OB 2 Success

35. A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time? 1. Encourage the parents to bond with their baby. 2. Notify the neonatalogist of the finding. 3. Perform the gestational age assessment. 4. Place the baby under the overhead warmer.

1 Babies are awake and alert for approx- imately 30 minutes to 1 hour immedi- ately after birth. This is the perfect time for the parents to begin to bond 2. with their babies

102. The nurse is conducting a state-mandated evaluation of a neonate's hearing. Infants are assessed for deficits because hearing-impaired babies are high risk for which of the following? 1. Delayed speech development. 2. Otitis externa. 3. Poor parental bonding. 4. Choanal atresia.

1 Babies learn to speak by imitating the speech of others in their environ- ment. If they are hearing impaired, there is a likelihood of delayed speech development.

86. A nurse is performing a postpartum assessment on a newly delivered client. Which of the following actions will the nurse perform? Select all that apply. 1. Palpate the breasts. 2. Auscultate the carotid. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum.

1, 3, 4, and 5 are correct. 1. The nurse should palpate the breasts to assess for fullness and/or engorgement. 2. The postpartum assessment does not in- clude carotid auscultation. 3. The nurse should check the client's vaginal discharge. 4. The nurse should assess the client's extremities. 5. The nurse should inspect the client's perineum.

73. The third stage of labor has just ended for a client who has decided to bottlefeed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

2 Estrogen drops precipitously after the placenta is delivered. Prolactin will elevate sharply in the client's bloodstream. Human placental lactogen drops precipi- tously after the placenta is delivered. Human chorionic gonadotropin is pro- duced by the fertilized ovum.

108. A mother confides to a nurse that she has no crib at home for her baby. The mother asks the nurse which of the following places would be best for the baby to sleep. Of the following choices, which location should the nurse suggest? 1. In bed with his 5-year-old brother. 2. In a waterbed with his mother and father. 3. In a large empty dresser drawer. 4. In the living room on a pull-out sofa.

3 3. A large empty drawer has a firm bot- tom so that the baby is unlikely to rebreathe his or her own carbon dioxide and the sides of the drawer will prevent the baby from falling out of "bed."

33. To check for the presence of Epstein's pearls, the nurse should assess which part of the neonate's body? 1. Feet. 2. Hands. 3. Back. 4. Mouth.

4 1. Epstein's pearls are not found on the feet. 2. Epstein's pearls are not found on the hands. 3. Epstein's pearls are not found on the back. 4. Epstein's pearls—small white specks (keratin-containing cysts)—are lo- cated on the palate and gums.

61. The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? 1. Provide the client with a nutritious meal. 2. Encourage the client to take a nap. 3. Assist the client with activities of daily living. 4. Assure the client that she is an excellent mother.

4 Nourishment is a need of the client in the taking in phase. Rest is a need of the client in the taking in phase. Assistance with self-care is a need of the client in the taking in phase. Clients in the taking hold phase need assurance that they are learning the skills they will need to care for their new baby.

5. A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Encourage the woman exclusively to breastfeed her baby. 2. Have the woman massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the woman.

1 Clients should be strongly encour- aged exclusively to breastfeed their babies to prevent engorgement. Massaging of the breast will stimulate more milk production. That is not the best action to take. It is unnecessary to culture the breast. This client is engorged; she does not have an infection. It is unnecessary to assess this client's temperature and pulse rate. This client is engorged; she is not infected.

74. The nurse has provided teaching to a post-op cesarean client who is being dis- charged on Colace (docusate sodium) 100 mg po tid. Which of the following would indicate that the teaching was successful? 1. The woman swallows the tablets whole. 2. The woman takes the pills between meals. 3. The woman calls the doctor if she develops a headache. 4. The woman does not worry when her urine turns orange.

1 Colace capsules should not be crushed, broken, or chewed. The capsule should be taken with juice or food to minimize the bitter taste. Headache is not a side effect of Colace. The medication does not change the color of a client's urine.

111. The nursing diagnosis—risk for suffocation—is included in a standard care plan in the neonatal nursery. Which of the following outcome goals should be included in relation to this diagnosis? 1. Baby is placed supine for sleep. 2. Baby is breastfed in the side-lying position. 3. Baby is swaddled when in the open crib. 4. Baby is strapped when seated in a car seat.

1 It has been shown that many neonatal SIDS deaths result from a form of suffocation. Babies breathe in their own exhaled carbon dioxide when they are placed prone for sleep. Ba- bies should be placed supine. Side-lying position for sleep has not been shown to affect the rate of neonatal suf- focation. The side-lying position does fa- cilitate breastfeeding, however. Swaddling babies does not reduce the risk of their being suffocated. Placing them supine in the crib reduces their risk. Swaddling is performed to maintain a neonate's temperature. Car seat safety is unrelated to suffoca- tion. Rather the baby is being protected from injury when strapped into a car seat during a car accident.

28. The nurse is caring for a postpartum client who experienced a second-degree per- ineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum.

1 It is appropriate to apply an ice pack to the area.

71. Which of the following complementary therapies can a nurse suggest to a multi- parous woman who is complaining of severe afterbirth pains? 1. Lie prone with a small pillow cushioning her abdomen. 2. Contract her abdominal muscles for a count of ten. 3. Slowly ambulate in the hallways. 4. Drink iced tea with lemon or lime.

1 Lying prone on a pillow helps to re- lieve some women's afterbirth pains.

110. A breastfeeding mother refuses to place her unclothed baby face down on her chest because, "Babies are always supposed to be put on their backs. Babies who are on their stomachs die from SIDS." The nurse's action should be based on which of the following? 1. Skin-to-skin contact facilitates breastfeeding and helps to maintain neonatal temperature. 2. The risk of SIDS increases whenever unsupervised babies are placed in the supine position. 3. SIDS rarely occurs before the completion of the neonatal period. 4. Back-to-sleep guidelines have been modified for breastfeeding babies.

1 Skin-to-skin contact (kangaroo care) has been shown to have many benefits for neonates, including promoting breast latch and stabilizing neonatal temperatures. Prone positioning, not supine, is con- traindicated when babies are not being supervised. A baby being held skin-to- skin on the mother's chest, however, is being supervised. Neonates have been diagnosed with SIDS, although the peak incidence of SIDS is between 2 and 4 months of age. Back-to-sleep guidelines are the same for all babies.

10. The nurse in the obstetric clinic received a telephone call from a bottlefeeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? 1. Intermittently apply ice packs to her axillae and breasts. 2. Apply lanolin to her breasts and nipples every 3 hours. 3. Express milk from the breasts every 3 hours. 4. Ask the primary health care provider to order a milk suppressant.

1 The client should apply ice packs to her axillae and breasts.

33. The obstetrician has ordered that a post-op cesarean section client's patient- controlled analgesia (PCA) be discontinued. Which of the following actions by the nurse is appropriate? 1. Discard the remaining medication in the presence of another nurse. 2. Recommend waiting until her pain level is zero to discontinue the medicine. 3. Discontinue the medication only after the analgesia is completely absorbed. 4. Return the unused portion of medication to the narcotics cabinet.

1 This answer is correct. Because the medication in a PCA pump is con- trolled by law, the medication must be wasted in the presence of another nurse.

8. The nurse is caring for a Seventh Day Adventist woman who delivered a baby boy by cesarean section. Which of the following questions should be asked regarding this woman's care? 1. "Would you like me to order a vegetarian clear liquid diet for you?" 2. "Is there anything special you will need for your Sabbath on Sunday?" 3. "Would you like to telephone your clergy to set up a date for the baptism?" 4. "Will a rabbi be performing the circumcision on your baby?"

1 This question is appropriate. Seventh Day Adventists usually follow vegetar- ian diets. This question is inappropriate. The Sev- enth Day Adventist Sabbath is on Satur- day, not on Sunday. This question is inappropriate. Baptism in the Seventh Day Adventist tradition is performed after the child reaches the age of accountability. This question is inappropriate. Rabbis are the leaders of people of the Jewish faith. And mohels, who are not neces- sarily rabbis, perform ritual Jewish circumcisions.

43. A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? 1. Assure the woman that frequent urination is normal after delivery. 2. Obtain an order for a urine culture. 3. Assess the urine for cloudiness. 4. Ask the woman if she is prone to urinary tract infections

1 This response is correct. Reassuring the client is appropriate. It is unlikely that the client has a urinary tract infection. The urine will be blood-tinged from the lochia. This question is unnecessary. It is un- likely that the client has a urinary tract infection.

16. A client who is 3 days postpartum asks the nurse, "When may my husband and I begin having sexual relations again?" The nurse should encourage the couple to wait until after which of the following has occurred? 1. The client has had her six-week postpartum check-up. 2. The episiotomy has healed and the lochia has stopped. 3. The lochia has turned to pink and the vagina is no longer tender. 4. The client has had her first postpartum menstrual period.

1 This response is correct. The couple is encouraged to wait until after invo- lution is complete. Although some clients do begin having intercourse once the episiotomy is healed and lochia stops, it is recommended that clients wait the full 6 weeks. The couple is encouraged to wait until after involution is complete. The couple is encouraged to wait until

55. During a postpartum assessment, it is noted that a G1P1001 woman, who delivered vaginally over an intact perineum, has a cluster of hemorrhoids. Which of the follow- ing would be appropriate for the nurse to include in the woman's health teaching? Select all that apply. 1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 3. The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. 4. The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. 5. The client should apply topical anesthetic as a relief measure.

1, 2, and 5 are correct. 1. Sitz baths do have a soothing affect for clients with hemorrhoids. 2. Clients often feel some relief when external hemorrhoids are reinserted into the rectum. 3. Oxytocin will have no affect on the hemorrhoids. 4. It is impossible to tell whether or not the hemorrhoids will change with subsequent pregnancies. 5. Topical anesthetics can provide relief from the discomfort of hemorrhoids.

34. A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed? 1. Respiratory rate 8 rpm. 2. Complaint of thirst. 3. Urinary output of 250 cc/hr. 4. Numbness of feet and ankles.

1. This action is appropriate. This client's respiratory rate is below normal. A complaint of thirst is within normal. There is no need to notify the physician. This urinary output is normal for a post- partum client. There is no need to notify the physician. Clients who have received epidurals will have numbness of their feet and ankles until the medication has metabolized. There is no need to notify the physician

62. The nurse takes a primipara her newborn for a feeding. The client holds the baby en face, strokes his cheek, and states that this is the first infant she has ever held. Which of the following nursing assessments is most appropriate? 1. Positive bonding and client needs little teaching. 2. Positive bonding but teaching related to infant care is needed. 3. Poor bonding and referral to a child abuse agency is essential. 4. Poor bonding but there is potential for positive mothering.

2 Although the client is showing signs of positive bonding, she definitely needs a great deal of teaching. This response is correct. The client is showing signs of positive bonding—en face positioning and stroking of the baby's cheeks—and is in need of infor- mation on child care. This action is absolutely inappropriate at this time. There are no signs of poor bonding or of abuse. There are no signs of poor bonding.

26. A breastfeeding client, G10P6408, delivered 10 minutes ago. Which of the follow- ing assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

2 An assessment of the woman's pulse rate is important, but it is not the most im- portant assessment. An assessment of the woman's fundus is the most important assessment to perform on this client. An assessment of the woman's bladder is important, but it is not the most impor- tant assessment. An assessment of the woman's breasts is important, but is not the most important assessment.

85. The surgeon has removed the surgical cesarean section dressing from a post-op day 1 client. Which of the following actions by the nurse is appropriate? 1. Irrigate the incision twice daily. 2. Monitor the incision for drainage 3. Apply steristrips to the incision line. 4. Palpate the incision for weaknesses.

2 Cesarean section incisions do not rou- tinely need to be irrigated. This is appropriate. The nurse should assess for all signs on the REEDA scale. The incision is held together with su- tures or staples. It is unnecessary to apply steristrips at this time. It is inappropriate for the nurse to pal- pate the suture line for weaknesses.

6. A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.

2 Clients are not recommended to pump their breasts after feedings unless there is a specific reason to do so. This statement is true. The best way to prevent engorgement is to feed the baby every 2 to 3 hours. Clients should not restrict babies' feed- ing times. Babies feed at different rates. Babies themselves, therefore, should reg- ulate the amount of time they need to complete their feeds. Clients are not recommended to supple- ment with formula unless there is a spe- cific reason to do so.

60. The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? 1. Teach baby care skills like diapering. 2. Discuss the labor and birth with the mother. 3. Discuss contraceptive choices with the mother. 4. Teach breastfeeding skills like pumping.

2 Clients in the taking in phase are not re- ceptive to teaching. During the taking in phase, clients need to internalize their labor experi- ences. Discussing the labor process is appropriate for this postpartum phase. Clients in the taking in phase do not fo- cus on future issues or needs. Clients in the taking in phase are not re- ceptive to teaching.

24. During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? 1. Diaphoresis. 2. Lochia alba. 3. Cracked nipples. 4. Hypertension.

2 Diaphoresis has usually subsided by this time. The nurse would expect that the client would have lochia alba. The nurse would not expect the client's nipples to be cracked. The nurse would not expect the client to be hypertensive.

64. A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.

2 Fathers have not been shown to experi- ence postpartum blues. This information is correct. The blues usually resolve within 2 weeks of delivery. Medications are usually not administered to relieve postpartum blues. Medications can be prescribed for clients who experi- ence postpartum depression or postpar- tum psychosis. This information is incorrect. The majority of women will experience post- partum blues during the first week or 2 postpartum.

42. A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.

2 Fundal height is measured using a cen- timeter tape during pregnancy, not in the postpartum period. The nurse should stabilize the base of the uterus with his or her dependent hand. The fundus should be palpated using the flat surface of the fingers. No vaginal examination should be per- formed by the nurse.

51. The nurse informs a postpartum woman that ibuprofen (Advil) is especially effec- tive for afterbirth pains. What is the scientific rationale for this? 1. Ibuprofen is taken every two hours. 2. Ibuprofen has an antiprostaglandin effect. 3. Ibuprofen is given via the parenteral route. 4. Ibuprofen is administered in high doses.

2 Ibuprofen is usually administered every 4 to 6 hours. This statement is correct. Ibuprofen has an antiprostaglandin effect. Ibuprofen is administered orally. This is not the reason why ibuprofen is especially effective for postpartum cramping.

4. To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with a povidone-iodine solution after toileting.

2 It is unnecessary to apply antibiotic oint- ment to the perineum after delivery. Clients should be advised to change their pads at each voiding. The clients should void about every 2 hours, but this action is not an infec- tion control measure. It is unnecessary to spray the perineum with a povidone-iodine solution. Plain water, however, should be sprayed on the perineum.

107. A mother and her 2-day-old baby are preparing for discharge. Which of the follow- ing situations would require the baby's discharge to be cancelled? 1. The parents only own a car seat that faces the rear of the car. 2. The baby's bilirubin is 19 mg/dL. 3. The baby's blood glucose is 59 mg/dL. 4. There is a large bluish spot on the left buttock of the baby.

2 The neonate should be placed in a rear- facing car seat. A bilirubin of 19 mg/dL is above the expected level. Therapeutic interven- tion is needed. A blood glucose level of 59 mg/dL is within normal levels for a neonate. Mongolian spots are normal variations seen on the neonatal skin.

87. During a postpartum assessment, the nurse performs a Homan's sign. Which of the following actions does the nurse perform? 1. Taps the patellae with a reflex hammer. 2. Dorsiflexes the feet. 3. Palpates the calves and ankles. 4. Monitors the color of the extremities.

2 The nurse would dorsiflex the feet when performing Homan's sign.

38. The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

2 The nurse would expect to see well- approximated edges.

15. A breastfeeding woman, 11⁄2 months postdelivery, calls the nurse in the obstetri- cian's office and states, "I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?" The nurse should base the response to the client on which of the following? 1. The woman is exhibiting signs of pathological galactorrhea. 2. The same hormone stimulates orgasms and the milk ejection reflex. 3. The woman should have a serum galactosemia assessment done. 4. The baby is stimulating the woman to produce too much milk.

2 The woman is not exhibiting symptoms of galactorrhea, which occurs when a woman produces breast milk even though she has not delivered a baby. This is true. Oxytocin stimulates sexual orgasms and is also the hormone that stimulates the milk ejection reflex. This is incorrect. Galactosemia is a ge- netic disease. Babies who have the dis- ease are unable to digest galactose, the predominant sugar in breast milk. This is an unlikely explanation of the problem.

109. A baby is just delivered. Which of the following physiological changes is of highest priority? 1. Thermoregulation. 2. Spontaneous respirations. 3. Extrauterine circulatory shift. 4. Successful feeding.

2 Thermoregulation is important, but it is not the highest priority. If a baby does not breathe, the remaining physiological transitions cannot successfully take place. Converting from an intrauterine circula- tory pattern to an extrauterine circula- tory pattern is important, but it is not the highest priority. Successful feeding is important but is not the highest priority.

49. A client, G1P0101, postpartum 1 day, is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and de- viated to the right. Which of the following actions should the nurse take first? 1. Notify the woman's primary health care provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad.

2 This action may be needed, but it is not the first action that should be taken. This action is the first that the nurse should take. This action may be needed, but it is not the first action that should be taken. This action is needed, but it is not the first action that should be taken.

31. The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance the day before. The baby's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate? 1. "Sometimes babies just don't deliver the way we expect them to." 2. "With all of your preparations, it must have been disappointing for you to have had a cesarean." 3. "I know you had to have surgery, but you are very lucky that your baby was born healthy." 4. "At least your husband was able to be with you when the baby was born."

2 This comment is inappropriate. It does not acknowledge the client's likely disap- pointment about having to have a ce- sarean section. This comment conveys sensitivity and understanding to the client. This comment may be true, but it does not acknowledge the client's likely disap- pointment about having to have a ce- sarean section. This comment may be true, but it does not acknowledge the client's likely disap- pointment about having to have a ce- sarean section.

76. A client who delivered a 3900-gram baby vaginally over a right lateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fiber foods and drink fluids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."

2 This is the best response. A right lat- eral episiotomy runs perpendicular to the perineum.

81. Why are obstetric clients most at high risk for cardiovascular compromise during the one hour immediately following a delivery? 1. Because the weight of the uterine body is significantly reduced. 2. Because the excess blood volume from pregnancy is circulating in the woman's periphery. 3. Because the cervix is fully dilated and the lochia flows freely. 4. Because the maternal blood pressure drops precipitously once the baby's head emerges.

2 This response is true. Once the pla- centa is birthed, the reservoir for the mother's large blood volume is gone.

22. The nurse is discussing the importance of doing Kegel exercises during the post- partum period. Which of the following should be included in the teaching plan? 1. She should repeatedly contract and relax her rectal and thigh muscles. 2. She should practice by stopping the urine flow midstream every time she voids. 3. She should get on her hands and knees whenever performing the exercises. 4. She should be taught that toned pubococcygeal muscles decrease blood loss.

2 To perform Kegel exercises, the client should be advised to contract and relax the muscles that stop the urine flow. This is a correct statement. Kegel exercises can be performed in any position. Lochia flow is unaffected by contracting the pubococcygeal muscles.

14. Which of the following statements is true about breastfeeding mothers as compared to bottlefeeding mothers? 1. Breastfeeding mothers usually involute completely by 3 weeks postpartum. 2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life. 3. Breastfeeding mothers show higher levels of bone density after menopause. 4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.

2. Although breastfeeding does have a pro- tective effect on postpartum blood loss, involution can take up to 6 weeks in breastfeeding women as well as bottle- feeding women. There is evidence to show that women who breastfeed their babies are less likely to develop type 2 dia- betes later in life Women who breastfeed have not been shown to have higher levels of bone den- sity later in life. Babies whose mothers breastfeed are less likely to develop infections than are bot- tlefed babies. The mothers, however, have not been shown to have the same protection.

30. A woman is receiving patient-controlled analgesia (PCA) post-cesarean section. Which of the following must be included in the patient teaching? 1. The client should monitor how often she presses the button. 2. The client should report any feelings of nausea or itching to the nurse. 3. The family should press the button whenever they feel the woman is in pain. 4. The family should inform the nurse if the client becomes sleepy.

2. This is unnecessary. PCA pumps monitor the number of attempts patients make. This information is correct. Clients often experience nausea and/or itching when PCA narcotics are administered. This is a false statement. Family members should not press the button for the client. This information is untrue. It is unneces- sary for family members to inform the nurse. It is not unusual for clients to fall asleep when receiving PCA.

13. A breastfeeding mother states that she has sore nipples. In response to the com- plaint, the nurse assists with "latch on" and recommends that the mother do which of the following? 1. Use a nipple shield at each breastfeeding. 2. Cleanse the nipples with soap 3 times a day. 3. Rotate infant positions at each feed. 4. Bottle feed for 2 days then resume breastfeeding.

3 3. Rotating positions at feedings is one action that can help to minimize the severity of sore nipples.

66. The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what is wrong with me. I feel terri- ble. I should be happy, but I'm not." Which of the following nursing diagnoses is appropriate for this client? 1. Suicidal thoughts related to psychotic ideations. 2. Posttrauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.

3 This diagnosis is inappropriate. There is no indication that this client is suicidal or psychotic. This diagnosis is inappropriate. There is no indication in the scenario that the client had a traumatic delivery. This diagnosis is appropriate. This client is showing signs of postpartum blues; one of the main reasons for this problem is related to the hormonal changes that occur after delivery. This diagnosis is inappropriate. Nothing in the scenario implies that the client is in spiritual difficulties.

47. The nurse is examining a 2-day postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy.

3 This response is correct. The involu- tion is normal and the lochia is rubra.

17. A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse that when she and her husband had intercourse for the first time after the delivery, "I couldn't stand it. It was so painful. The doctor must have done some- thing terrible to my vagina." Which of the following responses by the nurse is appropriate? 1. "After a delivery the vagina is always very tender. It should feel better the next time you have intercourse." 2. "Does your baby have thrush? If so, I bet you have a yeast infection in your vagina." 3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort." 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in for an assessment?"

3 This response is inappropriate. It is likely that as long as the woman breastfeeds she will experience vaginal dryness. This is an inappropriate response. It is unlikely that a proliferation of Candida is the problem. This response is correct. The woman should be encouraged to use a lubri- cating jelly or oil. It is unlikely that the problem is related to the episiotomy repair.

112. It has just been discovered that a newborn is missing from the maternity unit. The nursing staff should be watchful for which of the following individuals? 1. A middle-aged male. 2. An underweight female. 3. Pro-life advocate. 4. Visitor of the same race.

4 1. Males are rarely newborn abductors. 2. Women who abduct neonates are often overweight. They rarely appear under- weight. 3. Pro-life advocates have not been shown to be high risk for neonatal abduction. 4. Abductors usually choose newborns of their same race.

45. A bottlefeeding woman, 11⁄2 weeks postpartum from a vaginal delivery, calls the ob- stetric office to state that she has saturated 2 pads in the past 1 hour. Which of the following responses by the nurse is appropriate? 1. "You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." 2. "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." 3. "It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly." 4. "It is important for you to be examined by the doctor today. Let me check to see when you can come in."

4 4. This response is appropriate. The client should be examined to assess her involution.

46. A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate? 1. "You must wait to begin to perform exercises until after your six-week postpar- tum checkup." 2. "You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe." 3. "By next week you will be able to return to the exercise schedule you had during your prepregnancy." 4. "You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks."

4 4. This statement is correct. The client should begin with Kegel exercises shortly after delivery, move to ab- dominal tightening exercises in the next couple of days, and then slowly progress to stomach crunches, and so on.

39. A client, G1P1, who had an epidural, has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? 1. "You'll feel better later after you have had a chance to rest and to eat." 2. "Don't say that. There are many women who would be ecstatic to have that baby." 3. "I am sure that you will have another baby. I bet that it will be a natural delivery." 4. "To have things work out differently than you had planned is disappointing."

4 Even though this response may be true, the client's feelings are being ignored by the nurse. This response is inappropriate. Even though the baby is well, the client feels disappointed with her performance. Even though this response may be true, the client's feelings are being ignored by the nurse. This response shows that the nurse has an u

35. A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? 1. "That is very concerning. I will request that your physician order an enema for you." 2. "Two days is not that bad. Some patients go four days or longer without a movement." 3. "You have been taking antibiotics through your intravenous. That is probably why you are constipated." 4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."

4 It is not unusual for post-cesarean section clients to have had no bowel movements. The client should be advised to drink flu- ids and to ambulate to stimulate peristalsis. This response is inappropriate. This client is obviously very concerned about her bowel pattern. This response is inaccurate. Clients who have received antibiotics often complain of diarrhea as a result of the change in their intestinal flora. Consuming fluids and fiber and exer- cising all help clients to reestablish normal bowel function.

75. The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, G1P1001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6 ̊F, 82, 18; fundus firm at umbilicus; moderate lochia; ambulated to bathroom to void 4 times; breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? 1. Fluid volume deficit r/t excess blood loss. 2. Impaired skin integrity r/t vaginal delivery. 3. Impaired urinary elimination r/t excess output. 4. Knowledge deficit r/t lack of parenting experience.

4 This client is a primigravida. The nurse would anticipate that she is in need of teaching regarding infant care as well as self-care.

83. The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states, "Oh, I don't use those. I always use tampons." Which of the following actions by the nurse is appropriate at this time? 1. Remove the peripad and insert a tampon into the woman's vagina. 2. Advise the client that for the first two days she will be bleeding too heavily for a tampon. 3. Remind the client that a tampon would hurt until the soreness from the delivery resolves. 4. State that it is unsafe to place anything into the vagina until involution is complete.

4 This response is correct. It is unsafe to place anything in the vagina before involution is complete.

9. A client informs the nurse that she intends to bottlefeed her baby. Which of the following actions should the nurse encourage the client to perform? 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day.

4. It is unnecessary for a bottlefeeding mother to increase her fluid intake. It is inadvisable for a bottlefeeding mother to massage her breasts. It is inadvisable for a bottlefeeding mother to apply heat to her breasts. The mother should be advised to wear a supportive bra 24 hours a day for a week or so.

1. A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of the following must the nurse include in her discharge teach- ing regarding the vaccine? 1. The woman should not become pregnant for at least 4 weeks. 2. The woman should pump and dump her breast milk for 1 week. 3. The mother must wear a surgical mask when she cares for the baby. 4. Passive antibodies transported across the placenta will protect the baby.

1 This statement is correct. The rubella vaccine is a live attenuated vaccine. Severe birth defects can develop if the woman becomes pregnant within 4 weeks of receiving the injection. This is unnecessary. There is no risk to the baby whether the mother is bottle- feeding or breastfeeding. This statement is incorrect. There is no risk to the baby. This statement is incorrect. Because the mother has never had rubella, no passive antibodies to rubella crossed the placenta.

3. A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? 1. Remove wet blankets. 2. Assess Apgar score. 3. Insert eye prophylaxis. 4. Elicit the Moro reflex.

1 When newborns are wet they can be- come hypothermic from heat loss re- sulting from evaporation. They may then develop cold stress syndrome. The first Apgar score is not done until 60 seconds after delivery. The wet blan- kets should have been removed from the baby well before that time. Eye prophylaxis can be delayed until af- ter the parents have begun bonding with their baby. Although the baby's central nervous sys- tem must be carefully assessed, reflex as- sessment should be postponed until after the baby is dried and is breathing on his or her own.

19. A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal? Select all that apply. 1. Purple-colored patches on the buttocks and torso. 2. Bilateral whitish discharge from the breasts. 3. Bloody discharge from the vagina. 4. Sharply demarcated dark red area on the face. 5. Deep hair-covered dimple at the base of the spine.

1, 2, and 3 are correct. 1. The patches are called mongolian spots and they are commonly seen in babies of color. They will fade and disappear with time. 2. The whitish discharge is called witch's milk and is excreted as a result of the drop in maternal hormones in the baby's system. The discharge is temporary. 3. The bloody discharge is called pseudomenses and occurs as a result of the drop in maternal hormones in the baby's system. The discharge is temporary. 4. The demarcated area is a port wine stain, or capillary angioma. It is a permanent birthmark. 5. The dimple may be a pilonidal cyst or a small defect into the spinal cord (spina bifida). An ultrasound should be done to determine whether or not a pathological condition is present.

105. A mother tells the nurse that, because of family history, she is afraid her baby son will develop colic. Which of the following colic management strategies should the parents be taught? Select all that apply. 1. Small, frequent feedings. 2. Prone sleep positioning. 3. Tightly swaddling the baby. 4. Rocking the baby while holding him face down on the forearm. 5. Maintaining a home environment that is cigarette smoke-free.

1, 3, 4, and 5 are correct. 1. Small, frequent feedings reduce the symptoms of colic in some babies. 2. The prone sleep position is not recom- mended for babies under 1 year of age. 3. Some babies' symptoms have de- creased when they were tightly swaddled. 4. This is called the colic hold. The position does help to soothe some colicky neonates. 5. Babies who live in an environment where adults smoke have a higher in- cidence of colic than babies who live in a smoke-free environment.

69. An Asian client's temperature 10 hours after delivery is 100.2oF. She refuses to drink her iced water. Which of the following actions is most appropriate? 1. Replace the iced water with hot water. 2. Notify the client's health care provider. 3. Assess the client's breasts for engorgement. 4. Remind the client that drinking is very important.

1. This action is appropriate. Asians, many of whom believe in the hot-cold theory of disease, will often not drink cold fluids or eat cold foods during the postpartum. This action is not necessary at this time. This action is not indicated by the infor- mation in the scenario. This information is correct but it does not take into consideration the client's beliefs and traditions.

82. The nurse is initiating discharge teaching with a couple regarding the need for an infant car seat for the day of discharge. Which of the following responses indicates that the nurse acted appropriately? The nurse discussed the need with the couple: 1. on admission to the labor room. 2. in the client room after the delivery. 3. when the client put the baby to the breast for the first time. 4. the day before the client and baby are to leave the hospital.

1. Discharge teaching should be initiated at the time of admission. This nurse is correct in initiating the process in the labor room.

56. Which of the following is the priority nursing action during the immediate post- partum period? 1. Palpate fundus. 2. Check pain level. 3. Perform pericare. 4. Assess breasts.

1. Fundal assessment is the priority nursing action.

36. A post-cesarean section, breastfeeding client, whose subjective pain level is 2/5, re- quests her as needed (prn) narcotic analgesics every 3 hours. She states, "I have de- cided to make sure that I feel as little pain from this experience as possible." Which of the following should the nurse conclude in relation to this woman's behavior? 1. The woman needs a stronger narcotic order. 2. The woman is high risk for severe constipation. 3. The woman's breast milk volume may drop while taking the medicine. 4. The woman's newborn may become addicted to the medication.

2

93. A mother questions why the ophthalmic medication is given to the baby. Which of the following responses by the nurse would be appropriate to make at this time? 1. "I am required by law to give the medicine." 2. "The medicine helps to prevent eye infections." 3. "The medicine promotes neonatal health." 4. "All babies receive the medicine at delivery."

2 Although this is a true statement, it does not provide a rationale for the medica- tion administration. This response gives the mother a brief scientific rationale for the med- ication administration. This response is too vague. Although this is a true statement, it does not provide a rationale for the medica- tion administration.

103. A baby has just been circumcised. If bleeding occurs, which of the following actions should be taken first? 1. Put the baby's diapers on as tightly as possible. 2. Apply light pressure to the area with sterile gauze. 3. Call the physician who performed the surgery. 4. Assess the baby's heart rate and oxygen saturation.

2 Putting direct pressure on the site is the best way to stop the bleeding.

48. The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? 1. "Okay. I must be palpating your uterus." 2. "I understand but I still would like you to try to urinate." 3. "You still must be numb from the local anesthesia." 4. "That is a problem. I will have to catheterize you."

2 This is an incorrect statement. This statement is accurate. Mothers often do not feel bladder pressure af- ter delivery. Local anesthesia does not affect a client's ability to feel bladder distension. This statement is inappropriate. The nurse should escort the woman to the bathroom to urinate.

58. One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this di- agnosis? Select all that apply. 1. The client will drink sufficient quantities of fluid. 2. The client will have a stable white blood cell count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge. 5. The client will take two or three sitz baths each day.

2, 3, and 4 are correct. 1. Although clients should drink fluids, this is not a goal related to the identified nursing diagnosis. 2. An important goal is that the woman's WBC will remain stable. 3. An important goal is that the woman's temperature will remain normal. 4. An important goal is that the woman's lochia will smell normal. 5. Sitz baths are not given to prevent infec- tions. They do help to soothe the pain and/or the inflammation associated with episiotomies and hemorrhoids.

60. A mother is attempting to latch her newborn baby to the breast. Which of the fol- lowing actions are important for the mother to perform in order to achieve effec- tive breastfeeding? Select all that apply. 1. Place the baby on his or her back in the mother's lap. 2. Wait until the baby opens his or her mouth wide. 3. Hold the baby at the level of the mother's breasts. 4. Point the baby's nose to the mother's nipple. 5. Wait until the baby's tongue is pointed toward the roof of his or her mouth.

2, 3, and 4 are correct. 1. The baby should be placed "tummy-to- tummy" with the mother. Babies cannot swallow when their heads are turned. They must face the breast for effective feeding. 2. To achieve an effective latch of both the nipple and the areolar tissue, the baby must have a wide-open mouth. 3. Because the neonate's mouth muscles are relatively weak, it is important for the baby to be placed at the level of the breast. If the baby is placed lower, he or she is likely to "slip to the tip" of the nipple and cause nipple abrasions. 4. Babies latch best when they are posi- tioned at the breast, in preparation to opening their mouths, with their noses pointed toward their mothers' nipples. 5. The baby's tongue must be below the nipple to achieve effective suckling.

11. A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate? 1. Place child in isolette. 2. Administer oxygen. 3. Swaddle baby in blanket. 4. Apply pulse oximeter.

3 Cyanotic hands and feet are not signs of hypoxia in the neonate. 3. The baby's extremities are cyanotic as a result of the baby's immature circu- latory system. Swaddling helps to warm the baby's hands and feet. 4. There is no evidence in the stem that would warrant monitoring with the pulse oximeter.

94. A neonate is to receive the hepatitis B vaccine in the neonatal nursery. Which of the following must the nurse have available before administering the injection? 1. Hepatitis B immune globulin in a second syringe. 2. Sterile water to dilute the vaccine before injecting. 3. Epinephrine in case of severe allergic reactions. 4. Oral syringe since the vaccine is given by mouth.

3 3. Epinephrine should be available whenever vaccinations are adminis- tered in case the recipient should develop anaphylactic symptoms.

27. The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? 1. Elevate the head of the bed 60 degrees. 2. Report absence of bowel sounds to the physician. 3. Have her turn and deep breathe every 2 hours. 4. Assess for patellar hyperreflexia bilaterally.

3

47. A nurse is providing anticipatory guidance to a couple before they take home their newborn. Which of the following should be included? 1. If their baby is sleeping soundly, they should not awaken the baby for a feeding. 2. If they take their baby outside, they should put sunscreen on the baby. 3. They should purchase liquid acetaminophen to be used when ordered by the pe- diatrician. 4. They should notify their pediatrician when the umbilical cord falls off.

3. Liquid acetaminophen should be available in the home, but it should not be administered until the parent speaks to the pediatrician.

101. A nurse is assessing the bonding of the father with his newborn baby. Which of the following actions by the father would be of concern to the nurse? 1. He holds the baby in the en face position. 2. He calls the baby by a full name rather than a nickname. 3. He tells the mother to pick up the crying baby. 4. He falls asleep in the chair with the baby on his chest.

3. A father who expects his partner to quiet a crying baby may not be ac- cepting the parenting role.

45. A nurse is providing anticipatory guidance to a couple regarding the baby's immunization schedule. Which of the following statements by the parents shows that further teaching by the nurse is needed? 1. The first hepatitis B injection is given by 1 month of age. 2. The first polio injection will be given at 2 months of age. 3. The MMR (measles, mumps, and rubella) immunization should be administered before the first birthday. 4. Three DTaP (diphtheria, tetanus, and acellular pertussis) shots will be given during the first year of life.

3. Because the baby has received passive immunity from the mother, the MMR is not given until the second year of life.

65. A 2-day postpartum mother, G2P2002, states that her 2-year-old daughter at home is very excited about taking "my baby sister" home. Which of the following is an appropriate response by the nurse? 1. "It's always nice when siblings are excited to have the babies go home." 2. "Your daughter is very advanced for her age. She must speak very well." 3. "Your daughter is likely to become very jealous of the new baby." 4. "Older sisters can be very helpful. They love to play mother."

3. The nurse should forewarn the mother about the likelihood of the 2-year-old's jealousy.

36. The nurse notes that a newborn, who is 5 minutes old, exhibits the following char- acteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is? 1. 6 2. 7 3. 8 4. 9

3. The baby's Apgar is 8.

70. A medication order reads: Methergine (ergonovine) 0.2 mg po q 6 h 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia flow. 3. Blood pressure. 4. Episiotomy.

3. The blood pressure should be assessed before administering Methergine.

44. The nurse is assessing the laboratory report on a 2-day postpartum G1P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider? 1. White blood cells—12,500 cells/mm3. 2. Red blood cells—4,500,000 cells/mm3. 3. Hematocrit—26%. 4. Hemoglobin—11 g/dL

3. The client's hematocrit is well below normal. This value should be reported to the client's health care provider.

39. A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord? 1. Cleanse it with hydrogen peroxide if it starts to smell. 2. Remove it with sterile tweezers at one week of age. 3. Call the doctor if greenish drainage appears. 4. Cover it with sterile dressings until it falls off.

3. The green drainage may be a sign of infection. The cord should become dried and shriveled.

54. On admission to the labor and delivery unit, a client's hemoglobin (Hgb) was as- sessed at 11.0 gm/dL, and her hematocrit (Hct) at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery? 1. Hgb 12.5 gm/dL; Hct 37%. 2. Hgb 11.0 gm/dL; Hct 33%. 3. Hgb 10.5 gm/dL; Hct 31%. 4. Hgb 9.0 gm/dL; Hct 27%.

3. The nurse would expect these values—a slight decrease in both hemoglobin and hematocrit values.

79. A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant? 1. Assess client's fundal height. 2. Teach client how to massage her fundus. 3. Take the client's vital signs. 4. Document quantity of lochia in the chart.

3. This action can be delegated to a nursing assistant. Once the vital signs are checked, the nursing assistant can report the results to the nurse for his or her interpretation.

78. A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? 1. The client will breastfeed her baby every 2 hours. 2. The client will consume a normal diet. 3. The client will have a moderate lochial flow. 4. The client will ambulate to the bathroom every 2 hours.

3. This is the most important goal during the immediate postdelivery period.

12. A couple is asking the nurse whether or not their son should be circumcised. On which fact should the nurse's response be based? 1. Boys should be circumcised in order for them to establish a positive self-image. 2. Boys should not be circumcised because there is no medical rationale for the procedure. 3. Experts from the Centers for Disease Control and Prevention argue that circumcision is desirable. 4. A statement from the American Academy of Pediatrics asserts that circumcision is optional.

4 There is no evidence that circumcision status affects a boy's self-image. No official statements have been pub- lished regarding the rationality of per- forming circumcisions. The CDC has made no policy statement on circumcision. The AAP, although acknowledging that there are some advantages to cir- cumcision, states that there is not enough evidence to suggest that all baby boys be circumcised.

67. A Muslim woman requests something to eat after the delivery of her baby. Which of the following meals would be most appropriate for the nurse to give her? 1. Ham sandwich. 2. Bacon and eggs. 3. Spaghetti with sausage. 4. Chicken and dumplings.

4. Although this is not a traditional Muslim dish, the foods are allowable by Muslim tradition.

38. The mother notes that her baby has a "bulge" on the back of one side of the head. She calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers the right parietal bone but does not cross the suture lines. The nurse explains to the mother that the bulge results from which of the following? 1. Molding of the baby's skull so that the baby could fit through her pelvis. 2. Swelling of the tissues of the baby's head from the pressure of her pushing. 3. The position that the baby took in her pelvis during the last trimester of her pregnancy. 4. Small blood vessels that broke under the baby's scalp during birth.

4. Cephalhematomas are subcutaneous swellings of accumulated blood from the trauma of delivery. The bulges may be one sided or bilateral and the swellings do not cross suture lines.

65. A 2-day-old, exclusively breastfed baby is to be discharged home. Under what con- ditions should the nurse teach the parents to call the pediatrician? 1. If the baby feeds 8 to 12 times each day. 2. If the baby urinates 6 to 10 times each day. 3. If the baby has stools that are watery and bright yellow. 4. If the baby has eyes and skin that are tinged yellow.

4. If the baby has yellow sclerae, the baby is exhibiting signs of jaundice and the pediatrician should be contacted.

81. A woman who has just delivered has decided to bottlefeed her full-term baby. Which of the following should be included in the patient teaching? 1. The baby's stools will appear bright yellow and will usually be loose. 2. The bottle nipples should be enlarged to ease the baby's suckling. 3. It is best to heat the baby's bottle in the microwave before feeding. 4. It is important to hold the bottle to keep the nipple filled with formula.

4. In order to minimize the ingestion of large quantities of air, the bottle should be held so that the nipple is al- ways filled with formula.

106. A nurse, when providing discharge teaching to parents, emphasizes actions to prevent plagiocephaly and to promote gross motor development in their full-term newborn. Which of the following actions should the nurse advise the parents to take? 1. Breastfeed the baby frequently. 2. Make sure the baby receives vaccinations at recommended intervals. 3. Change the diapers regularly. 4. Minimize supine positioning during supervised play periods.

4. Prolonged supine posturing by babies can result in flattening of the backs of babies' heads (plagiocephaly). Being placed in the prone position while awake allows babies to practice gross motor skills like rolling over.

11. A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her infant. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottlefeed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.

4. The nurse should discuss the action of oxytocin.

37. A nurse is assessing a 1-day postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? 1. Fundus at the umbilicus. 2. Nodular breasts. 3. Pulse rate 60 bpm. 4. Pad saturation every 30 minutes.

4. This blood loss is excessive, especially for a postoperative cesarean section client. The surgeon should be notified.

29. A woman had a cesarean section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse's best response? 1. "I know that it hurts but it is very important for you to cough." 2. "Let me check your lung fields to see if coughing is really necessary." 3. "If you take a few deep breaths in, that should be as good as coughing." 4. "If you support your incision with a pillow, coughing should hurt less."

4. This is the appropriate response. The nurse is providing the client with a means of reducing the discomfort of postsurgical coughing.

77. After a client's placenta is birthed, the obstetrician states, "Please add 20 units of oxytocin to the intravenous and increase the drip rate to 250 cc/hr." The client has 750 cc in her IV and the IV tubing delivers fluid at the rate of 10 gtt/cc. To what drip rate should the nurse set the intravenous? ______ gtt/min

42 gtt/min The formula to calculate an intravenous drip rate is:

32. A postoperative cesarean section woman is to receive morphine 4 mg q 3-4 h subcutaneously for pain. The morphine is available on the unit in premeasured syringes 10 mg/1 mL. Each time the nurse administers the medication, how many milliliters (mL) of morphine will be wasted? ___________ mL

0.6 mL The formula to use is: Known dosage Desired dosage Known volume Desired volume 10mg 6mg 1 mL x mL 10 x 6 x 0.6 mL

84. A client has been transferred to the post-anesthesia care unit from a cesarean deliv- ery. The client had spinal anesthesia for the surgery. Which of the following inter- ventions should the nurse perform at this time? 1. Assess the level of the anesthesia. 2. Encourage the client to urinate in a bedpan. 3. Provide the client with the diet of her choice. 4. Check the incision for signs of infection.

1. This answer is correct. The nurse should assess the level of anesthesia every 15 minutes while in the postanesthesia care unit.

20. Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? 1. Hematocrit 39%. 2. White blood cell count 16,000 cells/mm3. 3. Red blood cell count 5 million cells/mm3. 4. Hemoglobin 15 grams/dL.

2 The hematocrit is often low in postpar- tum clients. The nurse would expect to see an ele- vated white cell count. The red cell count is often low in post- partum clients. The hemoglobin is often low in postpar- tum clients.

113. Which of the following behaviors should nurses know are characteristic of infant abductors? Select all that apply. 1. Act on the spur of the moment. 2. Create a diversion on the unit. 3. Ask questions about the routine of the unit. 4. Choose rooms near stairwells. 5. Wear over-sized clothing.

2, 3, 4, and 5 are correct. 1. Abductors usually plan their strategies carefully before taking the baby. 2. A common diversion is pulling the fire alarm to distract the staff. 3. Those who are inquisitive about where babies are at different times of the day may be planning an abduction. 4. Rooms near stairwells provide the abductor with a quick and easy get-away. 5. The abductor is able to hide a baby in oversized clothing or in large bags.

19. A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? 1. Take the woman's temperature. 2. Advise the woman to decrease her fluid intake. 3. Reassure the woman that this is normal. 4. Inform the neonate's pediatrician.

3 1. It is unlikely that the woman is febrile. 2. The woman should maintain an adequate fluid intake. 3. Diaphoresis is normal during the postpartum period. 4. There is no need to report the diaphore- sis to the baby's pediatrician.

5. A mother asks the nurse to tell her about the responsiveness of neonates at birth. Which of the following answers is appropriate? 1. "Babies have a poorly developed sense of smell until they are 2 months old." 2. "Babies can taste only salty and sour substances at birth." 3. "Babies are especially sensitive to being touched and cuddled." 4. "Babies are nearsighted with blurry vision until they are about 3 months of age."

3 1. All of the babies senses are well formed at birth 2. Babies respond to all forms of taste. They prefer sweet things 3 Babies' sense of touch is considered to be the most well-developed sense. 4. Babies see quite well at 8 to 12 inches. They prefer to look at the human face

50. The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? 1. The woman performs the procedure twice a day. 2. The woman sits in warm tap water for ten minutes. 3. The woman sprays her perineum from front to back. 4. The woman mixes tap water with hydrogen peroxide.

3

97. A full-term baby's bilirubin level is 15 on day 3. Which of the following neonatal behaviors would the nurse expect to see? 1. Excessive crying. 2. Increased appetite. 3. Lethargy. 4. Hyperreflexia.

3 3. Lethargy is one of the most common early symptoms of hyper- bilirubinemia.

63. A primipara, 4 hours postpartum, requests that the nurse diaper her baby after a feeding because, "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is ex- hibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.

3 The client is not exhibiting signs of so- cial isolation. The client is not exhibiting signs of child neglect. The client is exhibiting normal post- partum behavior. The client is not exhibiting signs of post- partum depression.

72. The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects? 1. Headache. 2. Nausea. 3. Cramping. 4. Fatigue.

3 The client should not develop a headache from Methergine. The client should not become nauseated from Methergine. Cramping is an expected outcome of the administration of Methergine. The client should not become fatigued from Methergine.

18. The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

3 The urinary output increases during the early postpartum period. The blood pressure should remain stable during the postpartum. The blood volume does drop precipi- tously during the early postpartum period. The estrogen levels drop during the early postpartum period.

53. A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks? 1. Skim milk. 2. Ginger ale. 3. Orange juice. 4. Chamomile tea.

3. The nurse would recommend that the iron be taken with orange juice be- cause ascorbic acid, which is in orange juice, promotes the absorption of iron into the body.

80. A client, G2P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? 1. Assess her feet and ankles for pitting edema. 2. Advise the client to stop feeding her baby while her blood pressure is assessed. 3. Lower both of her legs at the same time. 4. Measure the length of the episiotomy and document the findings in the chart.

3. This action is very important. If the legs are removed from the stirrups one at a time, the woman is at high risk for back and abdominal injuries.

25. The day after delivery a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong, "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specific gravity of the next voiding.

3. This response is correct. Polyuria is normal.

90. The nurse informs the parents of a breastfed baby that the American Academy of Pediatrics advises that babies be supplemented with which of the following vitamins? 1. Vitamin A. 2. Vitamin B12. 3. Vitamin C. 4. Vitamin D.

4 . Breast milk contains sufficient quantities of vitamin A. 2. Breast milk contains sufficient quantities of vitamin B12. 3. Breast milk contains sufficient quantities of vitamin C. 4. Many babies are vitamin D deficient because of the recommendation that they be kept out of direct sunlight to protect their skin from sunburn. For this reason, supplementation with vi- tamin D is recommended.

23. The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.

4 4. The fundus is usually 3 cm below the umbilicus on day 3 and the lochia usually has turned to serosa by day 3.

41. A client, G1P1001, 1-hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? 1. Provide the woman with a bedpan. 2. Advise the woman that the feeling is likely related to the trauma of delivery. 3. Remind the woman that she still has a catheter in place from the delivery. 4. Assist the woman to the bathroom.

4 The client should ambulate. There is nothing in the scenario indicating that the client must use a bedpan. It is likely that the client needs to uri- nate. In-dwelling catheters are rarely inserted for vaginal deliveries. This is the appropriate action by the nurse.

3. A patient, G2P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2oF. Which of the following is the appropriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the woman with cool compresses. 4. Encourage intake of water and other fluids.

4. It is likely that this client is dehy- drated. She should be advised to drink fluids.

95. A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions should the RN perform rather than delegating it to the CNA? 1. Bathe and weigh a 1-hour-old baby. 2. Take the apical heart rate and respirations of a 4-hour-old baby. 3. Obtain a stool sample from a 1-day-old baby. 4. Provide discharge teaching to the mother of a 4-day-old baby.

4. It is the registered nurse's responsi- bility to provide discharge teaching to clients. Only the RN knows the scientific rationales as well as the knowledge of teaching-learning prin- ciples necessary to provide accurate information and answer questions appropriately.

7. A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a diet?" Which of the following responses is appropriate? 1. "It is fine for you to start dieting right now as long as you drink plenty of milk." 2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding." 3. "You must eat at least 3000 calories per day in order to produce enough milk for your baby." 4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."

4. Many mothers who consume approxi- mately the same number of calories while breastfeeding as they did when they were pregnant do lose weight while breastfeeding.

59. Which of the following nursing interventions would be appropriate for the nurse to perform in order to achieve the client care goal: The client will not develop post- partum thrombophlebitis? 1. Encourage early ambulation. 2. Promote oral fluid intake. 3. Massage the legs of the client twice daily. 4. Provide the client with high fiber foods.

1

22. A neonate is in the active alert behavioral state. Which of the following would the nurse expect to see? 1. Baby is showing signs of hunger and frustration. 2. Baby is starting to whimper and cry. 3. Baby is wide awake and attending to a picture. 4. Baby is asleep and breathing rhythmically.

1 Showing signs of hunger and frustra- tion describes the active alert or active awake state. Starting to whimper and cry describes the crying behavioral state. This describes the quiet alert state; sometimes called wide-awake state. Sleeping and breathing regularly describe deep or quiet sleep.

57. Immediately after delivery, a woman is shaking uncontrollably. Which of the fol- lowing nursing actions is most appropriate? 1. Provide the woman with warm blankets. 2. Put the woman in Trendelenburg position. 3. Notify the primary health care provider. 4. Increase the intravenous infusion.

1 1. The appropriate action is to provide the client with warm blankets. 2. Postpartum shaking is very common. It is unnecessary to place the client in the Trendelenburg position. 3. Postpartum shaking is very common. It is unnecessary to notify the client's health care provider. 4. Postpartum shaking is very common. It is unnecessary to increase the client's intra- venous fluid rate.

2. A 3-day-postpartum client questions why she is to receive the rubella vaccine be- fore leaving the hospital. Which of the following rationales should guide the nurse's response? 1. The client's obstetric status is optimal for receiving the vaccine. 2. The client's immune system is highly responsive during the postpartum period. 3. The client's baby will be high risk for acquiring rubella if the woman does not receive the vaccine. 4. The client's insurance company will pay for the shot if it is given during the im- mediate postpartum period.

1 This statement is correct. Because the vaccine is teratogenic, the best time to administer it is when the client is not pregnant. This statement is incorrect. The immune systems of women during their pregnan- cies and immediately postpartum are slightly depressed. This statement is incorrect. The baby will be susceptible to rubella whether or not the woman receives the vaccine. In general, insurance companies will pay for vaccinations whenever they are needed.

57. A mother is told that she should bottlefeed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply. 1. Untreated, active tuberculosis. 2. Hepatitis B surface antigen positive. 3. Human immunodeficiency virus positive. 4. Chorioamnionitis. 5. Mastitis.

1 and 3 are correct. 1. A mother with active untreated TB should be separated from her baby until the mother has been on antibi- otic therapy for about 2 weeks. She can, however, pump her breast milk and have it fed to baby through an al- ternate feeding method. 2. Being hepatitis B surface antigen positive (HBSag ) is not a contraindication to breastfeeding. 3. Mothers who are HIV positive are ad- vised not to breastfeed because there is an increased risk of transmission of the virus to the infant. 4. Acute bacterial infections, such as chorioamnionitis, are not contraindica- tions to breastfeeding unless the medica- tion given to the mother is contraindi- cated. There are, however, very few antibiotics that are incompatible with breastfeeding. 5. It is recommended that a mother with mastitis continue to breastfeed. She must keep draining her breasts of milk to pre- vent the development of a breast abscess. Again, only antibiotics compatible with breastfeeding should be administered.

10. A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for devel- opmental dysplasia of the hip (DDH)? Select all that apply. 1. Grasp the baby's thighs with the thumbs on the inner thighs and forefingers on the outer thighs. 2. Gently adduct the baby's thighs. 3. Palpate the trochanter to sense changes during hip rotation. 4. Place the baby in a prone position. 5. Flex the baby's hips and knees at 90o angles.

1, 3, and 5 are correct. 1. With the baby placed flat on its back, the practitioner grasps the baby's thighs using his or her thumbs and in- dex fingers. 2. When assessing for Ortolani sign, the baby's thighs are abducted rather than adducted. 3. With the baby's hips and knees at 90o angles, the hips are abducted. With DDH, the trochanter dislocates from the acetabulum. 4. The baby is placed flat on its back. 5. Flex the baby's hips and knees at 90o angles.

51. A nurse is practicing the procedures for conducting cardiopulmonary resuscitation (CPR) in the neonate. Which site should the nurse use to assess the pulse of a baby? 1. Carotid. 2. Radial. 3. Brachial. 4. Pedal.

3 1. The recommended site for assessing the pulse of a neonate is the brachial pulse. The carotid pulse is used to assess the pulse of the child over 1 year and an adult. 2. The radial pulse is never recommended for use during CPR. 3. The recommended site for assessing the pulse of a neonate undergoing CPR is the brachial pulse. 4. The pedal pulse is never recommended for use during CPR.

25. A mother calls the nurse to her room because "My baby's eyes are bleeding." The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time? 1. Notify the pediatrician immediately and report the finding. 2. Notify the social worker about the probable maternal abuse. 3. Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear. 4. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and con- dition of the retina in each eye.

3 2. There is nothing in the stem that implies that the child has been abused. 3. Subconjunctival hemorrhages are a normal finding and are not pathologi- cal. They will disappear over time. Explaining this to the mother is the appropriate action. 4. There is nothing in the stem that implies that there has been any intraocular damage.

8. Four newborns are in the neonatal nursery. Which of the babies should the nurse report to the neonatalogist? 1. 16-hour-old baby who has yet to pass meconium. 2. 16-hour-old baby whose blood glucose is 50 mg/dL. 3. 2-day-old baby who is breathing irregularly at 70 breaths per minute. 4. 2-day-old baby who is excreting a milky discharge from both nipples.

3 2. This baby's glucose level is within normal limits. 3. Normal neonatal breathing is irregu- lar at 30 to 60 breaths per minute. This baby is tachypneic. 4. A milky discharge—witch's milk—is nor- mal. It results from the drop in maternal hormones in the neonatal system follow- ing delivery.

40. The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? 1. Assist with stitch removal on third postpartum day. 2. Administer analgesics every four hours per doctor orders. 3. Teach client to contract her buttocks before sitting. 4. Irrigate incision twice daily with antibiotic solution.

3 Episiotomy sutures are not removed. Clients who have had episiotomies may or may not require pain medication. The medicine should be offered throughout the day since it is usually ordered prn. This statement is correct. When clients contract their buttocks before sitting, they usually feel less pain than when they sit directly on the su- ture line. It is not recommended to irrigate epi- siotomy incisions.

29. In which of the following situations would it be appropriate for the father to place the baby in the en face position? 1. The baby is asleep with little to no eye movement, regular breathing. 2. The baby is asleep with rapid eye movement, irregular breathing. 3. The baby is awake, looking intently at an object, irregular breathing. 4. The baby is awake, placing hands in the mouth, irregular breathing.

3 This baby is in the quiet alert behav- ioral state. Placing the baby en face will foster bonding between the father and baby.

61. The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed? 1. The client states that the pain has decreased. 2. The nurse hears the baby swallow after each suck. 3. The baby's jaws move up and down once every second. 4. The baby's cheeks move in and out with each suck.

4 1. Unless the nipples have been damaged extensively, once babies are latched cor- rectly pain usually subsides. 2. Audible swallowing is an excellent indica- tor of breastfeeding success. 3. Slow, rhythmic jaw movement is an indi- cator of breastfeeding success. 4. Babies whose cheeks move in and out during feeds are attempting to use negative pressure to extract the milk from the breasts. This action is not an indicator of breastfeeding success.

12. The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend? 1. 1⁄2 cup raw celery dipped in 1 ounce cream cheese. 2. 8 ounce yogurt mixed with 1 medium banana. 3. 12 ounce strawberry milk shake. 4. 11⁄2 cup raw broccoli.

4 1. Celery is especially high in vitamin K, but it contains very little iron or vitamin A. Cream cheese is very high in fat. 2. Yogurt is high in calcium but is not high in either iron or vitamin A. Bananas are high in vitamin B6, potassium, and vita- min C, but they are not high in either iron or vitamin A. 3. Strawberries are very high in vitamin C, but they are not high in either iron or vitamin A. 4. Broccoli is very high in vitamin A and also contains iron.

8. A G2P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is as- sessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary health care provider.

4 Heavy lochia is not a normal finding. Moderate lochia, which is similar in quantity to a heavy menstrual period, is a normal finding. The woman's fundus is firm. There is no need to massage the fundus. The fundus is at the umbilicus and it is firm. It is unlikely that her bladder is full. Because of the heavy lochia, the nurse should notify the woman's health care provider.

74. A 4-day-old breastfeeding neonate whose birth weight was 2678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take? 1. Nothing because this is an acceptable weight loss. 2. Advise the mother to supplement feedings with formula. 3. Notify the neonatalogist of the excessive weight loss. 4. Give the baby dextrose water between breast feedings.

1. This baby has only lost 3.7% of his or her birth weight—100/2678 100% 3.7%. This is below the accepted weight loss of 5% to 10%. There is no need to supplement this baby's feeds. The weight loss is not excessive. Dextrose water is not recommended for babies.

9. The pediatrician has ordered vitamin K 0.5 mg IM for a newly born baby. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby? ______ mL

0.25 mL A simple ratio and proportion equation is needed to calculate the volume of vitamin K that should be given to the baby. Known volume : Known dosage Desired volume : Desired dosage 2 : 1 mL 0.5 : x The means are multiplied together and ex- tremes are multiplied together. 2x 0.5 x 0.25 mL

20. The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatalogist? 1. Intracostal retractions. 2. Caput succedaneum. 3. Epstein's pearls. 4. Harlequin sign.

1 Intracostal retractions are a sign of respiratory distress. Caput succedaneum is a normal finding in a neonate. Epstein's pearls are often seen in the mouths of neonates. Harlequin sign, although odd-appearing, is a normal finding in a neonate.

42. The nurse is teaching the parents of a female baby how to change the baby's dia- pers. Which of the following should be included in the teaching? 1. Always wipe the perineum from front to back. 2. Remove any vernix caseosa from the labial folds. 3. Put powder on the buttocks every time the baby stools. 4. Weigh every diaper in order to assess for hydration.

1 1. The perineum of female babies should always be cleansed from front to back to prevent bacteria from the rectum from causing infection. 2. Vernix may be in the labial folds at delivery. It is a natural lanolin that will be absorbed over time. Actively removing the vernix can actually irritate the baby's tissues. 3. Powder is not recommended for use on babies, especially in the diaper area. When mixed with urine, powders can produce an irritating paste. 4. The number of a baby's diapers should be counted to assess for hydration, but weighing the diapers of full-term babies is rarely needed.

53. The nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan? 1. Wash hands well before picking up the baby. 2. Refrain from having visitors for the first month. 3. Wear a mask to prevent transmission of a cold. 4. Sterilize the breast pump supplies for the first month.

1 Although this baby is being breastfed, he or she is still susceptible to illness. The best way to prevent transmission of pathogens is to wash hands care- fully before touching the baby. 2. Visitors, too, should wash hands before touching the baby, but it is unnecessary to isolate the baby from them. 3. The best way to prevent the transmission of a cold is to wash hands. Also, this baby is receiving protective antibodies through the breast milk. Masks are not necessary. 4. Sterilization is not necessary. All wash- able pieces of the equipment should be washed thoroughly in dish detergent and water and rinsed well. The dishwasher- safe pieces could be cleansed in the dishwasher.

75. A 2-day-postpartum breastfeeding client is complaining of pain during feedings. Which of the following may be causing the pain? 1. The neonate's frenulum is attached to the tip of the tongue. 2. The baby's tongue forms a trough around the breast during the feedings. 3. The newborn's feeds last for 30 minutes every 2 hours. 4. The baby is latched to the nipple and to about 1 inch of the mother's areola.

1 Babies with short frenulums—tongue- tied babies—are unable to extend their tongues enough to achieve a suf- ficient grasp. Painful and damaged nipples often result. The baby's tongue should be troughed to feed effectively. This is, on average, the feeding pattern of breastfed babies. Babies should latch to both the nipple and areola.

66. A nurse who is caring for a mother/newborn dyad on the maternity unit has identi- fied the following nursing diagnosis: Effective breastfeeding. Which of the follow- ing would warrant this diagnosis? 1. Baby's lips are flanged when latched. 2. Baby feeds every 4 hours. 3. Baby lost 12% of weight since birth. 4. Baby's tongue stays behind the gum line.

1 Both the upper and lower lips should be flanged. Breastfed babies usually feed every 2 to 3 hours. A 12% weight loss is significant in any neonate whether breastfeeding or bottle- feeding. When the tongue stays behind the gum line the baby is unable to strip the breast of milk.

78. Four pregnant women advise the nurse that they wish to breastfeed their babies. Which of the mothers should be advised to bottlefeed her child? 1. The woman with a neoplasm requiring chemotherapy. 2. The woman with cholecystitis requiring surgery. 3. The woman with a concussion. 4. The woman with thrombosis.

1 Breastfeeding is contraindicated when a woman is receiving chemotherapy. Neither the medical problem—in this case, cholecystitis—nor the planned sur- gery precludes breastfeeding. The mother may have to pump and dump a few feed- ings depending on the short-term med- ications that she will receive, but she will still ultimately be able to breastfeed. Breastfeeding is not contraindicated with a diagnosis of a concussion. Again, the mother may have to pump and dump a few feedings if she must take any incom- patible short-term medications, but she will still ultimately be able to breastfeed. Breastfeeding is not contraindicated with a diagnosis of thrombosis. Again, the mother may have to pump and dump a few feedings if she must take any incom- patible short-term medications, but she will still ultimately be able to breastfeed.

73. A mother, who gave birth 5 minutes ago, states that she would like to breastfeed. The baby's Apgar score is 9/9. Which of the following actions should the nurse perform first? 1. Assist the woman to breastfeed. 2. Assess the baby's blood pressures. 3. Administer the ophthalmic prophylaxis. 4. Take the baby's rectal temperature.

1 Breastfeeding should be instituted as soon as possible to promote milk pro- duction, stability of the baby's glucose levels, and meconium excretion, as well as to stabilize the baby's temper- ature through skin-to-skin contact. The blood pressure assessments can be deferred until after the baby has received the first feeding. Ophthalmic preps should be delayed un- til after the first feeding. The drops/ ointment can impact bonding by impair- ing the baby's vision. Skin-to-skin contact with the mother during breastfeeding effectively stabilizes neonatal temperatures.

4. To reduce the risk of hypoglycemia in a full-term newborn weighing 2900 grams, what should the nurse do? 1. Maintain the infant's temperature above 97.7oF. 2. Feed the infant glucose water every 3 hours until breastfeeding well. 3. Assess blood glucose levels every 3 hours for the first twelve hours. 4. Encourage the mother to breastfeed every 4 hours.

1 Hypothermia in the neonate is de- fined as a temperature below 97.7oF. Cold stress syndrome may develop if the baby's temperature is below that level. A healthy neonate does not need supple- mental feedings. And if supplements are needed, they should be either formula or breast milk. There is no indication in the stem that glucose assessments are needed for this baby. Babies should be breastfed every 2 to 3 hours. Feedings every 4 hours are not frequent enough.

64. The nurse is concerned that a bottlefed baby may become obese because of which activity by the mother? 1. She encourages the baby to finish the bottle at each feed. 2. She feeds the baby every 3 to 4 hours. 3. She feeds the baby a soy-based formula. 4. She burps the baby every 1⁄2 to 1 ounce.

1 It has been shown that bottlefed ba- bies are at higher risk for obesity than breastfed babies. One of the reasons is the insistence by some mothers that the baby finish the formula in a bottle even if the baby initially rejects it. The increased calorie intake leads to increased weight gain. Bottlefed babies usually feed every 3 to 4 hours. All formulas for full-term babies supply the same number of calories per ounce. It is recommended that bottlefed babies burp every 1⁄2 to 1 ounce when they are very young.

44. A nurse is advising a mother of a neonate being discharged from the hospital re- garding car seat safety. Which of the following should be included in the teaching plan? 1. Put the car seat facing forward only after the baby reaches twenty pounds. 2. The baby's car seat should be placed facing the rear in the front seat of the car. 3. A fist should fit between the straps of the seat and the baby's body. 4. Seat belt adjusters should always be used to support infant car seats.

1 It is unsafe for infants to be facing forward until they have reached 20 pounds, even if they are over 1 year of age. The baby should be facing the rear in the back seat of the car, not the front seat. The straps of a car seat should fit snugly allowing only 2 fingers to be inserted be- tween them and the baby. Seat belt adjusters that are being sold as adding to car seat safety have not been shown to be safe. In fact, most makers of car safety seats recommend that the ad- justers not be used. See http://www.aap. org/family/carseatguide.htm for car seat safety tips.

96. Four babies with the following conditions are in the well-baby nursery. The baby with which of the conditions is high risk for physiological jaundice? 1. Cephalhematoma. 2. Caput succedaneum. 3. Harlequin coloring. 4. Mongolian spotting.

1 Red blood cells in the cephalhe- matoma will have to be broken down and excreted. The byproduct of the destruction—bilirubin—increases the baby's risk for physiological jaundice. A caput is merely a collection of edema- tous fluid. There is no relation between the presence of a caput and jaundice. Harlequin coloration is related to the di- lation of blood vessels on one side of the baby's body. There is no relation between the presence of harlequin coloring and jaundice. Mongolian spots are hyperpigmented ar- eas primarily seen on the buttocks. There is no relation between the presence of mongolian spots and jaundice.

26. Which of the following full-term babies requires immediate intervention? 1. Baby with seesaw breathing. 2. Baby with irregular breathing with 10-second apnea spells. 3. Baby with coordinated thoracic and abdominal breathing. 4. Baby with respiratory rate of 52.

1 Seesaw breathing is an indication of respiratory distress. This is the normal breathing pattern of a neonate. When babies breathe, their abdomens and thoraces rise and fall in synchrony. The normal respiratory rate is 30 to 60 bpm.

83. A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a ce- sarean delivery, fetal position LMA, under epidural anesthesia. Which of the fol- lowing physiological findings would the nurse expect to see? 1. Soft pulmonary rales. 2. Absent bowel sounds. 3. Depressed Moro reflex. 4. Positive Ortolani sign.

1 Soft rales are expected because babies born via cesarean section do not have the advantage of having the amniotic fluid squeezed from the pulmonary system as occurs during a vaginal birth. The bowel sounds should be normal. The Moro reflex should be normal. Babies in the LMA position are not at high risk for developmental dysplasia of the hip. Breech babies are high risk for DDH.

7. A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate? 1. Do nothing because this is a normal weight loss. 2. Notify the neonatalogist of the significant weight loss. 3. Advise the mother to bottlefeed the baby at the next feed. 4. Assess the baby for hypoglycemia with a glucose monitor.

1 The baby has lost less than 4% of its birth weight. The normal weight loss for babies is 5% to 10%. The weight loss is within normal limits. Supplementation is not needed at this time. There is no indication in the stem that the baby is high risk for hypoglycemia.

58. A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the fol- lowing actions should the nurse perform first? 1. Compare mother's and baby's identification bracelets. 2. Help the mother into a comfortable position. 3. Teach the mother about a proper breast latch. 4. Tickle the baby's lips with the mother's nipple.

1 The first action the nurse should ever perform is to make sure that the cor- rect baby is being given to the correct mother. This is an important action but it is not the first action. This is an important action but it is not the first action. This is an important action but it is not the first action.

104. A nurse reads that the neonatal mortality rate in the United States for a given year was 5. The nurse interprets that information as: 1. 5 babies less than 28 days old per 1000 live births died. 2. 5 babies less than 1 year old per 1000 live births died. 3. 5 babies less than 28 days old per 100,000 births died. 4. 5 babies less than 1 year old per 100,000 births died.

1 The neonatal period is defined as the first 28 days of life. The neonatal mortality rate is defined as neonatal deaths per 1000 live births. There- fore, 5 babies less than 28 days old per 1000 live births died.

80. A client asks whether or not there are any foods that she must avoid eating while breastfeeding. Which of the following responses by the nurse is appropriate? 1. "No, there are no foods that are strictly contraindicated while breastfeeding." 2. "Yes, the same foods that were dangerous to eat during pregnancy should be avoided." 3. "Yes, foods like onions, cauliflower, broccoli, and cabbage make babies very colicky." 4. "Yes, spices from hot and spicy foods get into the milk and can bother your baby."

1 There are no foods that are absolutely contraindicated during lactation. Some babies may react to certain foods, but this must be determined on a case-by-case basis. Food restrictions are lifted once the baby is born. Some babies may be bothered by gas- producing foods, but this is not universal. Some babies may be bothered by hot and spicy foods, but this is not universal.

99. A 2-day-old baby's blood values are: blood type—O (negative). direct Coombs—(negative). hematocrit—50%. bilirubin—1.5 mg/dL. The mother's blood type is A. What should the nurse do? 1. Do nothing because the results are within normal limits. 2. Assess the baby for opisthotonic posturing. 3. Administer RhoGAM to the mother per doctor's order. 4. Call the doctor for an order to place the baby under bili-lights.

1 These findings are all within normal limits. There is no indication that this child has developed any signs of kernicterus, which is associated with opisthotonic posturing. The mother is Rh positive. Only mothers who are Rh negative and who deliver ba- bies who are Rh positive receive RhoGAM. The bilirubin level is very low. There is no indication that phototherapy is needed.

72. A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make? 1. Place a pillow in her lap. 2. Position the head of the baby in her elbow. 3. Put the baby on his back. 4. Move the breast toward the mouth of the baby.

1 This is true. The baby must be at the level of the breast in order to feed ef- fectively. In the cross-cradle position, the baby's head is in the mother's hand. The baby should be positioned facing the mother—"tummy-to-tummy." The baby should be brought to the mother. The mother should not move her body to the baby.

71. A breastfeeding mother who is 2 weeks postpartum is informed by her pediatrician that her 4-year-old has chickenpox (varicella). The mother calls the nursery nurse because she is concerned about having the baby in contact with the sick sibling. The mother had chickenpox as a child. Which of the following responses by the nurse is appropriate? 1. "The baby received passive immunity through the placenta, plus the breast milk will also be protective." 2. "The baby should stay with relatives until the ill sibling recovers from the episode of chickenpox." 3. "Chickenpox is transmitted by contact route so careful hand washing should prevent transmission." 4. "Because chickenpox is a spirochetal illness, both the child and baby should re- ceive the appropriate medications."

1 This statement is accurate. The baby has already been exposed to the chickenpox, including during the prodromal period. The baby received passive antibodies through the placenta and is now receiving antibodies via the breast milk; therefore, there is no need to remove the baby from the home. Chickenpox is highly contagious via droplet and contact routes. Chickenpox is transmitted via the herpes zoster virus

63. The nurse does not hear the baby swallow when suckling even though the baby ap- pears to be latched properly to the breast. Which of the following situations may be the reason for this observation? 1. The mother reports a pain level of 4 on a 5-point scale. 2. The baby has been suckling for over 10 minutes. 3. The mother uses the cross-cradle hold while feeding. 4. The baby lies with the chin touching the under part of the breast.

1 When the mother is anxious, overly fatigued, and/or in pain, the secretion of oxytocin is inhibited, and this, in turn, inhibits the milk ejection reflex and insufficient milk may be produced. If a baby is suckling effectively at the breast, the baby will swallow breast milk even after 10 minutes. The cross-cradle hold is one of the rec- ommended breastfeeding positions. Ideally, the baby's chin should touch the underside of the mother's breast.

46. A nurse is advising a couple of a newborn regarding when they should call their pe- diatrician. Which of the following responses show that the teaching was effective? Select all that apply. 1. If the baby repeatedly refuses to feed. 2. If the baby's breathing is irregular. 3. If the baby has no tears when he cries. 4. If the baby is repeatedly difficult to awaken. 5. If the baby's temperature is above 100.4oF.

1, 4, and 5 are correct. 1. Babies do not starve themselves. If a baby refuses to eat, it may mean that the baby is seriously ill. For example, babies with cardiac defects often refuse to eat. 2. Newborns normally breathe irregularly. Apnea spells of 10 seconds or less are normal. 3. Newborns do not tear when they cry. If a baby does tear, he or she may have a blocked lacrimal duct. 4. Although babies who are in the deep sleep state are difficult to arouse, the deep sleep state lasts no more than an hour. If the baby continues to be nonarousable, the pediatrician should be notified. 5. A temperature above 100.4oF is a febrile state for a newborn and the pediatrician should be notified.

98. The nursing management of a neonate with physiological jaundice should be di- rected toward which client care goal? 1. The baby shows no signs of kernicterus. 2. The baby does not develop erythroblastosis fetalis. 3. The baby has a bilirubin of 16 mg/dL on the day of discharge. 4. The baby spends at least 20 hours per day under phototherapy.

1. When bilirubin levels elevate to toxic levels, babies can develop kernicterus. Erythroblastosis fetalis is a syndrome re- sulting from the antigen-antibody reac- tion related to maternal-fetal blood in- compatibility. This bilirubin level is above the level most neonatalogists consider acceptable for discharge. Phototherapy is ordered when hyper- bilirubinemia is present or when the de- velopment of hemolytic jaundice is very likely.

55. A bottlefeeding mother is providing a return demonstration of how to burp the baby. Which of the following would indicate that further teaching is needed? 1. The woman gently strokes and pats her baby's back. 2. The woman positions the baby face down on her lap. 3. The woman waits to burp the baby until the baby's feeding is complete. 4. The woman states that a small amount of regurgitated formula is acceptable.

3. In the first few weeks of life, it is im- portant to burp babies frequently throughout feedings. Bottlefed babies often take in a great deal of air. Babies who burp only at the end of the feed often burp up large quantities of for- mula. Further teaching is needed.

70. On admission to the maternity unit, it is learned that a mother has smoked 2 packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following? 1. Breastfeeding is contraindicated if the mother smokes cigarettes. 2. Breastfeeding is protective for the baby and should be encouraged. 3. A 2-pack-a-day smoker should be reported to child protective services for child abuse. 4. A mother who admits to smoking cigarettes may also be abusing illicit substances.

2 Although it is recommended that the mother stop smoking, breastfeeding is not contraindicated when the mother smokes. This is true. Breastfeeding is protective of the baby and should be encouraged. Maternal smoking does not warrant a re- port to Child Protective Services (CPS). This statement is not true. There is no evidence to show that women who smoke at the time they deliver have a high inci- dence of illicit drug use.

69. A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate? 1. "That is correct. The rice cereal takes longer for them to digest so they sleep better and longer." 2. "It is recommended that babies receive only breast milk for the first 4 to 6 months of their lives." 3. "It is too early for rice cereal, but I would recommend giving the baby a bottle of formula at night." 4. "A better recommendation is to give apple sauce at 3 months of age and apple juice 1 month later."

2 Babies before the age of 4 to 6 months digest cereal poorly and may develop al- lergies from exposure to the proteins in the cereal. This is the correct response. It is recommended that babies receive breast milk at all feedings. When formula feeds are substituted, breastfeeding suc- cess is often compromised. Apple juice is added to the diet when rec- ommended by the pediatrician; usually well after cereals have been introduced.

43. The nurse has provided anticipatory guidance to a couple that has just delivered a baby. Which of the following is an appropriate short-term goal for the care of their new baby? 1. The baby will have a bath with soap every morning. 2. During a supervised play period, the baby will be placed on the tummy every day. 3. The baby will be given a pacifier after each feeding. 4. For the first month of life, the baby will sleep on its side in a crib next to the parents.

2 Babies do not need to have a full bath each day. Plus, daily soap baths can dry the newborn's skin. Tummy time, while awake and while supervised, helps to prevent plagio- cephaly and to promote growth and development. Pacifiers have been recommended by the AAP for sleep, but there is no recom- mendation that babies be given a pacifier after every feeding. It is strongly recommended that babies always be placed on their backs for sleep.

13. A baby boy is to be circumcised by the mother's obstetrician. Which of the follow- ing actions shows that the nurse is being a patient advocate? 1. Before the procedure, the nurse prepares the sterile field for the physician. 2. The nurse refuses to unclothe the baby until the doctor orders something for pain. 3. The nurse holds the feeding immediately before the circumcision. 4. After the procedure, the nurse monitors the site for signs of bleeding.

2 Circumcision is a surgical procedure that requires a sterile field and sterile tech- nique. The nurse is performing safe practice in this situation. The nurse is being a patient advocate since the baby is unable to ask for pain medication. The AAP has made a policy statement that pain medica- tions be used during all circumcision procedures. If a baby feeds immediately before the circumcision, he may aspirate his feeds. This is safe practice. To make sure the baby is not hemorrhag- ing at the incision site is also an example of safe nursing practice.

52. A baby has just been admitted into the neonatal nursery. Before taking the new- born's vital signs, the nurse should warm his or her hands and the stethoscope in order to prevent heat loss resulting from which of the following? 1. Evaporation. 2. Conduction. 3. Radiation. 4. Convection.

2 Heat loss resulting from evaporation oc- curs when the baby is wet and exposed to the air. Heat loss resulting from conduction occurs when the baby comes in con- tact with cold objects (hands or stethoscope). Heat lost resulting from radiation occurs when the baby is exposed to cool objects that the baby is not in direct contact with. Heat lost resulting from convection oc- curs when the baby is exposed to the movement of cooled air—for example, air conditioning currents.

40. A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be? 1. "Any powder made especially for babies should be fine." 2. "It is recommended that powder not be put on babies." 3. "There is no real difference except that many babies are allergic to cornstarch so it should not be used." 4. "As long as you only put it on the buttocks area, you can use any brand of baby powder that you like."

2 It is recommended that powders, even if advertised for the purpose, not be used on babies. It is recommended that powders, even if advertised for the purpose, not be used on babies. There is no evidence that most babies are allergic to cornstarch. It is irrelevant where the powder is being used; it is recommended that powders, even if advertised for the purpose, not be used on babies.

2. The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action? 1. Meconium is filled with enteric bacteria. 2. Amniotic fluid may contain harmful viruses. 3. The high alkalinity of fetal urine is caustic to the skin. 4. The baby is high risk for infection and must be protected.

2 Meconium is a sterile stool. Plus the new- born will not produce gastrointestinal bacteria until a few days after delivery. Amniotic fluid is a reservoir for viral diseases like HIV and hepatitis B. If the woman is infected with those viruses, the amniotic fluid will be infectious. Fetal urine is not highly alkaline. Although babies are at high risk for in- fection, there is no need for nurses to wear gloves routinely when caring for the babies. Immediately after delivery the nurse is protecting himself or herself from the baby, not the other way around.

84. A full-term neonate has brown adipose fat tissue (BAT) stores that were deposited during the latter part of the third trimester. What does the nurse understand is the function of BAT stores? 1. To promote melanin production in the neonatal period. 2. To provide heat production when the baby is hypothermic. 3. To protect the bony structures of the body from injury. 4. To provide calories for neonatal growth between feedings.

2 Melanin production is not related to the presence of BAT. Babies do not shiver. Rather, to pro- duce heat they utilize chemical ther- mogenesis, also called nonshivering thermogenesis. BAT is metabolized during hypothermic episodes to main- tain body temperature. Unfortunately, this can lead to metabolic acidosis. BAT is unrelated to injury prevention. Sufficient calories for growth are pro- vided from breast milk or formula.

6. A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal deliv- ery, questions the nurse because her baby's face is "purple." Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse's response should be based on which of the following? 1. Petechiae are indicative of severe bacterial infections. 2. Rapid deliveries can injure the neonatal presenting part. 3. Petechiae are characteristic of the normal newborn rash. 4. The injuries are a sign that the child has been abused.

2 Petechiae can be present as a result of an infectious disease; e.g., meningococ- cemia. In this situation, however, there is no indication that an infection is present. When neonates speed through the birth canal during rapid deliveries, the presenting parts become bruised. The bruising often takes the form of petechial hemorrhages. Erythema toxicum, the newborn rash, is characterized by papules or pustules on an erythematous base. There is nothing in the scenario to sug- gest that child abuse has occurred.

24. The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatalogist as soon as possible? 1. Blood in the diaper. 2. Grunting during expiration. 3. Deep red coloring on one side of the body with pale pink on the other side. 4. Lacy and mottled appearance over the entire chest and abdomen.

2 Pseudomenses is a normal finding in a 1-day-old female. Expiratory grunting is an indication of respiratory distress. This is a description of the harlequin sign, a normal neonatal finding. Neonates are often mottled when chilled. Unless other signs or symptoms are pres- ent, it is a normal finding.

21. Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? 1. Baby with respirations 42, oxygen saturation 96%. 2. Baby with Apgar 9/9, weight 4660 grams. 3. Baby with temperature 97.8oF, length 21 inches. 4. Baby with glucose 55 mg/dL, heart rate 121.

2 Respiratory rate between 30 and 60 and oxygen saturation above 95% are normal findings. Although the Apgar score—9—is excellent, the baby's weight—4660 grams—is well above the average of 2500 to 4000 grams. Babies who are large-for-gestational age are at high risk for hypoglycemia. Temperature 97.7o to 99oF and length 18 to 22 inches are normal findings. Blood glucose 40 to 60 mg/dL and heart rate 120 to 160 bpm are normal findings.

100. A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory re- ports a bilirubin assessment of 6.0 mg/dL. Which of the following would the nurse expect the neonatalogist to order for the baby at this time? 1. To be placed under phototherapy. 2. To be discharged home with the parents. 3. To be prepared for a replacement transfusion. 4. To be fed glucose water between routine feeds.

2 Since peak bilirubin levels are seen between days 3 and 5, and since the level is well within normal range, the nurse should expect that the baby will be discharged home with parents.

56. A breastfeeding baby is born with a tight frenulum. Which of the following is an important assessment for the nurse to make? 1. Integrity of the baby's uvula. 2. Presence of maternal nipple damage. 3. Presence of neonatal tongue injury. 4. The baby's breathing pattern.

2 The uvula and frenulum are distinctly different structures in the mouth. Babies who are tongue-tied—that is have a tight frenulum—have difficulty extending their tongues while breast- feeding. The mothers' nipples often become damaged as a result. A tight frenulum does not result in injury to the baby's tongue. There is no relationship between breath- ing ability and being tongue-tied.

23. A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response? 1. "The baby does rarely open his mouth but you can see that he isn't in any distress." 2. "Babies usually breathe in and out through their noses so they can feed without choking." 3. "Everything about babies is small. It truly is amazing how everything works so well." 4. "You are right. I will report the baby's small nasal openings to the pediatrician right away."

2 This is actually a true statement. Babies do rarely open their mouths to breathe when they are respiring. However, it is not the best response that the nurse could provide. This statement provides the mother with the knowledge that babies are obligate nose breathers in order to be able to suck, swallow, and breathe without choking. 3. Again, this statement is inherently true, but it is a meaningless platitude that will not satisfy the mother's need for information. 4. This response is inappropriate. Healthy newborns have small nares but aerate effectively as obligate nose breathers.

92. A nurse is about to administer the ophthalmic preparation to a newly born neonate. Which of the following is the correct statement regarding the medication? 1. It is administered to prevent the development of neonatal cataracts. 2. The medicine should be placed in the lower conjunctiva from the inner to outer canthus. 3. The medicine must be administered immediately upon delivery of the baby. 4. It is administered to neonates whose mothers test positive for gonorrhea during pregnancy.

2 This is the correct method of instilla- tion of the ophthalmic prophylaxis.

54. It is time for a baby, who is in the drowsy behavioral state, to breastfeed. Which of the following techniques could the mother use to arouse the baby? Select all that apply. 1. Swaddle or tightly bundle the baby. 2. Hand express milk onto the baby's lips. 3. Talk with the baby while making eye contact. 4. Remove the baby's shirt and change the diaper. 5. Play pat-a-cake with the baby.

2, 3, 4, and 5 are correct. 1. Babies who are in the drowsy behavioral state and who are tightly swaddled often fall asleep rather than become aroused. 2. The smell and/or the taste of the milk often will arouse a drowsy baby. 3. Drowsy babies will open their eyes when placed in the en face position and are interacted with. 4. Performing manipulations like diaper- ing or playing pat-a-cake often will arouse a drowsy baby. 5. Performing manipulations like diaper- ing or playing pat-a-cake often will arouse a drowsy baby.

50. A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the follow- ing needles could the nurse safely choose for the injection? 1. 5⁄8 inch, 18 gauge. 2. 5⁄8 inch, 25 gauge. 3. 1 inch, 18 gauge. 4. 1 inch, 25 gauge.

2. An 18-gauge needle is too thick to be used. A 5⁄8-inch, 25-gauge needle is an ap- propriate needle for a neonatal IM in- jection. A 1-inch needle is too long and the gauge is too thick. A 1-inch needle is too long.

41. The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included? 1. Clean the eyes from outer canthus to inner canthus. 2. Cleanse the ear canals with a cotton swab. 3. Assemble all supplies before beginning the bath. 4. Check temperature of the bath water with fingertips.

3. If items must be obtained while the bath is being given, the baby may be- come hypothermic from evaporation resulting from exposure to the air when wet.

85. A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? 1. Hemolysis of neonatal red blood cells by the maternal antibodies. 2. Physiological destruction of fetal red blood cells during the extrauterine period. 3. Pathological liver function resulting from hypoxemia during the birthing process. 4. Delayed meconium excretion resulting in the production of direct bilirubin.

2. With lung oxygenation, the neonate no longer needs large numbers of red blood cells. As a result, excess red blood cells (RBCs) are destroyed. Jaundice often results on days 2 to 4.

28. The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatalogist? 1. 1-day-old, HR 110 beats per minute in deep sleep. 2. 2-day-old, T 97.7oF, slightly jaundiced. 3. 3-day-old, breastfeeding every 4 hours, jittery. 4. 4-day-old, crying, papular rash on an erythematous base.

3

87. A nurse takes a Spanish-speaking Mexican woman her baby to breastfeed. The woman refuses to feed and makes motions like she wants to bottlefeed. Which of the following is a likely explanation for the woman's behavior? 1. She has decided not to breastfeed. 2. She thinks she must give formula before the breast. 3. She believes that colostrum is bad for the baby. 4. She thinks that she should bottlefeed.

3. It is a common belief among the women of many cultures, including Mexican, some Asian, and some Native Americans, that colostrum is bad for babies.

15. A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the infor- mation? 1. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide. 2. The mother covers the glans with antifungal ointment after rinsing off any discharge. 3. The mother squeezes soapy water from the wash cloth over the glans. 4. The mother replaces the dry sterile dressing before putting on the diaper.

3 . Antifungals are not indicated in this situation. 3. Squeezing soapy water over the penis cleanses the area without irritating the site and causing the site to bleed. 4. Dry dressings are not applied to the cir- cumcised penis. It is, however, usually recommended to liberally apply petro- leum jelly to the site before diapering. The petroleum jelly may be applied di- rectly to the penis via a sterile dressing or via a Vaseline-impregnated gauze

79. A woman states that she is going to bottlefeed her baby because, "I hate milk and I know that to make good breast milk I will have to drink milk." The nurse's re- sponse about producing high-quality breast milk should be based on which of the following? 1. The mother must drink at least 3 glasses of milk per day in order to absorb suf- ficient quantities of calcium. 2. The mother should consume at least 1 glass of milk per day but should also con- sume other dairy products like cheese. 3. The mother can consume a variety of good calcium sources like broccoli and fish with bones as well as dairy products. 4. The mother must monitor her protein intake more than her calcium intake because the baby needs the protein for growth.

3 1 The woman does not have to consume 3 glasses of milk per day. 2. It is unnecessary for the mother to con- sume any dairy products. 3. Dairy foods provide protein and other nutrients, including the important mineral calcium. The calcium can, however, be obtained from a number of other foods, such as broccoli and fish with bones. 4. Protein can be obtained from many other foods, including meat, poultry, rice, legumes, and eggs.

32. The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? 1. When the cheek of the baby is touched, the newborn turns toward the side that is touched. 2. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. 3. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. 4. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

3 1. This is a description of the rooting reflex. 2. This is a description of the Babinski reflex. 3. This is a description of the Moro reflex. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. 4. This is a description of the tonic neck reflex.

86. The pediatrician writes the following order for a term newborn: Vitamin K 1 mg IM. Which of the following responses provides a rationale for this order? 1. During the neonatal period, babies absorb fat-soluble vitamins poorly. 2. Breast milk and formula contain insufficient quantities of vitamin K. 3. The neonatal gut is sterile. 4. Vitamin K prevents hemolytic jaundice.

3 3. It takes about 1 week for the baby to be able to synthesize his or her own vitamin K. The gut, at birth, is sterile.

68. A mother is preparing to breastfeed her baby. Which of the following actions would encourage the baby to open the mouth wide for feeding? 1. Holding the baby in the en face position. 2. Pushing down on the baby's lower jaw. 3. Tickling the baby's lips with the nipple. 4. Giving the baby a trial bottle of formula.

3 3. Tickling the baby's lips with the nip- ple is the recommended method of encouraging a baby to open his or her mouth for feeding.

18. A neonate is being admitted to the well-baby nursery. Which of the following find- ings should be reported to the neonatalogist? 1. Umbilical cord with three vessels. 2. Diamond-shaped anterior fontanelle. 3. Cryptorchidism. 4. Café au lait spot.

3 A 3-vessel cord is a normal finding. 2. The anterior fontanelle is diamond- shaped. 3. Undescended testes—cryptorcidism— is an unexpected finding. It is one sign of prematurity. 4. Although multiple café au lait spots are seen in some neurological anomalies, the presence of one area of pigmentation is a normal finding.

31. A neonate is admitted to the nursery. The nurse makes the following assessments: weight 3845 grams, head circumference 35 cm, chest circumference 33 cm, positive Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be reported to the health care practitioner? 1. Birth weight. 2. Head and chest circumferences. 3. Ortolani sign. 4. Supernumerary nipples.

3 The circumferences are within normal limits. The head circumference should be 32 to 37 cm and the chest circumference 1 to 2 cm smaller than the head. 3. A positive Ortolani sign indicates a likely developmental dysplasia of the hip. In Ortolani sign, the thighs are gently abducted. If the trochanter dis- places from the acetabulum, the result is positive and indicative of develop- mental dysplasia of the hip. 4. Supernumerary nipples are normal. They appear on the mammary line. Usually only the primary nipples mature.

37. A neonate, who is being admitted into the well-baby nursery, is exhibiting each of the following assessment findings. Which of the findings must the nurse report to the primary health care provider? 1. Harlequin sign. 2. Extension of the toes when the lateral aspect of the sole is stroked. 3. Elbow moves past the midline when the scarf sign is assessed. 4. Telangiectatic nevi.

3 When the scarf sign is assessed, a premature baby would be able to move the elbow past the midline. A full-term baby would not be able to do this.

59. Which short-term goal is appropriate for a full-term, breastfeeding neonate? 1. The baby will regain birth weight by 4 weeks of age. 2. The baby will sleep through the night by 4 weeks of age. 3. The baby will stool every 3 to 4 hours by 1 week of age. 4. The baby will urinate 6 to 10 times per day by 1 week of age.

4 Breastfed babies usually regain their birth weights by about day 10. Rarely do babies sleep through the night by 4 weeks of age. By 1 week of age, breastfed babies should have 3 bright yellow stools in every 24- hour period, although some babies do stool more frequently. By 1 week of age, breastfed babies should be urinating at least 6 times in every 24-hour period.

1. The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that more teaching is needed when the mother states that which of the following diseases is included in the screening test? 1. Hypothyroidism. 2. Sickle cell anemia. 3. Galactosemia. 4. Cerebral palsy.

4 1. Congenital hypothyroidism is a malfunc- tion of or complete absence of the thy- roid gland that is present from birth. It is screened for in all 50 states. 2 Sickle cell disease is an autosomal reces- sive disease resulting in abnormally shaped red blood cells. It is screened for in all 50 states. 3 Galactosemia is an incurable autosomal recessive disease characterized by the ab- sence of the enzyme required to metabo- lize galactose. It is screened for in all 50 states. 4 Cerebral palsy (CP) is a disorder characterized by motor dysfunction resulting from a nonprogressive injury to brain tissue. The injury usually oc- curs during labor, delivery, or shortly after delivery. Physical examination is required to diagnose CP. Blood screening is not an appropriate means of diagnosis.

77. A physician writes in a breastfeeding mother's chart, "Ampicillin 500 mg q 6 h po. Baby should be bottlefed until medication is discontinued." What should be the nurse's next action? 1. Follow the order as written. 2. Call the doctor and question the order. 3. Follow the antibiotic order but ignore the order to bottlefeed the baby. 4. Refer to a text to see whether the antibiotic is safe while breastfeeding

4 1. Most medications are safely consumed by the breastfeeding mother. To blindly follow this order is poor practice. 2. Ultimately, this probably will be the nurse's action but he or she must have a rationale for questioning the order. 3. It is unacceptable to completely ignore an order even though the nurse may dis- agree with the order. 4. Once the reference has been consulted, the nurse will have factual information to relay to the physician—specifically that ampicillin is compatible with breastfeeding. A call to the doctor would then be appropriate.

89. The nurse observes a healthy woman of African descent expressing breast milk into her baby's eyes. Which of the following responses by the nurse is appropriate at this time? 1. Report the abusive behavior to the social worker. 2. Advise the mother that her action is potentially dangerous. 3. Observe the mother for other signs of irrational behavior. 4. Ask the woman about other cultural traditions.

4 1. This is not an example of abusive behavior. 2. Since the mother is healthy, this is not a potentially dangerous action. 3. This behavior is not irrational for a woman of African descent. 4. In Africa, breast milk is often ex- pressed into babies' eyes to prevent neonatal eye infections. Asking the woman about other cultural traditions is appropriate.

91. A 2-day-old neonate received a vitamin K injection at birth. Which of the following signs/symptoms in the baby would indicate that the treatment was effective? 1. Skin color is pink. 2. Vital signs are normal. 3. Glucose levels are stable. 4. Blood clots after heel sticks.

4 2. The therapeutic action of vitamin K is The therapeutic action of vitamin K is not related to skin color. not related to vital signs. 3. The therapeutic action of vitamin K is not related to glucose levels. 4. Vitamin K is needed for adequate blood clotting.

88. The nurse enters a Latin woman's postpartum room and notes that her neonate is wearing a hat and is covered in three blankets. The room temperature is 70oF. The nurse's action should be based on which of the following? 1. Overdressing babies is common in some cultures and should be ignored. 2. The mother has dressed the baby appropriately for the room temperature. 3. The nurse should drop the room temperature since the baby is overdressed. 4. Overheating is dangerous for neonates and the extra clothing should be removed.

4 4. The clothing should be removed and the mother should be educated about SIDS and about the correlation be- tween overheating and SIDS.

48. A mucousy baby is being left with the parents for the first time after delivery. Which of the following should the nurse teach the parents regarding use of the bulb syringe? 1. Suction the nostrils before suctioning the mouth. 2. Make sure to suction the back of the throat. 3. Insert the syringe before compressing the bulb. 4. Dispose of the drainage in a tissue or a cloth.

4 4. The drainage should be evaluated by the nurse. The drainage, therefore, should be disposed of in a tissue or cloth.

76. A newly delivered mother states, "I have not had any alcohol since I decided to be- come pregnant. I have decided not to breastfeed because I would really like to go out and have a good time for a change." Which of the following is the best re- sponse by the nurse? 1. "I understand that being good for so many months can become very frustrating." 2. "Even if you bottlefeed the baby, you will have to refrain from drinking alcohol for at least the next six weeks to protect your own health." 3. "Alcohol can be consumed at any time while you are breastfeeding." 4. "You may drink alcohol while breastfeeding, although it is best to wait until the alcohol has been metabolized before you feed again."

4 Alcohol is found in the breast milk in exactly the same concentration as in the mother's blood. Alcohol consump- tion is not, however, incompatible with breastfeeding. The woman should breastfeed immediately before consuming a drink and then wait 1 to 2 hours to metabolize the drink be- fore feeding again. If she decides to have more than one drink ,she can pump and dump her milk for a feed- ing or two.

34. The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatalogist? 1. The eyes cross and uncross when they are open. 2. The ears are positioned in alignment with the inner and outer canthus of the eyes. 3. Axillae and femoral folds of the baby are covered with a white cheesy substance. 4. The nostrils flare whenever the baby inhales.

4 Pseudostrabismus—eyes cross and un- cross when they are open—is normal in the neonate because of poor tone of the muscles of the eye. Ears positioned in alignment with the inner and outer canthus of the eyes is the normal position. In Down syndrome, ears are low set. Vernix caseosa covers and protects the skin of the fetus. Depending on the ges- tational age of the baby, there is often some left on the skin at birth. Nasal flaring is a symptom of respira- tory distress.

30. Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neona- talogist to evaluate? 1. The neonate with a temperature of 97.9oF and weight of 3000 grams. 2. The neonate with white spots on the bridge of the nose. 3. The neonate with raised white specks on the gums. 4. The neonate with respirations of 72 and heart rate of 166.

4 The normal temperature of a neonate is 97.5o to 99.5oF and the weight of a term neonate is between 2500 and 4000 grams. 2. Milia—white spots on the bridge of the nose—are exposed sebaceous glands. They are normal. 3. Epstein's pearls—raised white specks on the gums or on the hard palate—are nor- mal findings in the neonate. 4. The normal resting respiratory rate of a neonate is 30 to 60 and the normal resting heart rate of a neonate is 110 to 160.

14. Using the Neonatal Infant Pain Scale (NIPs), a nurse is assessing the pain response of a newborn who has just had a circumcision. A change in which of the following signs/symptoms is the nurse evaluating? Select all that apply. 1. Heart rate. 2. Blood pressure. 3. Temperature. 4. Facial expression. 5. Breathing pattern.

4 and 5 are correct. 1. Although assessed in other pain scales, the heart rate is not part of the NIPS scale. 2. Blood pressure is not assessed in any in- fant pain scale. 3. Temperature is not assessed in any infant pain scale. 4. Facial expression is one variable that is evaluated as part of the NIPS scale. 5. Breathing pattern is one variable that is evaluated as part of the NIPS scale.

62. The parents and their full-term, breastfed neonate were discharged from the hospi- tal. Which behavior 2 days later indicates a positive response by the parents to the nurse's discharge teaching? 1. The parents weigh their baby's diapers. 2. The parents measure the baby's intake. 3. The parents give one bottle of formula every day. 4. The parents take the baby to see the pediatrician.

4. The baby should be seen by the pedi- atrician.

67. A newborn was born weighing 3278 grams. On day 2 of life, the baby weighed 3042 grams. What percent of weight loss did the baby experience? _______ %

To determine how many grams the baby has lost, the test taker must subtract the new weight from the birth weight: 3278 3042 236 grams of weight loss Then, to determine the percentage of weight loss, the test taker must divide the difference by the original weight and multiply by 100%: 236 0.0719 3278 0.0719 1007.19%