the term infant, glucose levels should be 40 to 60 mg/dL on the first day and 50 to 90 mg/dL thereafter. There is no general consensus regarding the level of blood glucose that defines hypoglycemia; however, a level below 40 to 45 mg/dL in the term infant is often used. If an infant is placed in a warming unit, the skin needs to be exposed. Because the glucose level is normal, no supplemental feeding is necessary. Dextrose solution is only administered when the glucose levels are very low. There is no information in the stem indicating the need for admission to the NICU.

The postpartum patient who continually repeats the story of her labor, birth, and recovery experiences is performing which of the following tasks? a. Making the birth experience "real" b. Accepting her response to labor and birth c. Providing others with her knowledge of events d. Taking hold of the events leading to her labor and birth

ANS: A Reliving the birth experience makes the event real and helps the mother realize that the pregnancy is over and that the infant is born and is now a separate individual. She is in the taking-in phase, trying to make the birth experience seem real. This is to satisfy her needs, not the needs of others

The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective? a. No swelling or edema to the perineal area b. Patient complains that the sitz bath is too cold. c. Patient reports she took two sitz baths in 12 hours. d. Edges of the perineal laceration are well approximated.

ANS: A Sitz baths may be offered two to four times a day to women with episiotomies, painful hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and cleanse and comfort the traumatized perineum. Cool water reduces pain caused by edema and may be most effective within the first 24 hours. Ice can be added to cool the water to a comfortable level as the woman sits in it. Approximation of the edges of a wound facilitates wound healing. The purpose of the cold sitz bath is to decrease the edema secondary to tissue trauma

The postpartum nurse is reviewing dietary practices for an Asian patient. Which of the following should the nurse expect to observe as a dietary practice for this culture? a. Special foods brought from home. b. Preference for fresh fruits. c. Preference for "cold" foods. d. Request for ice water instead of hot water.

ANS: A Specific foods brought from home are a welcome sign of caring in many cultures. Some Asians believe that after childbirth the woman should eat only "hot" foods such as chicken, meat, and fish. Fresh fruit would be considered a "cold" food. Although ice water is commonly given to hospital patients, it is not acceptable to many Asians. For example, Southeast Asian women may refuse cold or ice water and prefer hot water or other warm beverages to keep warm.

In which position should the parents be instructed to place their newborn for sleep? a. On the back b. On the left side c. On the right side d. On the abdomen

ANS: A The American Academy of Pediatrics (AAP) recommends that mothers and fathers be taught to place infants consistently on the back for sleep. This position is associated with the lowest rate of SIDS. The side-lying position is not advised because of the possibility that the infant might roll to the prone position. The newborn should not be placed on the abdomen except for short periods under supervision in order to prevent plagiocephaly.

Which patient would be most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Primipara who delivered a 7-lb boy c. Patient who is bottle feeding her first child d. Patient who is breastfeeding her second child

ANS: A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The non-nursing mother may have engorgement problems that will cause her discomfort. The patient who is nursing her second child will have more afterpains than her first pregnancy; however, they will not be as severe as the grand multiparous patient.

A new mother states, "My baby is so thin and wrinkled. It looks like he has too much skin." Which is the most therapeutic response by the nurse in response to the patient's statement? a. "You sound disappointed about how your infant looks." b. "All mothers are concerned about how their babies look." c. "Don't worry. In no time he'll fill out his skin and look just fine." d. "You know, all the cigarettes you smoked interfered with the nourishment he needed."

ANS: A The nurse should clarify the patient's statement and allow her to verbalize her feelings. "All mothers are concerned about how their babies look" generalizes her concerns and does not answer the mother's question. "Don't worry. In no time he'll fill out his skin and look just fine" does not directly answer the mother's question and could leave her feeling like she asked an unacceptable question. "You know, all the cigarettes you smoked interfered with the nourishment he needed" is condescending and hurtful and would not allow for further conversation between the nurse and mother

Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level? a. Distended bladder b. Normal involution c. Been lying on her right side too long d. Stretched ligaments that are unable to support the uterus

ANS: A The presence of a full bladder will displace the uterus. A palpated fundus on the right side of the abdomen above the expected level is not an expected finding. Position of the patient should not alter uterine position. The problem is a full bladder displacing the uterus.

Which patient is more likely to have less stress adjusting to her role as a mother? a. A 26-year-old woman who is returning to work in 10 weeks b. A 35-year-old anxious mother who has had no contact with babies or children c. A 16-year-old teenager who lives with her parents and has a strained relationship with her mother d. A 25-year-old woman who knew at 16 weeks of gestation that she was pregnant with twins, who were delivered by cesarean birth

ANS: A The woman who has the least amount of stress in her life will adjust more quickly to her role as a mother. The anxious mother with no real experience with babies may have a difficult time adjusting to motherhood. The teenager has a significant amount of stress in her life, which could make adjusting to her role as a mother more difficult. The 25-year-old mother has the added stress of twins, which may make motherhood adjustment more difficult.

The nurse is teaching the postpartum patient about newborn transitional stools. Which should the nurse include in the teaching session with regard to transitional stools? (Select all that apply.) a. They are a greenish brown color. b. They are of a looser consistency. c. They have a tarlike consistency. d. They have a consistency of mustard. e. They are seedy, with a sweet-sour smell.

ANS: A, B Meconium stools are followed by transitional stools, a combination of meconium and milk stools. They are greenish brown and of a looser consistency than meconium. Stools that are tarlike are meconium stools. Infants fed with breast milk are seedy, with a sweet-sour smell; the meconium has the consistency of mustard.

Which vaccinations are indicated for the postpartum patient if she does not have immunity? (Select all that apply.) a. Pertussis b. Rubella c. Diphtheria, tetanus (Tdap) d. RhoGAM e. Varicella

ANS: A, B, C, E If a patient who has delivered does not have evidence of immunity, CDC recommendations advise that pertussis, rubella, Tdap, and varicella should be administered. RhoGAM is required if there is evidence of sensitization in response to Rh factor identification based on maternal and fetal blood results.

The nurse is conducting a body system assessment of the newborn. Which are abnormal findings that the nurse should report? (Select all that apply.) a. Low-set ears b. Yellow sclera c. A doll's eye sign d. Edema of the eyelids e. Absence of the grasp reflex

ANS: A, B, E Low-set ears may indicate chromosomal abnormalities. The sclera should be white or bluish white. A yellow color indicates jaundice. Absence of reflexes may indicate a serious neurologic problem. The doll's eye sign is a normal finding in the newborn; when the head is turned quickly to one side, the eyes move toward the other side. Edema of the eyelids and subconjunctival hemorrhages (reddened areas of the sclera) result from pressure on the head during birth, which causes capillary rupture in the sclera.

The nurse is performing a gestational age assessment on a newborn. Which characteristics indicate a preterm newborn? (Select all that apply.) a. Translucent skin b. Extended limp arms and legs c. The ear springs back when folded d. Square window angle of 45 degrees or less e. Large clitoris and labia minora in the female newborn

ANS: A, B, E The very preterm infant's skin is translucent because it is thin and has little subcutaneous fat beneath the surface. Preterm neonates have immature flexor muscles and little energy or muscle tone. Therefore they have extended and limp arms and legs that offer little resistance to movement by the examiner. In the preterm female infant, the labia majora are small and separated, and the clitoris and labia minora are large by comparison. In the term neonate, the ear springs back to its original position immediately. The more mature the neonate, the smaller the angle of the square window assessment until the palm folds flat against the forearm at term, the result of maternal hormones at the end of pregnancy.

Which newborn is at higher risk for developing hypoglycemia? (Select all that apply.) a. Post-term newborn b. 38 weeks' gestation newborn c. Small-for-gestational-age newborn d. Large-for-gestational-age newborn e. Term newborn delivered by cesarean birth

ANS: A, C, D Many newborns are at increased risk for hypoglycemia. In the preterm, late preterm (born between 34 weeks and 36 6/7 weeks of gestation), and small-for-gestational-age infant, adequate stores of glycogen or even fat for metabolism may not have accumulated. Stores may be used up before birth in the post-term infant because of poor intrauterine nourishment from a deteriorating placenta. Large-for-gestational-age infants and those with diabetic mothers may produce excessive insulin that consumes available glucose quickly. The newborn born at 38 weeks and the newborn born by cesarean at term have lower risk for hypoglycemia.

Which of the following are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.) a. Provide comfort and ample time for rest. b. Keep the baby wrapped to avoid cold stress. c. Position the infant face to face with the mother. d. Point out the characteristics of the infant in a positive way. e. Limit the amount of modeling so the mother doesn't feel insecure.

ANS: A, C, D Provide comfort and ample time for rest, because the mother must replenish her energy and be relatively free of discomfort before she can progress to initiating care of the infant. Position the infant in an en face position and discuss the infant's ability to see the parent's face. Face to face and eye to eye contact is a first step in establishing mutual interaction between the infant and parent. Point out the characteristics of the infant in a positive way: "She has such pretty little hands and beautiful eyes." The baby should be kept warm, but parents should be assisted to unwrap the baby (keeping or rewrapping the body part not being inspected) to inspect the toes, fingers, and body. The nurse should model behaviors by holding the infant close, making eye contact with the infant, and speaking in high-pitched, soothing tones.

The nurse is planning comfort measures to implement for a patient after a vaginal birth. Which measures should the nurse plan to include in the patient's care plan? (Select all that apply.) a. Sitz baths four times a day b. Use of only warm water with the sitz baths c. Topical anesthetic spray after perineal care d. Ice pack to the perineum for the first 24 hours e. Relax the perineal and buttock areas when sitting

ANS: A, C, D Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized perineum. Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Anesthetic sprays decrease surface discomfort and allow more comfortable ambulation. Cool water in the sitz bath reduces pain caused by edema and may be most effective within the first 24 hours. The mother should be advised to squeeze her buttocks together, not relax them, before sitting, and to lower her weight slowly onto her buttocks

The nurse is teaching a non-breastfeeding patient measure to suppress lactation. Which information should the nurse include in the teaching session? (Select all that apply.) a. Avoid massaging the breasts. b. Allow warm shower water to run over the breasts. c. If the breasts become engorged, pumping is recommended. d. Ice packs or cabbage leaves can be applied to the breasts to relieve discomfort. e. Wear a sports bra 24 hours a day until the breasts become soft.

ANS: A, D, E The patient should be advised to avoid massaging the breasts because this will stimulate milk production. Instruct the patient to wear a sports bra or other well-fitting bra 24 hours a day until the breasts become soft. Manage breast discomfort by application of ice, or cold cabbage leaves, which reduce vasocongestion. Advise the patient to refrain from allowing warm water to fall directly on the breasts during showers and pumping because these actions will stimulate milk production.

The nurse is performing a gestational age assessment on a newborn. Which characteristic indicates the greatest gestational maturity? a. The infant's arms and legs are extended. b. There is some peeling and cracking of the skin. c. There are few rugae on the scrotum and the testes are high in the scrotum. d. The arm can be positioned with the elbow beyond the midline of the chest.

ANS: B Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. Extended arms and legs are a sign of preterm infants. Few rugae on the scrotum indicate a younger age in the newborn. The arm being able to be positioned with the elbow beyond the midline of the chest is a result of the scarf sign and indicates a newborn of a younger age.

During fetal circulation the pressure is greatest in the a. left atrium. b. right atrium. c. hepatic system. d. pulmonary veins.

ANS: B Pressure in the fetal circulation is greatest in the right atrium, which allows right-to-left shunting that aids in bypassing the lungs during intrauterine life. The pressure increases in the left atrium after birth and will close the foramen ovale. The liver does not filter the blood during fetal life until the end. It is functioning by birth. Blood bypasses the pulmonary vein during fetal life.

Which fundal assessment finding at 12 hours after birth requires further assessment? a. The fundus is palpable at the level of the umbilicus. b. The fundus is palpable two fingerbreadths above the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: B The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate.

The mother-baby nurse is providing care to a patient and her newborn 2 hours after delivery. On review of the newborn's chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mother's chart? a. Race: non-White b. A longer than usual labor c. Administration of an epidural d. Delivery by cesarean birth

ANS: B A caput succedaneum is an area of localized edema that appears over the vertex of the newborn's head as a result of pressure against the mother's cervix during labor. The pressure interferes with blood flow from the area, causing localized edema at birth. The edematous area crosses suture lines, is soft, and varies in size. The longer the labor, the more pronounced the caput. Mongolian spots are associated with infants born to non-White parents. An epidural may be a contributing factor to a prolonged labor, but it is the pressure of the head against the cervix that gives rise to the caput. If labor is prolonged without descent of the head, a cesarean birth may follow but is not the cause of the caput.

An example of binding in during the postpartum period is a a. new mother telling her friends all about her labor and birth experience. b. father looking at his newborn and stating that he "looks like I did when I was a baby." c. mother reporting increasing anxiety during the postpartum period because she feels like she is without support. d. mother wanting some time alone so that she can catch up on needed sleep

ANS: B A new mother telling her friends all about her labor and birth experience is an example of binding in or claiming. A new mother telling her friends all about her labor and birth experience is an example of the taking-in phase of maternal adaptation. A mother who reports increasing anxiety during the postpartum period because she feels like she is all alone may be problematic and indicates that the patient is experiencing significant stressors during the postpartum period. A mother wanting some time alone so that she can catch up on needed sleep is a normal reaction to the demands of the newborn and reflects that the patient may need additional support during this time.

The nurse is explaining how a newly delivered baby initiates respirations. Which statement explains this process most accurately? a. Drying off the infant b. Chemical, thermal, and mechanical factors c. An increase in the PO2 and a decrease in the PCO2 d. The continued functioning of the foramen ovale

ANS: B A variety of these factors are responsible for initiation of respirations. Tactile stimuli aid in initiating respirations but are not the main cause. The PO2 decreases at birth and the PCO2 increases. The foramen ovale closes at birth.

The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount? a. Saturated peripad b. 10 to 15 cm (4- to 6-inch) stain on the peripad c. 2.5 to 10 cm (1- to 4-inch) stain on the peripad d. Less than a 1-inch stain on the peripad

ANS: B Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: • Scant—less than 2.5 cm (1-inch) stain on the peripad • Light—less than a 10 cm (4 inch) stain • Moderate—less than a 15 cm (6 inch) stain • Heavy—saturated peripad • Excessive—saturated peripad in 15 minutes Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth because some of the endometrial lining is removed during surgery.

A newborn is admitted to the special care nursery with hypothermia. Which complication should the nurse monitor for closely? a. Hyperglycemia b. Metabolic acidosis c. Respiratory acidosis d. Vasodilation of peripheral blood vessels

ANS: B Cold stress can cause a significant rise in oxygen demands. Metabolism of glucose in the presence of insufficient oxygen causes increased production of acids. Metabolism of brown fat also releases fatty acids. The result can be metabolic acidosis, which can be a life-threatening condition. Cold stress causes hypoglycemia because glucose is being metabolized. Cold stress does not cause respiratory acidosis. As the infant's body attempts to conserve heat, vasoconstriction, not vasodilation, of the peripheral blood vessels occurs to reduce heat loss from the skin surface.

Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands? a. Radiation b. Conduction c. Convection d. Evaporation

ANS: B Conduction occurs when the infant comes in contact with cold objects. Radiation is the transfer of heat to a cooler object that is not in direct contact with the infant. Convection occurs when heat is transferred to the air surrounding the infant. Evaporation can occur during birth or bathing as a result of wet linens or clothes, or insensible heat loss.

The postpartum nurse has completed discharge teaching for a patient being discharged after an uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is necessary? a. "I may not have a bowel movement until the 2nd postpartum day." b. "If I breastfeed and supplement with formula, I won't need any birth control." c. "I know my normal pattern of bowel elimination won't return until about 8 to 10 days." d. "If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband."

ANS: B For some women, ovulation resumes as early as 3 weeks postpartum. Therefore contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the patient does not feel any need for birth control with breastfeeding and supplementing with formula. The first stool usually occurs within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume by 8 to 14 days after birth.

Which description best explains the term reciprocal attachment behavior? a. Behavior during the sensitive period when the infant is in the quiet alert stage b. Positive feedback that the infant exhibits toward parents during the attachment process c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d. Behavior by the infant during the sensitive period to elicit feelings of "falling in love" from the parents

ANS: B In this definition, reciprocal refers to the feedback from the infant during the attachment process. The quiet alert state is a good time for bonding; however, does not define reciprocal attachment. Reciprocal attachment deals with feedback behavior and is not unidirectional.

Which of the following guidelines should the nurse implement to prevent the abduction of a newborn from the hospital? a. Restricting the amount of time infants are out of the nursery b. Questioning anyone who is seen walking in the hallways carrying an infant c. Allowing no visitors in the maternity area except those who have identification bracelets d. Instructing the parents not to give the baby to anyone except the nurse assigned that day

ANS: B Infants should be transported in the hallways only in their cribs. In many facilities babies are cared for in the mother's room, rather than a well-baby nursery. Infants need to spend time with the parents to facilitate the bonding process and facilitate learning. It is impossible for one nurse to be on call for one mother and baby for the entire shift; therefore the parents need to be able to identify all of the staff that will be caring for them. Most maternity units have special identification badges unique to that area. All patients should be oriented to these identification badges.

Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Maintain room temperature at 21°C (70°F). b. Place a blanket over the scale before weighing the infant. c. Take the rectal temperature every hour to detect early changes. d. Undress the infant completely for assessments so that they can be finished quickly.

ANS: B Padding the scale prevents heat loss from the infant to a cold surface by conduction. The room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. Hourly assessments are not necessary for a normal newborn with a stable temperature. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature by convection.

Which infant is at greater risk to develop cold stress? a. Full-term infant delivered vaginally without complications. b. 36-week infant with an Apgar score of 7 to 9. c. 38-week female infant delivered via cesarean birth because of cephalopelvic disproportion. d. Term infant delivered vaginally with epidural anesthesia.

ANS: B Preterm infants are at greater risk to develop cold stress because of thin skin, decreased subcutaneous fat, and poor muscle tone.

Which statement best explains why a newborn with a congenital defect of the penis should not be circumcised? a. There is increased risk of infection. b. The foreskin might be needed for future repairs. c. A circumcision will make the defect more visible. d. There is no medical rationale for a circumcision.

ANS: B The foreskin may be used to correct a defect. There is no significant increase in infection. A circumcision would not make the defect more noticeable. A circumcision is a decision made by the parents; however, in this case the foreskin might be needed to correct a defect. Such defects include epispadias and hypospadias.

An infant at term was born at 0105 hours. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score? a. 0115 to 0130 b. 0200 to 0600 c. 1400 to 1800 d. 2000 to 2300

ANS: B The new Ballard score is often used to determine gestational age based on neuromuscular and physical characteristics. It is designed to assess gestational age from 20 to 44 weeks. The assessment is most accurate when performed within 12 hours of birth. The Ballard score is accurate within a 2-week window of gestational age.

Which of the following is the most likely cause of regurgitation when a newborn is fed? a. The gastrocolic reflex b. A relaxed cardiac sphincter c. An underdeveloped pyloric sphincter d. Placing the infant in a prone position following a feeding

ANS: B The underlying cause of newborn regurgitation is a relaxed cardiac sphincter. The gastrocolic reflex increases intestinal peristalsis after the stomach fills. The pyloric sphincter goes from the stomach to the intestines. The infant should be placed in a supine position.

The nurse is conducting discharge teaching for a patient going home after a cesarean birth. Which signs and symptoms should the patient be taught to report? (Select all that apply.) a. Mild incisional pain b. Feeling of pelvic fullness c. Lochia changing from red to pink in color d. Frequency, urgency, or burning on urination e. Redness or edema of the abdominal incision

ANS: B, D, E The signs and symptoms to watch for after a cesarean birth are feelings of pelvic fullness, frequency, urgency or burning on urination, and redness or edema of the abdominal incision. Mild incisional pain is expected and the lochia should change from a bright red (rubra) to a pinkish color (serosa).

The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? a. Pulse rate of 50 b. Temperature of 38C (100.4F) c. Firm fundus, but excessive lochia d. Lightheaded when moving from a lying to standing position

ANS: C Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38C (100.4F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand.

A postpartum patient asks, "Will these stretch marks ever go away?" Which is the nurse's best response? a. "No, never." b. "Yes, eventually." c. "They will fade to silvery lines but won't disappear completely." d. "They will continue to fade and should be gone by your 6-week checkup."

ANS: C Stretch marks never disappear altogether, but they do gradually fade to silvery lines. Stating never is true, but more information can be added, such as the changes that will occur with the stretch marks. Stretch marks do not disappear.

Which information should the nurse teach to new parents regarding the use of a bulb syringe? a. Use it only once per day. b. Suction the back of the throat vigorously. c. Insert the syringe into the sides of the mouth. d. Always suction the mouth before suctioning the nose.

ANS: C The syringe should be inserted into the sides of the mouth rather than the back of the throat to avoid a vagal response and bradycardia. Suction can occur as needed. Vigorous suction of the back of the throat may stimulate the vagal nerve and produce bradycardia. The mouth should be suctioned first to prevent aspiration.

A maculopapular rash with a red base and a small white papule in the center is commonly known as a. milia. b. Mongolian spots. c. erythema toxicum. d. Café-au-lait spots.

ANS: C A maculopapular rash with a red base and a small white papule in the center is a description of erythema toxicum, a normal rash in the newborn. Milia are minute epidermal cysts on the face of the newborn. Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sacrum. Café-au-lait spots are pale tan (the color of coffee with milk) macules. Parents should be reassured that occasional spots occur normally in most newborns.

The nurse is planning to conduct the initial assessment of a full-term newborn. Included in the plan is providing a neutral thermal environment. To accomplish this plan, what is the desired environmental temperature to conduct the assessment? a. 24 to 27°C (75.2 to 80.6°F) b. 28 to 31.5°C (82.4 to 88.7°F) c. 32 to 33.5°C (89.6 to 92.3°F) d. 34 to 37.5°C (93.2 to 99.5°F)

ANS: C A neutral thermal environment is one in which the infant can maintain a stable body temperature with minimal oxygen need and without an increase in metabolic rate. The range of environmental temperature that allows this stability is called the thermoneutral zone. In healthy, unclothed, full-term newborns, an environmental temperature of 32 to 33.5°C (89.6 to 92.3°F) provides a thermoneutral zone. When the infant is dressed, the thermoneutral range is 24 to 27°C (75.2 to 80.6°F).

Which measure is optimal in order to prevent abdominal distention following a cesarean birth? a. Rectal suppositories b. Carbonated beverages c. Early and frequent ambulation d. Tightening and relaxing abdominal muscles

ANS: C Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs; however, do not prevent it. Carbonated beverages may increase distention. Ambulation is the best prevention. Abdominal strengthening will not prevent distention.

Which assessment finding of a newborn requires prompt action by the nurse? a. Respiratory rate of 50 breaths per minute b. Cyanosis of the extremities c. Pause in breathing lasting 20 seconds d. Pause in breathing for 15 seconds followed by rapid respirations

ANS: C Apnea is a pause in breathing lasting 20 seconds or more, or accompanied by cyanosis, pallor, bradycardia, and/or decreased muscle tone. Apnea is abnormal and requires prompt intervention. A respiratory rate of 50 breaths per minute is still within the normal range. Tachypnea is considered to be 60 breaths per minute or more. Cyanosis of the extremities or acrocyanosis is normal during the first day after birth and if the infant becomes cold. Periodic breathing is pauses in breathing lasting 5 to 10 seconds without other changes followed by rapid respirations for 10 to 15 seconds. This occurs in some full-term infants during the first few days but is more common in preterm infants.

Inspection of a newborn's head following birth reveals a hard ridged area and significant molding. The anterior and posterior fontanels show no sign of depression. Delivery history indicates that the mother was pushing for over 3 hours and had epidural anesthesia. A vacuum extraction was necessary. Based on this information the nurse would a. continue to monitor newborn and anticipate that molding will subside. b. inspect and document location of fontanels to complete the head assessment. c. contact the pediatric provider. d. note findings as being within normal limits as a result of the strenuous birth process.

ANS: C Assessment data reveal a significant finding, and the nurse should suspect craniosynostosis (premature closing of sutures) and therefore should contact the pediatric provider immediately. Even though the birth process was difficult and vacuum extraction was used, this does not account for the physical findings. Continuing to monitor is not a prudent action at this time. Although it is important to note the presence of fontanels, the immediate action would be to make the appropriate referral for medical intervention

The nurse is developing a plan of care for the patient's fourth stage of labor. One nursing intervention is to promote bonding. Specifically, which nursing action will facilitate the bonding process? a. Encourage the patient to call the baby by his or her first name. b. Stimulate the grasp reflex by placing the patient's finger in the infant's palm. c. Ask the patient if she wants her baby placed on her chest immediately after birth. d. Assess for familial characteristics and remark on the resemblance to the patient or the father.

ANS: C Bonding refers to the rapid initial attraction felt by parents for their infant. It is unidirectional, from parent to child, and is enhanced when parents and infants are permitted to touch and interact during the first 30 to 60 minutes after birth. During this time, the infant is in a quiet, alert state and seems to gaze directly at the parents. Infants are often placed skin to skin on the mother's chest or abdomen for bonding time immediately after birth. Nurses frequently delay procedures such as measurements and medication administration that would interfere with this time, so that parents can focus on their newborn baby. Attachment follows a progressive or developmental course that changes over time. It is rarely instantaneous. Unlike bonding, attachment is reciprocal—it occurs in both directions between parent and infant.

The nurse is explaining the procedure of newborn screening to parents prior to discharge. Which statement by the parents indicates a need for further teaching? a. "We understand the tests are performed at 24 to 48 hours." b. "We're glad all the tests can be done on one blood sample." c. "We wish the tests would screen for congenital hypothyroidism, it runs in our family." d. "We know that if the tests are done before 24 hours, the tests will need to be repeated at 1 to 2 weeks."

ANS: C Common disorders often included in newborn screening are phenylketonuria (PKU), hypothyroidism, galactosemia, hemoglobinopathies such as sickle cell disease and thalassemia, and congenital adrenal hyperplasia. The parents require further teaching if they suggest that congenital hypothyroidism is not screened. The newborn screening tests are performed at 24 to 48 hours after birth. Newborn screening requires a blood sample taken from the infant's heel, and only one blood sample is needed for all tests. Tests performed within the first 24 hours of life are less sensitive than those performed after 24 hours. Infants tested before 12 to 24 hours of age should have repeat tests at 1 to 2 weeks of age so that disorders are not missed because of early testing.

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as a. albumin binding. b. enterohepatic circuit. c. conjugation of bilirubin. d. deconjugation of bilirubin

ANS: C Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. Albumin binding attaches something to a protein molecule. Enterohepatic circuit is the route whereby part of the bile produced by the liver enters the intestine, is resorbed by the liver, and then is recycled into the intestine. Unconjugated bilirubin is fat-soluble.

A 38 weeks' gestation fetus is delivered via cesarean birth and transported to the newborn nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an initial assessment in the newborn nursery. Which is the priority nursing diagnosis? a. Risk for injury related to potential equipment malfunction of radiant warmer b. Altered tissue perfusion related to use of medications during delivery process c. Ineffective airway clearance due to mode of delivery and use of anesthetics d. Risk for ineffective thermoregulation related to gestational age

ANS: C Delivery via cesarean birth may affect the newborn's ability to remove excess fluid secretions because the infant did not move down the birth canal and thus may be at risk for airway concerns. There is no evidence to support that the equipment is malfunctioning. Although the use of medications may affect the newborn in terms of respiratory, cardiac, and neurologic depression, Apgar scores do not indicate any immediate deficit. The infant is at term based on reported gestational age and therefore is not a risk for ineffective thermoregulation because of this fact.

Which of the following behaviors would be applicable to a nursing diagnosis of Risk for Impaired Parenting? a. En face behavior is observed between father and infant. b. Mother relates that she feels exhilarated postbirth. c. Mother states that she feels excessive fatigue as a result of the childbirth experience. d. Father displays finger tipping behavior toward infant.

ANS: C Fatigue can contribute to altered parenting, because it may affect the level of interaction between parent and child. En face behavior acknowledges maternal-paternal attachment. A feeling of exhilaration is normal following a changing life cycle event such as childbirth. Finger tipping behavior conveys a sense of identification or claiming behavior.

The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which statement best describes the manifestations of hypothermia in the newborn? a. Newborns shiver to generate heat. b. Newborns have decreased oxygen demands. c. Newborns have increased glucose demands. d. Newborns have a decreased metabolic rate.

ANS: C In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. Shivering is not an effective method of heat production for newborns. Oxygen demands increase with hypothermia. The metabolic rate increases with hypothermia.

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is a. seen at 3 days of age. b. the residue of a milk curd. c. passed in the first 24 hours of life. d. lighter in color and looser in consistency.

ANS: C Meconium should be passed in the first 24 hours of life. Meconium stool is the first stool of the newborn. Meconium stool is made up of matter in the intestines during intrauterine life. Meconium is dark in color and sticky.

The nurse is receiving shift report on her mother-baby couplet assignment. Which infant should the nurse evaluate first? a. 38-weeks' gestation female newborn with a blood sugar level of 60 mg/dL b. Term male newborn with a noted axillary temperature of 37.2°C (99°F) c. 40-weeks' gestation female newborn with reported poor feed at last attempt d. 39-weeks' gestation male newborn who has been crying prior to initial bath

ANS: C Newborns who are poor feeds may be showing initial signs of hypoglycemia, so this newborn should be assessed first at the start of the shift. Although the newborn is term, and it is more likely to see hypoglycemia with preterm infants, sometimes hypoglycemia is asymptomatic. Blood sugar results are within normal range and the newborn is considered to be term. Temperature is within normal range and the newborn is term. This newborn is considered to be term, and crying alone does not increase risk stratification.

Which action should the nurse take in order to provide support and encouragement to the new postpartum patient? a. Recount how she solved her own problems. b. Correct the new mother at every opportunity. c. Praise the mother's early attempts at infant care. d. Explain to the new mother that everything will be fine.

ANS: C Positive reinforcement of the mother's attempt to provide care to the newborn will promote a healthy self-concept. The mother needs to learn how to solve problems on her own. Each person may use different techniques that work for that person. Correcting her actions would be discouraging to a new mother. She needs encouragement. Saying everything will be fine is blocking communication and further teaching.

A family is concerned about how their 2-year-old son is going to react to the new baby. Which intervention would help facilitate sibling attachment? a. Have the mother and father spend individual time with their son to allay potential anxiety over the new baby coming in and displacing his position in the family as the only child. b. Make sure that their son is supervised at all times when the baby is brought home from the hospital and is in his presence. c. Include the son in helping to take care of the baby and reinforce the label of "big brother" as a special role. d. Observe the son's reaction to the baby and let him decide when he wants to be introduced to his new sibling.

ANS: C Providing the older son with a special role designation and involving him in the care of the baby will facilitate sibling attachment. Spending individual time with the older child is recommended but will not facilitate sibling attachment. Although the older child should be supervised because of his age in terms of infant safety, this level of overprotection may inhibit sibling attachment. Observation of his behavior may be warranted; however, the age of the child (2 years) does not warrant this type of control.

A newborn that is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight? a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th

ANS: C The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. An infant between the 10th and 90th percentiles is average for gestational age. An infant in less than the 10th percentile is small for gestational age.

The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which statement is important to understand regarding the properties of vitamin K? a. It is necessary for the production of platelets. b. It is important for the production of red blood cells. c. It is not initially synthesized because of a sterile bowel at birth. d. It is responsible for the breakdown of bilirubin and the prevention of jaundice

ANS: C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. The platelet count in term of newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors. Vitamin K is important for blood clotting. Vitamin K is necessary to activate the clotting factors.

The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, the preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding? a. Weigh the peripad. b. Replace the peripad. c. Contact the health care provider. d. Document the finding in the patient's chart.

ANS: C The lochia of the cesarean birth mother will go through the same phases as that of the woman who had a vaginal birth; however, the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and an indication of hemorrhage. The health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss; but, this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits.

A nursing student has been caring for a patient and newborn all morning. After taking the newborn to the nursery for hearing screening, the student is returning the infant to his mother. Which procedure is correct for identifying the newborn? a. Ask the mother to state her name and the name of her infant. b. Call out the mother's full name before leaving the infant with her c. Have the mother read her printed band number and verify that it matches the infant's number. d. Return the infant with no special procedure because the student knows the mother and infant.

ANS: C The mother and infant should have identifying armbands with matching numbers. Both of these bands should be reviewed to determine that the mother has the correct infant. The other actions do not adequately verify the identities of mother and infant.

A new patient asks, "Why are you doing a gestational age assessment on my baby?" The nurse's best response is a. "It was ordered by your physician." b. "This must be done to meet insurance requirements." c. "It helps us identify infants who are at risk for any problems." d. "The gestational age determines how long the infant will be hospitalized."

ANS: C The nurse should provide the mother with accurate information about various procedures performed on the newborn. Assessing gestational age is a nursing assessment and does not have to be ordered. It is not necessary for insurance needs. Gestational age does not dictate hospital stays. Problems that occur because of gestational age may prolong the stay.

The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours ago. The partner is watching his wife and asking questions about newborn care. The 4-year-old big brother is punching his mother on the back. What should the nurse do next? a. Report the incident to the social services department. b. Advise the parents that the older son needs to be reprimanded. c. No action; this is a normal family adjusting to family change. d. Report to oncoming staff that the mother is probably not a good disciplinarian.

ANS: C The observed behaviors are normal variations of families adjusting to change. There is no need to report this one incident. Giving advice at this point would make the parents feel inadequate. This is normal for an adjusting family.

How can nurses prevent evaporative heat loss in the newborn? a. Placing the baby away from the outside wall and the windows b. Keeping the baby out of drafts and away from air conditioners c. Drying the baby after birth and wrapping the baby in a dry blanket d. Warming the stethoscope and nurse's hands before touching the baby

ANS: C Wet linens or wet clothes can cause heat loss by evaporation. Radiation heat loss is caused by placing the baby near cold surfaces or equipment. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. Conduction heat loss occurs when the baby comes into contact with cold objects or surfaces.

To differentiate between caput succedaneum and cephalohematoma in a newborn, the nurse would consider the following clinical information. (Select all that apply.) a. These are both normal presentations because of the birth process and will resolve within 24 to 48 hours. b. Cephalohematoma manifests as a localized area of swelling as compared with caput succedaneum, which appears as a general swelling of the head. c. A cephalohematoma can develop several hours or days after the birth event, whereas caput succedaneum is noted shortly before or immediately after the birth event. d. Edema that crosses suture lines is observed with caput succedaneum. e. With a cephalohematoma, bleeding occurs between the bone and skull.

ANS: C, D, E Cephalohematoma can be detected up to 24 to 48 hours after the birth process. This clinical condition is caused by bleeding between the periosteum and skull and is a serious medical condition. Caput succedaneum occurs in the presence of pressure from the vaginal canal on the fetal head during the birth process. Swelling is localized and crosses the suture line, whereas with cephalohematoma the swelling is more generalized and crosses the suture line. Caput resolves within 12 to 48 hours after the birth event.

Which action by the nurse can result in hyperthermia in the newborn? a. Placing a cap on the newborn b. Wrapping the newborn in a warm blanket c. Placing the newborn in a skin to skin position with the mother d. Placing the newborn in the radiant warmer without attaching the skin probe

ANS: D Newborns may be overheated by poorly regulated equipment designed to keep them warm. When radiant warmers, warming lights, or warmed incubators are used, the temperature mechanism must be set to vary the heat according to the infant's skin temperature; this prevents too much or too little heat. Alarms to signal that the infant's temperature is too high or too low should be functioning properly. If the skin probe is not used, the alarms will not function properly. Putting a hat on the newborn, wrapping the newborn in a warm blanket, or placing the newborn skin to skin with the mother will not cause hyperthermia

A nursing student is helping the nursery nurse with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. Which is the best interpretation of this information? a. This is an emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

ANS: D The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and birth. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. This is a common condition for infants delivered by cesarean section. Surfactant is produced by the lungs, so aspiration is not a concern. It is common to have some fluid left in the lungs; this will be absorbed within a few hours.

Which infant has the lowest risk of developing high levels of bilirubin? a. The infant who developed a cephalohematoma b. The infant who was bruised during a difficult birth c. The infant who uses brown fat to maintain temperature d. The infant who is breastfed during the first hour of life

ANS: D The infant who is fed early will be less likely to retain meconium and resorb bilirubin from the intestines back into the circulation. Cephalohematomas will release bilirubin into the system as the red blood cells die off. Bruising will release more bilirubin into the system. Brown fat is normally used to produce heat in the newborn.

Which should the nurse do to provide support to a patient who must return to full-time employment 6 weeks after a vaginal birth? a. Discuss child care arrangements with her. b. Allow her to solve the problem on her own. c. Reassure her that she'll get used to leaving her baby. d. Allow her to express her positive and negative feelings freely.

ANS: D Allowing the patient to express feelings will provide positive support in her process of maternal adjustment. Discussing child care arrangements is an important step in anticipatory guidance, although this is not the best way to offer support. The new mother should be instrumental in solving the problem; however, allowing her time to express her feelings and talk the problem over will assist her in making this decision. Reassuring her that she will get used to leaving the baby blocks communication and belittles the patient's feelings.

To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse utilize? a. Assess lochial flow rather than palpating the fundus. b. Palpate forcefully through the abdominal dressing. c. Place hands on both sides of the abdomen and press downward. d. Gently palpate, applying the same technique used for vaginal deliveries.

ANS: D Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs to be checked.

In providing and teaching cord care, which guidance is most appropriate? a. Cord care is done only to control bleeding. b. Alcohol is the only agent used for cord care. c. It takes a minimum of 24 days for the cord to separate. d. Keeping the cord dry will decrease bacterial growth.

ANS: D Bacterial growth increases in a moist environment; therefore keeping the umbilical cord dry impedes bacterial growth. Evidence-based practice guidelines show that cleaning the cord with water when necessary and keeping it clean and dry is the best method of care. No other agents are necessary to facilitate drying of the cord. The cord will fall off within 10 to 14 days.

Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention? a. Pain level 5 on scale of 0 to 10 b. Saturated pad over a 2-hour period c. Urinary output of 500 mL in one voiding d. Uterine fundus 2 cm above the umbilicus

ANS: D By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum patient.

During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels? a. Increased pulmonary vascular resistance b. Decreased systemic resistance c. Decreased pressure in the left heart d. Dilation of pulmonary vessels

ANS: D Dilation of pulmonary vessels occurs in response to increased oxygen levels. Decrease in pulmonary vascular resistance occurs. Increase in systemic vascular resistance occurs. Increased pressure in the left heart occurs.

To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care? a. Have the patient drink carbonated beverages to promote urinary excretion. b. Tell the patient that because of postpartum diuresis there is less risk to develop dehydration. c. Limit fluid intake to prevent polyuria. d. Teach the patient to perform pelvic floor exercises to combat potential stress incontinence.

ANS: D Educating the patient to use pelvic floor exercises (Kegel exercises) will help strengthen pelvic floor muscles. Carbonated beverages will lead to increased gas and potential gastrointestinal discomfort. During the postpartum period, the patient is at greater risk for dehydration and thus should increase fluids. Limitation of fluids is not warranted during the postpartum period.

Which maternal event is abnormal in the early postpartal period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

ANS: D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.

Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Fever and increased blood pressure b. Postpartum hemorrhage and eclampsia c. Urinary tract infection and uterine rupture d. Postpartum hemorrhage and urinary tract infection

ANS: D Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after the birth

A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will fade after birth due to a. increased estrogen. b. increased progesterone. c. decreased human placental lactogen. d. decreased melanocyte-stimulating hormone

ANS: D Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after birth. Estrogen levels decrease after birth. Progesterone levels decrease after birth. Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation.

A multiparous patient arrives to the labor unit and urgently states, "The baby is coming RIGHT NOW!" The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action? a. Dry the baby off. b. Turn up the temperature in the patient's room. c. Pour warmed water over the baby immediately after birth. d. Place the baby on the patient's abdomen after the cord is cut.

ANS: D Movement of heat away from the body occurs when newborns have direct contact with objects that are cooler than their skin. Placing infants on cold surfaces or touching them with cool objects causes this type of heat loss. The reverse is also true; contact with warm objects increases body heat by conduction. Warming objects that will touch the infant or placing the unclothed infant against the mother's skin (skin to skin) helps prevent conductive heat loss. Drying the baby off helps prevent heat loss through evaporation. Adjusting the temperature in the patient's room helps with heat loss through convection. Pouring warm water over a baby occurs with the first bath, which is conducted after the baby's temperature has stabilized. Pouring warm water over the baby prior to that time will increase heat loss through evaporation.

A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse's most appropriate response at this time? a. "When did these symptoms begin?" b. "Sounds like normal postpartum depression." c. "Are you having trouble getting enough sleep?" d. "Are you able to get out of bed and provide care for your baby?"

ANS: D Postpartum blues must be distinguished from postpartum depression and postpartum psychosis, which are disabling conditions and require therapeutic management for full recovery. Nurses need to assess the depression to ascertain if she is unable to cope with daily life. Postpartum blues are self-limiting and frequently occur by the fifth postpartum day and resolve in 2 weeks. The response "Sounds like postpartum depression" does not offer the patient any help or encouragement through this challenging time. Asking if she is getting enough sleep does not add to the assessments already identified in the stem. Enough information exists to determine that she has the signs and symptoms of postpartum blues. The nurse must differentiate between postpartum blues and depression.

If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided? a. No specific instructions b. Drinking plenty of fluids to prevent fever c. Recommendation to stop breastfeeding for 24 hours after the injection d. Explanation of the risks of becoming pregnant within 28 days following injection

ANS: D Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration. The mother does need to understand potential side effects and that pregnancy is discouraged for 3 months. The mother should be afebrile before the vaccine. Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding.

The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse's priority action related to this finding? a. Inform the health care provider. b. Encourage the patient to urinate. c. Massage the uterus to expel clots. d. Document the finding in the patient's chart.

ANS: D The location of the uterine fundus helps determine whether involution is progressing normally. Immediately after birth, the uterus is about the size of a large grapefruit or softball and weighs approximately 1000 g (2.2 lb). The fundus can be palpated midway between the symphysis pubis and umbilicus in the midline of the abdomen. Within 12 hours, the fundus rises to approximately the level of the umbilicus. This finding is expected and can be followed with documentation. No further action is needed.