OB EXAM 3 Review

A nurse is assessing a newborn 1 hr after birth. which of the following respiratory rates is within the expected reference range for a newborn? a) 22/min b) 48/min c) 100/min d) 110/min

48/min Rationale: The expected reference range for a newborn's resting respiratory rate is 30 to 60/min.

***A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant? 8

8 2x HR, muscle tone, reflex irritability + 1x weak cry, acrocyanosis

***A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.) A. "I'll expect the plastic ring to fall off by itself within a week." B. "I'll apply petroleum jelly to his penis with diaper changes." C. "I'll wash his penis with warm water and mild soap each day." D. "I'll call the doctor if I see any bleeding." E. "I'll make sure his diaper is loose in the front."

A. "I'll expect the plastic ring to fall off by itself within a week." D. "I'll call the doctor if I see any bleeding." E. "I'll make sure his diaper is loose in the front."

A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching? A. "My baby will be placed under special lights if the test result is positive." B. "My baby needs to be on formula or breast milk before the test can be done." C. "This test checks for a genetic disorder that can be managed by diet." D. "Sometimes the test is repeated in the doctor's office at the baby's 2-week check-up."

A. "My baby will be placed under special lights if the test result is positive." Rationale: Phototherapy is used to reduce circulating unconjugated bilirubin in infants who have hyperbilirubinemia. Phototherapy for hyperbilirubinemia uses light energy to lower the bilirubin level in the newborn's blood. This would not be appropriate therapy for PKU.

A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide? A. "This infection is treated with one dose of azithromycin." B. "If your sexual partner has no symptoms, no medication is needed." C. "You have to avoid sexual relations for 3 days." D. "You need to return in 6 months for retesting."A. "This infection is treated with one dose of azithromycin." Rationale: A single dose of azithromycin is an appropriate treatment for a chlamydial infection. An acceptable alternative is doxycycline twice a day for 7 days.

A. "This infection is treated with one dose of azithromycin." Rationale: A single dose of azithromycin is an appropriate treatment for a chlamydial infection. An acceptable alternative is doxycycline twice a day for 7 days.

***A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make? A. "You should place your nipple and some of the areola into her mouth." B. "Babies know instinctively how much of the nipple to take into their mouth." C. "Your baby's mouth is rather small so she will only take part of the nipple." D. "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth."

A. "You should place your nipple and some of the areola into her mouth." Rationale: Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby's mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness.

A nurse is instructing a male client about a semen analysis to be done for suspected infertility. Which of the following should be included in the teaching? A. Abstain from ejaculation for at least 2 to 5 days prior to the test. B. Refrigerate the specimen after collection. C. Leave the specimen at room temperature for 3 to 4 hr prior to transport to the laboratory. D. Collect the specimen using a condom with spermicidal lubricant.

A. Abstain from ejaculation for at least 2 to 5 days prior to the test. Rationale: The client should be instructed to abstain from ejaculation for at least 2 to 5 days prior to the test.

***A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn? A. Cold stress B. Shivering C. Basal metabolic rate reduction D. Brown fat production

A. Cold stress

A nurse in a college health clinic is speaking to a group of adolescents about toxic shock syndrome (TSS). Which of the following should the nurse include in the teaching as increasing the risk for contracting TSS? A. High-absorbency tampons B. Mosquito bites C. Travel to foreign countries D. Multiple sexual partnersA. High-absorbency tampons Rationale: Toxic shock syndrome, a severe disease caused by a toxin made by Staphylococcus aureus, is characterized by shock and multiple organ dysfunction. Approximately 50% of all cases involve menstruating women using highly absorbent tampons.

A. High-absorbency tampons Rationale: Toxic shock syndrome, a severe disease caused by a toxin made by Staphylococcus aureus, is characterized by shock and multiple organ dysfunction. Approximately 50% of all cases involve menstruating women using highly absorbent tampons.

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following? A. Hyperinsulinemia B. Increased deposits of fat in the chest and shoulder area C. Brachial plexus injury D. Increased blood viscosity

A. Hyperinsulinemia Rationale: High levels of maternal glucose increase the production of fetal insulin. High fetal insulin levels interfere with the production of surfactant.

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care? A. Hypoglycemia B. Hypomagnesemia C. Hyperbilirubinemia D. Hypocalcemia

A. Hypoglycemia Rationale: Newborns of mothers who have diabetes are at high risk for hypoglycemia due to the loss of high levels of glucose after the umbilical cord is cut. This results in fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the lower level of blood glucose. Because severe hypoglycemia can lead to cyanosis and seizures, prevention of hypoglycemia becomes the nurse's priority focus of care.

***A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta? A. Increased blood pressure in the arms with decreased blood pressure in the legs B. Decreased blood pressure in the arms with increased blood pressure in the legs C. Increased blood pressure in both the arms and the legs D. Decreased blood pressure in both the arms and the legs

A. Increased blood pressure in the arms with decreased blood pressure in the legs Rationale: There is a narrowing next to the ductus arteriosus that results in an increased pressure proximal to the defect, with a decreased pressure distal to the obstruction. Therefore, an increased blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta.

A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following? A. Maternal/newborn blood group incompatibility B. Absence of vitamin K C. Physiologic jaundice D. Maternal cocaine abuse

A. Maternal/newborn blood group incompatibility Rationale: Maternal/newborn blood group incompatibility is the most common form of pathologic jaundice and the jaundice appears within the first 24 hr of life.

A A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care? A. Observe for meconium in respiratory secretions. B. Monitor for hyperglycemia. C. Identify manifestations of anemia. D. Monitor for hyperthermia.

A. Observe for meconium in respiratory secretions. Rationale: When a fetus is SGA, there is an increased risk for intrauterine hypoxia due to the presence of meconium in the amniotic fluid. The nurse should observe for meconium in respiratory secretions when suctioning the newborn at delivery. Newborns who are SGA are at risk for perinatal asphyxia due to the stress of labor and are often depressed. They require careful resuscitation and suctioning at delivery.

***A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet? A. Peanut butter B. Potatoes C. Apple juice D. Broccoli

A. Peanut butter Rationale: The nurse should instruct the client to eliminate protein-rich foods that contain phenylalanine from the diet. These include meats, eggs, milk, nuts, and wheat products.

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find? A. Over-riding suture lines B. Dilated scalp veins C. Hypertension D. A backward sloping appearance of the forehead.

B. Dilated scalp veins Rationale: Manifestations of hydrocephalus in newborns include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement.

***A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions? A. Perform a sharp hand clap near the infant. (its also dropping baby at 30 degree angle from supine position) b. hold the newborn vertically allowing one foot to touch the table surface c. place a finger at the base of the newborn's toes d. turn the newborn's head quickly to one side

A. Perform a sharp hand clap near the infant. rationale: to elicit the moro reflex, the nurse performs. a sharp hand clap near the newborn and observes symmetric abduction and extension of the arms, fanning of the fingers with the thumb and forefinger to form a C, and then a return to a relaxed flexion position

***A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition? A. Placental insufficiency B. Preterm delivery C. Fetal hyperinsulinemia D. Perinatal asphyxia

A. Placental insufficiency Rationale: Placental insufficiency is a cause of small for gestational age. It can result from maternal infections, embryonic placental deficiency, teratogens, or chromosomal abnormalities.

A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider? A. Poor sucking B. Blue coloring of the hands and feet C. Soft, edematous area on the scalp D. Facial edema

A. Poor sucking Rationale: Vacuum-assisted birth involves attaching a vacuum cup to the fetal head and using negative pressure to assist in the birth of the head, placing the newborn at risk for a subdural hematoma. The nurse should report manifestations of cerebral irritation, such as listlessness and poor sucking to the provider.

A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority? A. Respiratory distress B. Hypothermia C. Accidental lacerations D. Acrocyanosis.

A. Respiratory distress Rationale: Shortly before labor, there is a decreased production of fetal lung fluid and a catecholamine surge that promotes fluid clearance from the lungs. Newborns born by cesarean, in which labor did not occur, can experience lung fluid retention, which leads to respiratory distress. The priority assessment when using the airway, breathing, circulation (ABC) approach to client care is to monitor the newborn for respiratory distress.

***A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do when her * newborn cries persistently. Which of the following strategies should the nurse suggest? (Select all that apply.) A. Take the newborn for a ride in the car. B. Keep the newborn in the center of a large crib. C. Carry the newborn in a front or back pack. D. Swaddle the newborn in a receiving blanket. E. Allow the newborn to continue crying.

A. Take the newborn for a ride in the car. C. Carry the newborn in a front or back pack. D. Swaddle the newborn in a receiving blanket.

***A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select all that apply.) A. Transverse palmar creases B. Large ears C. Muscular hypertonicity D. Protruding tongue E. Low birth weight

A. Transverse palmar creases D. Protruding tongue

A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching? A. Vaginal intercourse can be resumed after 2 weeks. B. Products of conception will be present in vaginal bleeding. C. Increased intake of zinc-rich foods is recommended. D. Aspirin may be taken for cramps.

A. Vaginal intercourse can be resumed after 2 weeks. Rationale: The client should avoid vaginal intercourse and the use of tampons for 2 weeks following discharge.

***A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the * medication into which of the following muscles? A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal D. Deltoid

A. Vastus lateralis Rationale: The nurse should administer vitamin K, or phytonadione, into the vastus lateralis muscle in the thigh. This medication prevents and treats hemorrhagic disease of the newborn, as newborns are born with vitamin K deficiency.

***A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply.) A. Vitamin K injection B. Hepatitis B immunization C. Antibiotic ointment to both eyes D. Lidocaine gel to the umbilical stump E. Haemophilus influenza type b immunization (Hib)

A. Vitamin K injection B. Hepatitis B immunization C. Antibiotic ointment to both eyes

A nurse is reviewing the health history of a client who has a new prescription for a combined oral contraceptive & (COC). The nurse recognizes that which of the following client medications can interfere with the effectiveness of the COC? A. Antihypertensives B. Anticonvulsants C. Antioxidants D. Antiemetics

B. Anticonvulsants Rationale: Anticonvulsants when taken simultaneously with COCs can decrease their effectiveness. The anticonvulsants included are: phenytoin, phenobarbital, carbamazepine, oxcarbazepine, topiramate, and primidone.

A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority? A. Platelets 200,000/mm3 B. Bilirubin 19 mg/dL C. Blood glucose 45 mg/dL D. Hemoglobin 22 g/dL

B. Bilirubin 19 mg/dL Rationale: Bilirubin 19 mg/dL is above the expected reference range for a newborn at 4 hr of age. A bilirubin level greater than 15 mg/dL or an increase by more than 6 mg/dL in 24 hr is pathologic or nonphysiologic jaundice. Pathologic jaundice is a result of an underlying disease and occurs before 24 hr of age; therefore, this is the nurse's priority finding.

****A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? a. "Mongolian spots can be found on the skin of many newborns." B. "A caput succedaneum occurs due to compression of blood vessels." c. "This is a cephalhematoma, which can occur spontaneously." cross the suture line. It appears after the birth and will take 3 to 6 weeks to resolve. D. "This is erythema toxicum, which is a transient condition."

B. "A caput succedaneum occurs due to compression of blood vessels." Rationale: A caput succedaneum is an area of edema on the newborn's occiput, often seen where the cup of the vacuum was applied. It is present at birth and will disappear within 3 to 4 days.

***A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching? A. "I will place my baby on his stomach when he is sleeping." B. "I should remove extra blankets from my baby's crib." C. "I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps." D. "I should place my baby's crib next to the heater to keep him warm during the winter."

B. "I should remove extra blankets from my baby's crib." Rationale: Loose bedding such as sheets and blankets could cover the baby's head and lead to suffocation

A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse? A. "Fertilization takes place in the outer third of the fallopian tube." B. "Implantation occurs between 2 and 3 weeks after conception." C. "Sperm remain viable in the woman's reproductive tract for 2 to 3 days." D. "Bleeding or spotting can accompany implantation."

B. "Implantation occurs between 2 and 3 weeks after conception." Rationale: This statement requires clarification because implantation occurs between 6 to 10 days following conception.

A nurse is providing teaching about newborn care to a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching? A. "I should keep my baby's head covered." B. "My baby's temperature will be checked rectally every hour." C. "I should place my baby on my stomach and cover her with a warm blanket." D. "My baby's bassinet should be kept away from fans and air conditioning."

B. "My baby's temperature will be checked rectally every hour." Rationale: The newborn's axillary temperature should be checked every hour until the newborn's temperature stabilizes. Frequent rectal temperature checks are not recommended and can lead to rectal mucosal injury.

***A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? A. Ask another nurse to verify the heart rate. B. Document this as an expected finding. C. Call the provider to further assess the newborn. D. Prepare the newborn for transport to the NICU.

B. Document this as an expected finding. Rationale: The expected reference range for an apical pulse in a newborn who is awake is 120 to 160/min. The nurse should document this as an expected finding.

A nurse is completing an assessment of a 1-month-old newborn. Which of the following developmental skills is an expected finding? A. Displays a social smile B. Follows movements of objects with eyes C. Reacts to sounds by turning head D. Makes babbling sounds

B. Follows movements of objects with eyes Rationale: A 1-month-old infant is able to follow movements with their eyes.

***A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan* of care to prevent jaundice? A. Begin phototherapy. B. Initiate early feeding. C. Suction excess mucus with a bulb syringe. D. Prepare for an exchange blood transfusion.

B. Initiate early feeding. Rationale: Prevention of jaundice can be facilitated best by early and frequent feeding, which stimulates intestinal activity and passage of meconium. Jaundice occurs due to elevated serum bilirubin, which is excreted primarily in the newborn's stool. Physiologic jaundice manifests after 24 hr and is considered benign. However, bilirubin may accumulate to hazardous levels and lead to a pathologic condition.

A nurse is caring for a preterm newborn who has a nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following? A. Overstimulation B. Necrotizing enterocolitis C. Need for placement of a gastrostomy tube D. Intraventricular hemorrhage

B. Necrotizing enterocolitis Rationale: Premature newborns who are formula fed are much more likely to contract this acute inflammatory disease of the gastrointestinal mucosa.

***A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care? A. Obtain rectal temperatures. B. Place the newborn in the prone position. C. Cover the lesion with a dry dressing. D. Apply snug, clean diapers.

B. Place the newborn in the prone position. Rationale: Placing the newborn in the prone position prevents trauma to the lesion. The newborn's knees should be assessed for evidence of skin breakdown

***A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority? A. Suction the nose with a bulb syringe. B. Suction the mouth with a bulb syringe. C. Use a suction catheter with low negative pressure. D. Turn the newborn on his side.

B. Suction the mouth with a bulb syringe. Rationale: The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.

A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. Which of the following should the nurse expect? A. Cyanosis with crying B. Systolic murmur C. Weak pulses D. Chronic hypoxemia

B. Systolic murmur Rationale: A patent ductus arteriosus is failure of the artery connecting the aorta and pulmonary artery to close after birth, causing a left-to-right shunt. A systolic murmur is a clinical manifestation found in newborns who have a large patent ductus arteriosus.

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching? A. "I will use mild soap." should not be used on the face. B. "I will use a basin during bathing." C. "Baby powder will help prevent a diaper rash." D. "I will test the water on my wrist for temperature before bathing."

C. "Baby powder will help prevent a diaper rash." Rationale: Lotions, creams, oils, or powders can alter a newborn's skin and provide a medium for bacterial growth or cause an allergic response. Powders can be inhaled, leading to respiratory distress. This statement requires the nurse to clarify instruction on newborn care.

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make? A. "You are so young. Are you ready for the responsibilities of a sexual relationship?" B. "Because of your age, I think that a barrier method would be the best choice." C. "Before I can help you, I need to know more about your sexual activity." D. "A provider can help you with that after a physical examination."

C. "Before I can help you, I need to know more about your sexual activity." Rationale: This is an example of providing a general lead when using therapeutic communication. It allows the client to provide information that will enhance effective consultation about the best form of contraception for her.

A nurse is teaching about nutrition guidelines to a parent of a newborn. Which of the following statements by the parent indicates understanding of the teaching? A. "I should start solid foods when my baby is 3 months old." B. "I should introduce cow's milk when my baby is 9 months old." C. "I should wait to give fruit juice until my baby is 6 months of age." D. "I should wait to begin fluoride supplements until my baby is 4 months of age."

C. "I should wait to give fruit juice until my baby is 6 months of age." Rationale: Fruit juice provides minimal nutritional value to the infant's diet. Therefore, fruit juices should be limited and not offered until the infant is 6 months of age.

A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction? A. "I will keep my baby's head elevated while he is feeding." B. "I will allow my baby to burp several times during each feeding." C. "I will tip the nipple so air is present as my baby sucks." D. "My baby will have soft, formed yellow stools."

C. "I will tip the nipple so air is present as my baby sucks." Rationale: The nipple should be held so it fills only with formula. The infant should not be permitted to suck air.

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make? A. "There is no need to worry about that. Most forms of hearing loss are not inherited." B. "Look at how she looks as you when you speak. That's a good sign." C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." hearing loss, but determine whether or not a newborn requires further evaluation. D. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles."

C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." Rationale: Most states mandate hearing screening for all newborns. The two tests in use do not diagnose hearing loss, but determine whether or not a newborn requires further evaluation.

A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection, and will need intravenous antibiotic therapy. The client tells the nurse, "My parents think I am a virgin. I don't think I can tell them I have this kind of an infection." Which of the following responses should the nurse make? A. "Give your parents a chance; they'll understand." B. "If you want me to, I can tell your parents for you." C. "You seem scared to talk to your parents." D. . "Your parents will have to be told why you are being admitted."

C. "You seem scared to talk to your parents." Rationale: This is an open-ended therapeutic statement that focuses on the adolescent's concern and allows for further exploration of the client's fear of telling her parents that she is sexually active.

***A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care? A. Position the newborn to promote extension of muscles. B. Use fingertips when calming the newborn. C. Cluster the newborn's care activities. D. Keep the newborn in a well-lit nursery.C. Cluster the newborn's care activities. Rationale: By clustering activities and organizing care, the nurse prevents excessive interruptions and allows the newborn extended periods of rest and energy conservation that promote development.

C. Cluster the newborn's care activities. Rationale: By clustering activities and organizing care, the nurse prevents excessive interruptions and allows the newborn extended periods of rest and energy conservation that promote development.

***A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? A. Placing the newborn on a warm surface b. Preventing air drafts C. Drying the newborn's skin thoroughly D. Maintaining ambient room temperature at 24° C (75° F)

C. Drying the newborn's skin thoroughly Rationale: Heat loss through evaporation occurs when moisture on the skin is converted to a vapor. This process is the most significant cause of heat loss in the first few days of life but is minimized by quickly and thoroughly drying the infant

***A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? A. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months B. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen C. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth D. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days

C. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth Rationale: A newborn whose mother is positive for the hepatitis B surface antigen should receive both the hepatitis B vaccine and the hepatitis B immune globulin within 12 hr of birth.

.A nurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature? a) Phosphatidylglycerol (PG) absent B. Biophysical profile score of 8 C. Lecithin/sphingomyelin (L/S) ratio of 2:1 D. Nonstress test is reactiveC. Lecithin/sphingomyelin (L/S) ratio of 2:1Rationale: An L/S ratio of 2:1 is an indication of fetal lung maturity.

C. Lecithin/sphingomyelin (L/S) ratio of 2:1 Rationale: An L/S ratio of 2:1 is an indication of fetal lung maturity.

***A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis? A. Absent bowel sounds B. Increased sodium levels C. Projectile vomiting after feedings D. Golf ball-sized mass over the left quadrant

C. Projectile vomiting after feedings Rationale: Pyloric stenosis is a narrowing and thickening of the pyloric canal between the stomach and the duodenum, resulting in projectile vomiting

A nurse is reinforcing teaching about contraceptive methods with a client. Which of the following should the nurse recognize as a contraindication for diaphragm use? A. The client is 42 years old. B. The client smokes cigarettes. C. The client has pelvic relaxation. D. The client has a 3-month-old infant.

C. The client has pelvic relaxation. Rationale: Pelvic relaxation and large cystocele are contraindications for diaphragm use.

***A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention* by the nurse? A. A pink rash appears on the newborn's trunk. B. The newborn's eyes are covered with a mask. C. The mother applies lotion to the newborn's skin. D. The newborn's stools increase in number.

C. The mother applies lotion to the newborn's skin. Rationale: Lotions and ointments should not be applied as they can absorb heat and cause burns.

A nurse is caring for a client who is considering several methods of contraception. which of the following methods of contraception should the nurse identify as being most reliable? a) male condom B. An intrauterine device (IUD) C. An oral contraceptive D. A diaphragm with spermicide.

Rationale: An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most reliable methods of contraception.

A nurse is caring for a client who is 16 -hr postpartum and states "My baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse provide? A. "Most new mothers feel somewhat anxious about things like this." B. "There's nothing for you to worry about. Newborns often breathe this way." C. "Why do you think there is something wrong with that?" D. "Let's sit here together and observe your baby while you feed him."

D. "Let's sit here together and observe your baby while you feed him."

***A nurse is reviewing contraception options for four clients. The nurse should identify that which of the following clients has a contraindication for receiving oral contraceptives? A. A 26-year-old client who has migraine headaches at the start of each menstrual cycle B. A 28-year-old client who has a history of pelvic inflammatory disease C. A 32-year-old client who has benign breast disease D. A 38-year-old client who reports smoking one pack of cigarettes every day

D. A 38-year-old client who reports smoking one pack of cigarettes every day Rationale: A client who is over the age of 35 and smokes is at increased risk of thromboembolism.

***A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect? A. Absent plantar reflexes B. Lengthened thigh on the affected side C. Inwardly turned foot on the affected side D. Asymmetric thigh folds

D. Asymmetric thigh folds Rationale: Gluteal and thigh skin folds that are not equal and symmetric is a sign of DDH.

*** A nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following* interventions should the nurse suggest? A. Apply mineral oil to the nipples between feedings. B. Keep the nipples covered between breastfeeding sessions. C. Increase the length of time between feedings. D. Change the newborn's position on the nipples with each feeding.

D. Change the newborn's position on the nipples with each feeding. Rationale: When the client's nipple is sore due to breastfeeding, the client should break the suction with her finger, remove the newborn from the breast, and try a different position. The newborn's mouth should be open wide before connecting with the nipple.

A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant? A. Remove the hood every hour for 10 min to facilitate bonding. B. Insert an orogastric tube for decompression of the stomach. C. Place the newborn in Trendelenburg position. D. Maintain oxygen saturations between 93% to 95%.

D. Maintain oxygen saturations between 93% to 95%. Rationale: Rates of retinopathy of prematurity and bronchopulmonary dysplasia in preterm newborns are reduced if oxygen saturations are maintained between 93% and 95%.

***A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene? A. The mother cleans the newborn's eyes from the inner canthus outwards. B. The mother cleans the umbilical cord with tap water. C. The mother leaves the yellow exudate on the circumcision site. D. The mother plans to use a cotton-tipped swab to clean the nares.

D. The mother plans to use a cotton-tipped swab to clean the nares. Rationale: To prevent injury, the mother should use the corner of a washcloth to clean the newborns ears and nares.

A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition? A. Moist skin B. Protruded abdomen C. Gray umbilical cord D. Wide skull sutures

D. Wide skull sutures Rationale: Newborns who are SGA have wide skull sutures due to inadequate bone growth. Head circumference is smaller than in a normal newborn and there is reduced brain capacity.

A nurse is caring for a client who just delivered a newborn. following the delivery, which nursing action should be done first to care for the newborn? a) clear the respiratory tract b) dry the infant off and cover the head c) stimulate the infant cry d) cut the umbilical cord

a) clear the respiratory tract

***A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia * due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons? A) The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. B) The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. C. The client has a history of receiving a transfusion with Rh-negative blood. D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.

The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. Rationale: If the Rh-negative client has been exposed to Rh-positive fetal blood, she will produce antibodies against Rh factor. These antibodies can cross the placenta and destroy the red blood cells of the Rh-positive fetus. This accelerated rate of red blood cell destruction results in the increased release of bilirubin. The newborn's serum bilirubin level can rise quickly.

***A nurse is preparing to assess a newborn who is post mature. which of the following findings should the nurse expect? SATA a) cracked, peeling skin b) positive moro reflex c) short, soft fingernails d) abundant lanugo e) vernix in the folds and creases

a) cracked, peeling skin b) positive moro reflex Cracked, peeling skin is correct Physical findings that indicate postmaturity in a newborn (gestational age of greater than 42 weeks) include cracked, peeling skin, positive moro reflex

A nurse is caring for a client who is postpartum and is breastfeeding. The client states that she is concerned about dietary precautions since she has a family history of food allergies .The nurse offers which of the following? A. you might want to avoid eating peanuts." B. "Rice cereals can be a problem during lactation." C. "Foods you eat do not affect breast milk." D. "The infant needing more sleep can indicate a food allergy."

You might want to avoid eating peanuts." Rationale: There are no standard foods that are contraindicated during breastfeeding. With a family history of food allergies, it is important to avoid eating highly allergenic foods, such as peanuts, as well as other foods to which the client has a known allergy.

A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states the she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? a) what part of the exam makes you most nervous? b) don't worry, I will be with you during the exam? c) all you need to do is relax d) a pelvic exa is required if you want birth control pill

a) what part of the exam makes you most nervous? Rationale: This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique of clarification to encourage the client to tell the nurse more about her concerns.

***A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are* noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn's Apgar score. a. 6 points

a. 6 points Correct Rationale: The Apgar score is 6 out of a possible 10. It is based on 5 signs evaluated at 1 and 5 min after delivery that indicate the physiologic state of the newborn as he transitions from intrauterine life to extrauterine life: heart rate over 100/min = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in response to suctioning of the nares = 1; body pink in color with blue extremities = 1. A score of 4 to 6 indicates moderate difficulty adjusting to life outside of the womb.

***A nurse is teaching the parent of a newborn about car seat use. which of the following information should the nurse include? a. position the newborn at a 45-degree angle in the car seat b. place the retainer clip across the newborn's abdomen c. keep the car seat rear-facing until the newborn can sit unsupported d. place the shoulder harness straps below the level of the newborns armpits

a. position the newborn at a 45-degree angle in the car seat rationale: the nurse should instruct the parent to place the newborn at a 45 degree angle to prevent the newborn's head from falling forward and obstructing the airway

A nurse is caring foterm-42r a newborn immediately following birth. After assuring a patient airway, what is the priority nursing action? a) administer vitamin k b) dry the skin c) administer eye prophylaxis d) place an identification bracelet

b) dry the skin

***A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding? A. Caput succedaneum B. Cephalhematoma c. molding d. pilonidal dimple

b. cephalhematoma rationale: a cephalhematoma is a swelling, indication bleeding under the the subcutaneous tissue of the newborn's scalp. the location of blood is beneath the periosteum of the cranial bone and therefore does not cross the suture line.

PAIN CUES (3)

brows furrowed eyes forcibly closed mouth open, sqaurish

A nurse in labor and delivery is caring for a client. following delivery of the placenta, the nurse examines the umbilical cord. which of the following vessels should the nurse expect to observe in the umbilical cord? a) two veins and one artery b) one artery and one vein c) two arteries and one vein d) two arteries and two veins

c) 2 arteries and vein

A nurse in a clinic is teaching the mother of a 4-month-old infant who has been breastfed. The mother plans to switch her infant to an iron-fortified formula. Which of the following should be included in the teaching? A. Iron facilitates development of vision in infants. B. Iron facilitates growth of bones in infants. C. Iron stores in infants begin to deplete. D. Iron is poorly absorbed in infants.

c. Iron stores in infants begin to deplete. Rationale: Iron stores in infants are adequate until about 6 months of age. Infants who are weaned before 6 months of age should be given iron-fortified formula until 12 months of age. Iron stores will also be supplemented with the addition of iron-fortified cereals and iron-rich foods to the infant's diet at 6 months of age.

***A nurse is completing a newborn gestational age assessment. Which of the following findings should be recorded as part of this assessment on the newborn? A. Acrocyanosis of hands and feet b. anterior fontanel soft and level c. plantar creases cover 2/3 of sole d. vernix caseosa in inguinal creases

c. plantar creases cover 2/3 of sole rationale: observing the presence pf creases on the plantar surfaces is one of the components of a gestational age assessment

***A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention? A. A newborn who is 24 hr post-delivery and has not voided B. A newborn who is 18 hr post-delivery and has acrocyanosis C. A newborn who is 24-hr post-delivery and has not passed meconium D. A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F). A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F) Rationale: Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by increased heat production related to sepsis or decreased heat loss.

d. A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F) Rationale: Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by increased heat production related to sepsis or decreased heat loss.

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. which of the following findings should the nurse expect? a) copious vernix b) scant scalp hair c) increased subcutaneous fat d) dry, cracked skin

dry, cracked skin Rationale: A newborn who is postmature has dry, cracked skin.

A nurse is caring for a client who is to undergo a biophysical profile. the client asks the nurse what is being evaluated during this test. which of the following should the nurse include? SATA a) fetal breathing b) fetal motion c) fetal neck translucency d) amniotic fluid volume

fetal breathing fetal motion amniotic fluid volume

*a nurse is teaching a newborn's parent to care for the umbilical cord stump. which of the following instructions should the nurse include? a) wash the cord daily with the mild soap and water b) cover the cord with the diaper c) apply petroleum jelly to the cord stump d) give a sponge bath until the cord stump falls off

give a sponge bath until the cord stumps falls off Rationale: Immersing the umbilical cord stump in water can delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off.

a nurse in the nursery is caring for a newborn. the grandmother of the newborn asks is she can take the newborn to the mother's room. which of the following is an appropriate response by the nurse? a) you may carry your grandchildren to the room b) you can push the baby to the room in a wheeled bassinet c) have the mother call and I will take the baby to the room d) if you show me your photo identification, yo can take the infant

have the mother call and i will take the baby to the room rationale: Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting an infant to remain in the mother's room.

A nurse is caring for a newborn who has myelomeningocele. which of the following nursing goals has the priority in the care of this infant? a) maintain the integrity of the sac b) promote maternal-infant bonding c) educate the parents about the defect d) provide age-appropriate stimulation

maintain the integrity of the sac Rationale: Myelomeningocele is a congenital disorder that causes the spine and spinal canal to not close prior to birth, which results in the spinal cord, meninges, and nerve roots protruding out of the child's back in a fluid-filled sac. Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord and to maintain the integrity of the sac.

A nurse is planning a care for newborn who is small for gestational age SGA. which of the following is the priority intervention the nurse should include in the newborn's plan of care? a) monitor I&O b) monitor axillary temperature c) monitor blood glucose levels d) monitor weight

monitor blood glucose levels Rationale: Decreased stores of glycogen and a lower rate of gluconeogenesis place newborns who are SGA at higher risk for hypoglycemia. Monitoring of blood glucose levels is a priority intervention.

A nurse is completing the admission assessment of a newborn. which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference? a) sternal notch b) nipple line c) xiphoid process d) fifth intercostal space

nipple line Rationale: The nurse should measure the newborn's chest circumference at the nipple line.

*** a nurse is caring for a preterm newborn who is an incubator to maintain a neutral thermal environment. the father of the newborn asks the nurse why this is necessary. which of the following responses should the nurse make? a) preterm newborns have a smaller body surface area than normal newborn b) the added brown fat later in a preterm newborn reduces his ability to generate heat c) preterm newborn lack adequate temperature control mechanism d) the heat in the incubator rapidly dries the sweat of preterm newborns

preterm newborn lack adequate temperature control mechanism Rationale: Preterm newborns have poor body control of temperature and need support to avoid losing heat. They require an external heat source, such as an incubator.

* A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch? a) babinski b) rooting c) moro d) stepping

rooting Rationale: The rooting reflex is elicited when the client strokes the newborn's lips, cheek, or corner of the mouth with her nipple. The newborn will turn his head while making sucking motions with his mouth and latch onto the nipple.

A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. the mother expresses concern about the amount of weight the newborn has lost since birth. which of the following is a response the nurse should make? a) you might want to offer water supplements between feedings b) it is due to the newborn's loss of the influence of the maternal hormones c) this might be related to your baby having 3 stools a day d) the cause might be too short or infrequent feedings

the cause might be too short or infrequent feedings Rationale: Breastfed newborns typically lose 5% to 6% of body weight before gaining weight. Slow weight gain might be due to inadequate breastfeeding, incorrect feeding techniques, or maternal factors such as breasts not emptying, stress, and fatigue.

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. which of the following responses by the nurse is approriate? a) the newborn might be actively shedding the virus b) the newborn is at risk for developing a TORCH infection c) the child might develop encephalitis, a complication of rubella d) exposure to rubella will suppress the newborn's immune response

the newborn might be actively shedding the virus Rationale: Infants born to mothers who have rubella will continue to shed the rubella virus for up to 18 months postdelivery.

A nurse is caring for a new mother who is concerned that her newborn's eyes cross. which of the following statements is a therapeutic response by the nurse? a) i will call your primary care provider to report concerns b) i will take your baby to the nursery for further examination c) this occurs because newborns lack muscle control to regulate eye movement d) this is concern, but strabismus is easily treated with patching

this occurs because newborns lack muscle control to regulate eye movement

A nurse is completing discharge instructions for a new mother and her 2 day old newborn. The mother asks, "how will i know if my baby gets enough breast milk?" which of the following responses should the nurse make? a) your baby should have a wake cycle of 30 to 60 minutes after each feeding b) your baby should wet 6 to 8 diapers per day c) your baby should burp after each feeding d) your baby should sleep at least 6 hours between feedings

your baby should wet 6 to 8 diapers per day Rationale: Newborns should wet 6 to 8 diapers per day. This is an indication that the newborn is getting enough fluids.