OB Final Exam - Quiz 7

107. What is the primary rationale for nurses wearing gloves when handling the newborn? Select one: a. To protect the nurse from contamination by the newborn b. To protect the baby from infection c. Because the nurse has the primary responsibility for the baby during the first 2 hours d. As part of the Apgar protocol

Correct Answer: A

109. Which information should the nurse provide to a breastfeeding mother regarding optimal self-care? Select one: a. She should avoid trying to lose large amounts of weight. b. She will need an extra 1000 calories a day to maintain energy and produce milk. c. She can return to prepregnancy consumption patterns of any drinks as long as she gets enough calcium. d. She must avoid exercising because it is too fatiguing.

Correct Answer: A

108. A mother is changing the diaper of her newborn son and notices that his scrotum appears large and swollen. The client is concerned. What is the best response from the nurse? Select one: a. "I don't know, but I'm sure it is nothing." b. "Your baby might have testicular cancer." c. "Your baby's urine is backing up into his scrotum." d. "A large scrotum and swelling indicate a hydrocele, which is a common finding in male newborns."

Correct Answer: D

106. The nurse is teaching the parents of a healthy newborn about infant safety. Which of the following should be included in the teaching plan? (Select all that apply). Select one or more: a. Water temperature for the infant's bath should be 100.4 degrees F. b. Do not cook while holding an infant c. Cover electrical outlets d. Remove strings from infant sleepwear, bedding, and pacifiers to prevent strangulation.

Correct Answers: A, B, C & D

105. The perinatal nurse is caring for Christy following the birth of her first child. Based on Christy's history, the RN recognizes that risk factors for postpartum depression include: Select one or more: a. Loss of friends based on upcoming divorce; family is unable to assist. b. Separated from spouse pending divorce. c. Unplanned cesarean delivery secondary to Category III fetal tracing. d. Good prenatal care with uneventful pregnancy

Correct answers: A, B, & C Rationale: Recognized risk factors for postpartum depression include a history of depression before pregnancy, depression or anxiety during pregnancy, poor quality relationship with partner, life/child care stresses, and complications of pregnancy/childbirth.

104. Which of the following actions can decrease the risk for a postpartum infection? (Select all that apply.) Select one or more: a. Diet high in protein and vitamin C. b. Increased fluid intake. c. Ambulating within a few hours after delivery d. Good hand washing techniques by staff and patients.

Correct answers: A, B, & D Rationale: Protein and vitamin C assist with tissue healing. Rehydrating a woman after delivery can assist with decreasing risk for infections. Early ambulation decreases risk for infection by promoting uterine drainage. Hand washing by staff and patients has been shown to be the number one measure in the transmission of infection.

67. Instructions to a mother of an uncircumcised male infant should include which of the following? Select one: a. Instruct her to use a cotton swab to clean under the foreskin. b. Instruct her to clean the penis by retracting the foreskin. c. Instruct her to clean the penis with alcohol. d. Instruct her not to retract the foreskin.

Do not force the foreskin over the penis or use cotton swabs to clean under the foreskin as this may damage the inner layer of the foreskin which can lead to adhesion formation. Gently cleanse the penis when bathing the infant and when changing the diaper. The correct answer is: Instruct her not to retract the foreskin.

100. A perinatal nurse assesses a term newborn for respiratory functioning. The nurse knows that which of the following conditions is normal for newborns? Select one: a. A respiratory rate of 60 to 80 breaths per minute b. A breathing pattern that is often shallow, diaphragmatic, and irregular c. Periodic episodes of apnea d. Retractions of the chest wall

Expected findings when assessing the neonate's respiratory system include 30-60 breaths per minute; slightly irregular, diaphragmatic/abdominal breathing; increase in rate when crying; decrease in rate when sleeping. Abnormal findings include periods of apnea >15 seconds; tachypnea; respirations <30 per minute The correct answer is: A breathing pattern that is often shallow, diaphragmatic, and irregular

5. The nurse is massaging a boggy uterus. The uterus does not respond to the massage. Which medication would the nurse expect would be given first: Select one: a. Methergine b. Epinephrine c. Carboprost (Hemabate) d. Oxytocin or pitocin

If the cause of the hemorrhage is uterine atony, continual fundal massage with lower uterine segment support is mandatory. While one member of the team massages the fundus, another nurse establishes intravenous access with a large bore needle and administers oxytocic drugs in the following order: oxytocin (Pitocin), followed by methylergonovine (Methergine), and carboprost (Hemabate).

116. Felicity Chan, a new mother, is accompanied by her mother during her hospital stay on the postpartum unit. Felicity's mother makes specific, various requests of the nurses including bringing warm tea, a cot to sleep on, and that the baby not be bathed at this time. Felicity's mother is also concerned about the amount of work that Felicity may be doing in the provision of infant care. Felicity asks for help with breastfeeding. After Felicity has finished breastfeeding, her mother asks for a bottle so they can warm it and "feed" the baby. How would the perinatal nurse best respond to Felicity's mother in a culturally sensitive way? Select one: a. Ask Felicity's mother to leave for 30 minutes to allow for some private time with Felicity to explore her learning needs privately. b. Ask both Felicity and her mother about the preferred infant feeding method, and assess what they already know. c. Convey to Felicity and her mother an understanding of the concepts of "hot" and "cold" within their belief system. d. Ask Felicity what she knows about breastfeeding, and provide information to both women to support Felicity's decision.

In certain multicultural populations such as India, Thailand, and China, the woman's postpartum confinement lasts for 40 days. During this time, prolonged rest with restricted activity is believed to be essential. The postpartum period is an important time for ensuring future good health, and great emphasis is placed on allowing the mother's body to regain balance after the birth of a child. To provide sensitive, appropriate care, nurses need to adopt a flexible approach when caring for women who embrace non-Western health beliefs and practices. The nurse should advocate for the patient by inquiring about her feeding preferences and by providing information to the mother and her family to support her in her decision. Felicity has obviously chosen to breastfeed; therefore, the best answer is to ask her what she knows about breastfeeding and to provide her and her mother information that supports her feeding choice. The correct answer is: Ask Felicity what she knows about breastfeeding, and provide information to both women to support Felicity's decision.

111. Heat loss through radiation can be reduced by: (Select all that apply). Select one or more: a. Removing wet blankets used to dry the infant after birth from the crib b. Placing a stocking cap on the neonate's head and placing in a crib c. Providing skin-to-skin contact with the mother and covering both with a warm blanket when the room temperature is cool d. Placing crib near a warm wall

Loss of body heat through radiation results from transfer of heat from the neonate to cooler objects not in direct contact with the neonate, such as cold walls of the crib, cold equipment, wet blankets, cold room temperature, etc.

101. A healthy, full-term baby boy is scheduled for a circumcision. Nursing actions prior to the procedure include which of the following? (Select all that apply.) Select one or more: a. Obtain written consent from the parents b. Administer acetaminophen PO 1 hour before procedure per provider order. c. Feed the neonate glucose water 30 minutes before the procedure. d. Verify that the neonate has voided

Nursing actions include obtaining written consent, administering acetaminophen as per provider order, and ensuring the neonate has voided; neonate should not eat 2-3 hours prior to the procedure to avoid risk of vomiting and aspiration The correct answers are: Obtain written consent from the parents, Administer acetaminophen PO 1 hour before procedure per provider order., Verify that the neonate has voided

84. Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security. SATA. a. The baby should be carried in the parent's arms from the room to the nursery. b. The mom should request that a second staff member verify the identity of any questionable person. c. Because of infant security systems, the baby can be left unattended in the client's room. d. The mother should check the photo identification of any person who comes to her room. e.

Parents should use caution when posting photographs of their infant on the internet. The correct answers are: "The mom should request that a second staff member verify the identity of any questionable person." "The mother should check the photo identification of any person who comes to her room." "Parents should use caution when posting photographs of their infant on the internet."

81. A woman gave birth to a healthy infant boy 5 days ago. What type of lochia does the nurse expect to find when evaluating this client? Select one: a. lochia rubra b. lochia serosa c. lochia alba d. lochia sangra

The correct answer is "lochia serosa"

The nurse assessing a newborn for heat loss is aware that nonshivering thermogenesis utilizes the newborn's stores of brown adipose tissue (BAT) to provide heat in the cold-stressed newborn. Select one: True False

The correct answer is 'True'. Brown adipose tissue, also known as "brown fat," is a unique highly vascular fat found only in newborns. BAT promotes an increase in metabolism, heat production, heat transfer to the peripheral system. Heat is produced by intense lipid metabolic metabolism but reserves are rapidly depleted during periods of cold stress.

88. A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle feeding. Which statement regarding bottle feeding using commercially prepared infant formulas might influence their choice? a. Bottle feeding using a commercially prepared formula increase the risk that the infant will develop allergies. b. Bottle feeding requires that multivitamin supplements be given to the infant. c. Commercially prepared formula ensures that the infant is getting iron in a form that is easily absorbed. d. Bottle feeding helps the infant sleep through the night.

The correct answer is: "Bottle feeding using a commercially prepared formula increase the risk that the infant will develop allergies."

37. Many first-time parents do not plan on having their parents' help immediately after the newborn arrives. Which statement by the nurse is the most appropriate when counseling new parents regarding the involvement of grandparents? a. "Grandparent involvement can be very disruptive to the family." b. "They are getting old. You should let them be involved while they can." c. "Grandparents can help you with parenting skills." d. "You should tell your parents to leave you alone."

The correct answer is: "Grandparents can help you with parenting skills."

47. A new mother wants to be sure that she is meeting her daughter's needs while feeding the baby commercially prepared infant formula. The nurse should evaluate the mother's knowledge about appropriate infant feeding techniques. Which statement by the client reassures the nurse that correct learning had taken place? a. "Since reaching 2 weeks of age, I add rice cereal to my daughter's formula to ensure adequate nutrition." b. "I refrigerate any leftover formula for the next feeding." c. "I burp my daughter during and after the feeding as needed." d. "I warm the bottle in my microwave oven."

The correct answer is: "I burp my daughter during and after the feeding as needed."

79. Nurses should be able to teach breastfeeding mothers the signs that the infant has correctly latched on. Which client statement indicates a poor latch? Select one: a. "My baby's jaw glides smoothly with sucking." b. "My baby sucks with cheeks rounded, not dimpled." c. "I feel a firm tugging sensation on my nipples but not pinching or pain." d. "I hear a clicking or smacking sound."

The correct answer is: "I hear a clicking or smacking sound."

60. Pelvic floor exercises, also known as Kegel exercises, will help to strengthen the perineal muscles and encourage healing after childbirth. The nurse requests the client to repeat back instructions for this exercise. Which response by the client indicates successful learning? Select one: a. "I stand while practicing this new exercise routine." b. "I perform 10 of these exercises every day." c. "I contract my thighs, buttocks, and abdomen." d. "I pretend that I am trying to stop the flow of urine in midstream."

The correct answer is: "I pretend that I am trying to stop the flow of urine in midstream."

90. A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. What is the nurse's most appropriate response? a. "Does your physician know that you are planning to eat that?" b. "Didn't you like your lunch?" c. "I'll warm the soup in the microwave for you." d. "What is that anyway?"

The correct answer is: "I'll warm the soup in the microwave for you."

49. Which statement by a newly delivered woman indicates that she knows what to expect regarding her menstrual activity after childbirth? Select one: a. "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." b. "My first menstrual cycle will be heavier than normal and then will be light for several months after." c. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." d. "I will not have a menstrual cycle for 6 months after childbirth."

The correct answer is: "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles."

82. The nurse is caring for a recently immigrated Chinese woman in the postpartum unit. Based on cultural beliefs and practices of the woman, the nurse would anticipate which of the following? Select all that apply. a. The woman prefers cold water for drinking. b. The woman prefers not to shower. c. The woman prefers to have her female relatives care for her baby. d. The woman prefers a wide variety of foods to eat.

The correct answer is: "The woman prefers to have her female relatives care for her baby."

46. A nurse is making a home visit on the twelfth postpartum day to assess a 23-year-old primipara woman and her full-term, healthy baby. Breastfeeding is the method of infant nutrition. The woman tells the nurse that she does not think her milk is good because it looks very watery when she expresses a little before each feeding. The nurse's best response is: a. "This is normal. You only have to be concerned when your baby does not gain weight." b. "What types of foods are you eating? A lack of protein in the diet can cause watery looking breast milk." c. "How much fluid are you drinking while you are nursing your baby? Too much fluid during the feeding session can dilute the breast milk." d. "This is normal and is referred to as foremilk which is higher in water content. Later in the feeding the fat content increases and the milk becomes richer in appearance."

The correct answer is: "This is normal and is referred to as foremilk which is higher in water content. Later in the feeding the fat content increases and the milk becomes richer in appearance."

87. The nurse is assessing the neonate's skin and notes the presence of a rash with red macules and papules on the trunk. The name for this common neonatal skin condition is: a. milia b. neonatal acne c. erythema toxicum d. pustular melanosis

The correct answer is: "erythema toxicum"

48. A woman gave birth to an infant boy 10 hours ago. Where does the nurse expect to locate this woman's fundus? Select one: a. Nonpalpable abdominally b. 2 centimeters below the umbilicus c. 1 centimeter above the umbilicus d. Midway between the umbilicus and the symphysis pubis

The correct answer is: 1 centimeter above the umbilicus

66. The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)? Select one: a. 100 to 120 b. 120 to 160 c. 80 to 100 d. 150 to 180

The correct answer is: 120 to 160

23. At 1 minute after birth a nurse assesses an infant and notes a heart rate of 80 beats per minute, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. Which Apgar score does the nurse calculate based upon these observations and signs? Select one: a. 4 b. 5 c. 6 d. 7

The correct answer is: 5

102. Screening for critical congenital heart disease (CCHD) was added to the uniform screening panel in 2011. The nurse has explained this testing to the new mother. Which action by the nurse related to this test is correct? Select one: a. Testing is performed with an electrocardiogram. b. Screening is performed when the infant is 12 hours of age. c. A passing result is an O2 saturation of ≥95%. d. Oxygen (O2) is measured in both hands and in the right foot.

The correct answer is: A passing result is an O2 saturation of ≥95%.

71. Which client is most likely to experience strong and uncomfortable afterpains? Select one: a. A woman who is a gravida 4, para 4-0-0-4 b. A woman who experienced oligohydramnios c. A woman whose infant weighed 5 pounds, 3 ounces d. A woman who is bottle-feeding her infant

The correct answer is: A woman who is a gravida 4, para 4-0-0-4

75. The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks' gestation with no birth trauma. The nurse's findings include the following parameters: heart rate 136 beats per minute; respiratory rate 64 breaths per minute; temperature 98.2°F (36.8°C); length 49.5 cm; and weight 3500 g. The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate consultation with the baby's health-care provider? Select one: a. Respiratory rate b. Presence of a heart murmur c. Absent bowel sounds d. Weight

The correct answer is: Absent bowel sounds - Bowel sounds are present but may be hypoactive for the first few days

7. Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb. 13 oz. daughter. She experiences severe cramps with breastfeeding. The perinatal nurse best describes this condition as: Select one: a. Afterpains b. Uterine hypertonia c. Bladder hypertonia d. Rectus abdominis diastasis

The correct answer is: Afterpains. Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Patients often describe the sensation as a discomfort similar to menstrual cramps. Afterpains are also related to the increase of oxytocin released in response to infant suckling.)

13. A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As the nurse prepares her for discharge, she begins to cry. The nurse's next action should be what? Select one: a. Explain that she is experiencing postpartum blues. b. Point out how lucky she is to have a healthy baby. c. Allow her time to express her feelings. d. Assess her for pain.

The correct answer is: Allow her time to express her feelings. The nurse needs to hear from the patient why she is crying before offering a response.

33. A 25-year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to: a. Explain that this is normal for second-time moms. b. Assess the location and firmness of the fundus. c. Change her pad and return in 1 hour to reassess. d. Give her 10 units of oxytocin as per standing order.

The correct answer is: Assess the location and firmness of the fundus.

52. The nurse is developing a plan of care for a client who is in the "taking-in" phase after delivering a healthy baby boy. Which of the following should the nurse include in the plan? Select one: a. Assist the woman in selecting a nutritious meal plan. b. Teach baby care skills like diapering. c. Discuss the pros and cons of circumcision. d. Counsel her regarding future sexual encounters.

The correct answer is: Assist the woman in selecting a nutritious meal plan. The "taking-in" phase is a period of dependent behaviors and occurs during the first 24-48 hours. Assisting her in ordering her meals allows her to focus on her comfort while acknowledging her decreased ability to make decisions. Teaching infant skills is probably more appropriate during the "taking-hold" phase. "Letting go" phase would include resumption of sexual intimacy. See Table 22-4

26. An infant boy was delivered minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. When should the Apgar assessment be performed? dcb Select one: a. At least twice, 1 minute and 5 minutes after birth b. Every 15 minutes during the newborn's first hour after birth c. Only if the newborn is in obvious distress d. Once by the obstetrician, just after the birth

The correct answer is: At least twice, 1 minute and 5 minutes after birth

14. The nursery nurse notes the presence of diffuse edema on a baby girl's head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edema has disappeared. The nurse documents the following condition in the infant's chart. Select one: a. Caput succedaneum b. Cephalhematoma c. Subperiosteal hemorrhage d. Epstein pearls

The correct answer is: Caput succedaneum Caput succedaneum is localized soft tissue edema of the scalp; feels spongy; may cross suture lines; results from prolonged pressure of the head against the maternal cervix during labor; resolves within the first week of life.

30. A new mother asks whether she should feed her newborn colostrum, because it is not "real milk." What is the nurse's most appropriate answer? Select one: a. Giving colostrum is important in helping the mother learn how to breastfeed before she goes home. b. Colostrum is high in antibodies, protein, vitamins, and minerals. c. Colostrum is unnecessary for newborns. d. Colostrum is lower in calories than milk and should be supplemented by formula.

The correct answer is: Colostrum is high in antibodies, protein, vitamins, and minerals.

22. Match the definition or description to the appropriate term. HINT: not all terms are used. a) Conditions occurring in late pregnancy, usually as a result of maternal or placental factors. typically have a weight less than the 10th percentile and length and head circumference will be greater than the 10th percentile. b) Less than the 10th percentile c) Conditions occurring in the first trimester that affect all aspects of fetal growth. d) Rate of growth does not meet expected growth pattern 1) IUGR 2) Asymmetric IGR 3) SGA 4) Symmetric SGA

The correct answer is: Conditions occurring in late pregnancy, usually as a result of maternal or placental factors. typically have a weight less than the 10th percentile and length and head circumference will be greater than the 10th percentile. → Asymmetric IUGR, Less than the 10th percentile → SGA, Conditions occurring in the first trimester that affect all aspects of fetal growth. → Symmetric SGA, Rate of growth does not meet expected growth pattern. → IUGR 1→d 2→a 3→b 4→c

2. A postpartum client is concerned that her breasts are engorged and uncomfortable. What is the nurse's explanation for this physiologic change? Select one: a. Congestion of veins and lymphatic vessels b. Hyperplasia of mammary tissue c. Accumulation of milk in the lactiferous ducts and glands d. Overproduction of colostrum

The correct answer is: Congestion of veins and lymphatic vessels

98. The perinatal nurse teaches the postpartum woman about the normal process of diuresis that she can expect to occur approximately 6 to 8 hours after birth. A decrease in which of the following hormones is primarily responsible for the diuresis? Select one: a. Prolactin b. Progesterone c. Lactogen d. Estrogen

The correct answer is: Estrogen

36. The postpartum nurse is caring for a couple who experienced an unplanned emergency cesarean birth. The nurse observes the following behaviors: Parents are gently touching their newborn. Mother is softly singing to her baby. Father is gazing into his baby's eyes. Based on this data, the correct nursing diagnosis is altered parent-infant bonding related to emergency cesarean birth. a. True b. False

The correct answer is: False.

24. The nurse is using the New Ballard Scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? Select one: a. Faint red marks on the soles of the feet b. Abundant lanugo c. Flexed posture d. Smooth, pink skin with visible veins

The correct answer is: Flexed posture

50. Which statement, related to the reconditioning of the urinary system after childbirth, should the nurse understand? Select one: a. Fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium. b. With adequate emptying of the bladder, bladder tone is usually restored 2 to 3 weeks after childbirth. c. Kidney function returns to normal a few days after birth. d. Diastasis recti abdominis is a common condition that alters the voiding reflex.

The correct answer is: Fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium.

20. The nurse is teaching the parents of a 1-day-old baby how to give their baby a bath. Which of the following actions should be included? Select one: a. Clean the eye from the outer aspect to the inner aspect. b. Keep the door of the room open to allow for ventilation. c. Gather all supplies before beginning the bath. d. Bathe daily with warm soapy water.

The correct answer is: Gather all supplies before beginning the bath. Bathing is done in a warm room free from drafts. Gather all items required prior to beginning the bath. Cleanse eyes from the inner to outer aspects using a clean corner of the washcloth per eye. Daily bathing with soap is not necessary and can cause skin irritation.

95. A nurse is performing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for congenital dislocation of the hip? Select one: a. Grasp the inner aspects of the baby's calves with thumbs and forefingers. b. Gently abduct the baby's thighs listening for clicks at the joints. c. Palpate the baby's patellae to assess for subluxation of the bones. d. Dorsiflex the baby's feet.

The correct answer is: Gently abduct the baby's thighs listening for clicks at the joints. The Barlow-Ortolani maneuver evaluates for congenital hip dislocation. The infants knees are flexed toward the trunk and thighs are then gently abducted. The examiner observes for symmetrical leg length, full range of motion, no clicks at joints and equal gluteal folds.

78. A postpartum woman telephones the provider regarding her 5-day-old infant. The client is not scheduled for another weight check until the infant is 14 days old. The new mother is worried about whether breastfeeding is going well. Which statement indicates that breastfeeding is effective for meeting the infant's nutritional needs? Select one: a. Has at least one breast milk stool every 24 hours b. Sleeps for 6 hours at a time between feedings c. Gains 1 to 2 ounces per week d. Has at least six to eight wet diapers per day

The correct answer is: Has at least six to eight wet diapers per day

69. At a 2-month well-baby examination, it was discovered that an exclusively breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse develop a feeding plan for the infant to increase his weight gain. Which change in dietary management will assist the client in meeting this goal? Select one: a. Start iron supplements. b. Have a bottle of formula after every feeding. c. Begin solid foods. d. Have one extra breastfeeding session every 24 hours.

The correct answer is: Have one extra breastfeeding session every 24 hours.

43. The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients? a. If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks. b. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. c. Federal law prohibits newborn genetic testing without parental consent. d. Hearing screening is now mandated by federal law.

The correct answer is: If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks.

43. A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation for administration of Vitamin K to the infant, the nurse will explain to the parents that an injection of this medication: a. Influences the activation of coagulation factors to prevent delayed clotting and hemorrhagic disease. b. Prevents high levels of unconjugated bilirubin the newborn's blood. c. Prevents the excessive loss of RBCs. d. Aids the liver in regulation of blood glucose.

The correct answer is: Influences the activation of coagulation factors to prevent delayed clotting and hemorrhagic disease.

18. What is the most critical physiologic change required of the newborn after birth? Select one: a. Full function of the immune defense system b. Initiation and maintenance of respirations c. Closure of fetal shunts in the circulatory system d. Maintenance of a stable temperature

The correct answer is: Initiation and maintenance of respirations

8. Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman spontaneously empty her bladder as soon as possible. If all else fails, what tactic might the nurse use? Select one: a. Placing oil of peppermint in a bedpan under the woman b. Inserting a sterile catheter c. Asking the physician to prescribe analgesic agents d. Pouring water from a squeeze bottle over the woman's perineum

The correct answer is: Inserting a sterile catheter, Pouring water from a squeeze bottle over the woman's perineum is a first intervention

42. To accurately measure the neonate's head, the nurse places the measuring tape around the head: a. Just above the ears and eyebrows. b. Middle of the ear and over the eyes. c. Middle of the ear and over the bridge of the nose. d. Just below the ears and over the upper lip.

The correct answer is: Just above the ears and eyebrows.

73. During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby, moving forward as a family? Select one: a. Taking in b. Taking on c. Letting go d. Taking hold

The correct answer is: Letting go

35. Karen, a G2 P2, experienced a precipitous birth 90 minutes ago. Her infant is 4200 grams and a repair of a second-degree laceration was needed following the birth. As part of the nursing assessment, the nurse discovers that Karen's uterus is boggy. Furthermore, it is noted that Karen's vaginal bleeding has increased. What is the nurse's most appropriate actions? Select all that apply. a. Assess vital signs including blood pressure and pulse. b. Massage the uterine fundus with continual lower segment support. c. Measure and document each perineal pad changed in order to assess blood loss. d. Assess for bladder distention and encourage patient to void.

The correct answer is: Massage the uterine fundus with continual lower segment support; Assess for bladder distention and encourage patient to void.

72. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. What is the nurse's highest priority at this time? Select one: a. Calling the woman's primary health care provider b. Beginning an intravenous (IV) infusion of Ringer's lactate solution c. Massaging the woman's fundus d. Assessing the woman's vital signs

The correct answer is: Massaging the woman's fundus - making uterus firm will slow down bleeding

39. While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive _____ reflex. a. glabellar b. tonic neck c. Moro d. Babinski

The correct answer is: Moro.

9. Rho immune globulin will be ordered postpartum if which situation occurs? Select one: a. Mother Rh+, baby Rh- b. Mother Rh-, baby Rh+ c. Mother Rh-, baby Rh- d. Mother Rh+, baby Rh+

The correct answer is: Mother Rh-, baby Rh+

45. Which statement is the best rationale for recommending formula over breastfeeding? a. Mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. b. Other family members or care providers also need to feed the baby. c. Mother sees bottle feeding as more convenient. d. Mother lacks confidence in her ability to breastfeed.

The correct answer is: Mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk.

64. The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, approximately 500,000 women in America experience a more severe syndrome known as PPD. Which statement regarding PPD is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis? Select one: a. This syndrome affects only new mothers. b. PPD symptoms are consistently severe. c. PPD can easily go undetected. d. Only mental health professionals should teach new parents about this condition.

The correct answer is: PPD can easily go undetected.

17. A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? Select one: a. Physiologic jaundice is caused by blood incompatibilities between the mother and the infant blood types. b. Physiologic jaundice is also known as breast milk jaundice. c. Physiologic jaundice occurs during the first 24 hours of life. d. Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life

The correct answer is: Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life

55. As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Based on the most recent evidence, which information is incorrect and should be discussed with parents? Select one: a. Prevent exposure to people with upper respiratory tract infections. b. Avoid loose bedding, water beds, and beanbag chairs. c. Keep the infant away from secondhand smoke. d. Place the infant on his or her abdomen to sleep.

The correct answer is: Place the infant on his or her abdomen to sleep. (Infants should always be placed on their backs to sleep.

40. The nurse assesses that a full-term neonate's temperature is 97.1°F (36.2°C). The first nursing action is to: a. Turn up the heat in the room. b. Place the neonate on the mother's chest with a warm blanket over the mother and baby. c. Take the neonate to the nursery and place in a radiant warmer. d. Notify the neonate's primary provider.

The correct answer is: Place the neonate on the mother's chest with a warm blanket over the mother and baby.

21. A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. What is the most appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy? Select one: a. Placing eye shields over the newborn's closed eyes b. Limiting the newborn's intake of milk to prevent nausea, vomiting, and diarrhea c. Applying an oil-based lotion to the newborn's skin to prevent dying and cracking d. Changing the newborn's position every 4 hours

The correct answer is: Placing eye shields over the newborn's closed eyes

41. Typical signs of abusive head trauma (AHT, also known as Shaken Baby Syndrome) include which of the following? (Select all that apply.) a. Broken clavicle b. Poor feeding c. Vomiting d. Breathing problems

The correct answer is: Poor feeding; Vomiting; Breathing problems.

15. During a telephone follow-up conversation with a woman who is 4 days postpartum, the woman tells the nurse, "I don't know what's wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which condition might this new mother be experiencing? Select one: a. Postpartum blues b. Attachment difficulty c. Postpartum depression (PPD) d. Letting-go

The correct answer is: Postpartum blues

29. Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them regarding pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? Select one: a. A glass of wine just before pumping will help reduce stress and anxiety. b. Premature infants more easily digest breast milk than formula. c. The mother should pump every 2 to 3 hours, including during the night. d. The mother should only pump as much milk as the infant can drink.

The correct answer is: Premature infants more easily digest breast milk than formula. The question asks- The nurse who instructs them regarding pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? This answer (the mother should pump every 2-3 hours, including during the night) does not address knowledge of lactation, as indicated in this statement. The answer "Premature infants more easily digest breast milk than formula" does.

65. After giving birth to a healthy infant boy, a primiparous client, 16 years of age, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is "Deficient knowledge of infant care." What should the nurse be certain to include in the plan of care as he or she prepares the client for discharge? Select one: a. Give the client written information on bathing her infant. b. Teach the client how to feed and bathe her infant. c. Provide time for the client to bathe her infant after she views a demonstration of infant bathing. d. Advise the client that all mothers instinctively know how to care for their infants.

The correct answer is: Provide time for the client to bathe her infant after she views a demonstration of infant bathing.

113. A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment after childbirth. Recognizing the needs of women during this stage, how should the nurse respond? Select one: a. Foster an active role in the baby's care. b. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs. c. Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session while she is in the hospital. d. Provide time for the mother to reflect on the events of her labor and delivery.

The correct answer is: Provide time for the mother to reflect on the events of her labor and delivery.

103. Which type of formula is not diluted with water, before being administered to an infant? Select one: a. Concentrated b. Powdered c. Modified cow's milk d. Ready-to-use

The correct answer is: Ready-to-use

3. What should the nurse's next action be if the client's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day? Select one: a. Immediately begin antibiotic therapy. b. Immediately inform the physician. c. Recognize that this count is an acceptable range at this point postpartum d. Have the laboratory draw blood for reanalysis.

The correct answer is: Recognize that this count is an acceptable range at this point postpartum

1. The nurse should be cognizant of which postpartum physiologic alteration? Select one: a. Hypercoagulable state protects the new mother from thromboembolism, especially after a cesarean birth. b. Lowered white blood cell count after pregnancy can lead to false-positive results on tests for infections. c. Respiratory function returns to nonpregnant levels by 6 to 8 weeks after childbirth d. Cardiac output, pulse rate, and stroke volume all return to prepregnancy normal values within a few hours of childbirth.

The correct answer is: Respiratory function returns to nonpregnant levels by 6 to 8 weeks after childbirth

32. What are the most common causes for subinvolution of the uterus? a. Postpartum hemorrhage and infection b. Uterine tetany and overproduction of oxytocin c. Multiple gestation and postpartum hemorrhage d. Retained placenta fragments and infection

The correct answer is: Retained placenta fragments and infection.

61. The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella non-immune (titer 1:8 or enzyme immunoassay [EIA] 0.8); hematocrit, 30%. How should the nurse best interpret these data? Select one: a. Rh immune globulin is necessary within 72 hours of childbirth. b. Rubella vaccine should be administered. c. Blood transfusion is necessary. d. Kleihauer-Betke test should be performed.

The correct answer is: Rubella vaccine should be administered.

44. One of the following neonates is at highest risk for cold stress: a. LGA neonate at 38 weeks gestation. b. AGA neonate at 37 weeks gestation. c. SGA neonate at 33 weeks gestation. d. SGA neonate at 40 weeks gestation.

The correct answer is: SGA neonate at 33 weeks gestation.

93. The nurse observes that a first-time mother appears to ignore her newborn. Which strategy should the nurse use to facilitate mother-infant attachment? Select one: a. Tell the mother she must pay attention to her infant. b. Arrange for the mother to watch a video on parent-infant interaction. c. Show the mother how the infant initiates interaction and attends to her. d. Demonstrate for the mother different positions for holding her infant while feeding.

The correct answer is: Show the mother how the infant initiates interaction and attends to her.

77. Painful nipples are a major reason why women stop breastfeeding. A primary intervention to decrease nipple irritation is: Select one: a. Teaching proper techniques for latching-on and releasing of suction b. Applying hot compresses to breast prior to feeding c. Instructing woman to express colostrum or milk at the end of the feeding session and rub it on her nipples d. Air drying nipples for 10 minutes at the end of the feeding session

The correct answer is: Teaching proper techniques for latching-on and releasing of suction While all these interventions are correct, the primary intervention is to ensure correct latching-on and suction release as problems with these lead to early cessation of breastfeeding.

4. A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman's vital signs, which finding would be of greatest concern to the nurse? Select one: a. Temperature 36.8° C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg b. Temperature 37.4° C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg c. Temperature 37.9° C, heart rate 120 bpm, respirations 20 breaths per minute, and blood pressure 90/50 mm Hg d. Temperature 38° C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg

The correct answer is: Temperature 37.9° C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg. These vital signs best demonstrate the body's attempt to compensate for significant blood loss

96. Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? Select one: a. The baby with respirations 52, oxygen saturation 98% b. The baby with Apgar 9/9, weight 2960 grams c. The baby with temperature 96.3°F, length 17 inches d. The baby with glucose 60 mg/dL, heart rate 132

The correct answer is: The baby with temperature 96.3°F, length 17 inches

38. In follow-up appointments or visits with parents and their new baby, it is useful if the nurse can identify infant behaviors that can either facilitate or inhibit attachment. What is an inhibiting behavior? a. The infant clings to the parents. b. The infant seeks attention from any adult in the room. c. The infant cries only when hungry or wet. d. The infant's activity is somewhat predictable.

The correct answer is: The infant seeks attention from any adult in the room.

114. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? Select one: a. The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth. b. The nurse should immediately notify the pediatrician for this emergency situation. c. If this baby was born vaginally, then a pneumothorax could be indicated. d. The neonate must have aspirated surfactant.

The correct answer is: The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth. Baby did not experience the chest pressure during a vaginal delivery, therefore, negative intrathoracic pressure did not help to draw air into the lungs and clear fluid. Read p524

28. A newly delivered mother who intends to breastfeed tells her nurse, "I am so relieved that this pregnancy is over so that I can start smoking again." The nurse encourages the client to refrain from smoking. However, this new mother is insistent that she will resume smoking. How will the nurse adapt her health teaching with this new information? Select one: a. The mother should not smoke in the same room her baby is in. b. Smoking has little-to-no effect on milk production c. The effects of secondhand smoke on infants are less significant than for adults. d. No relationship exists between smoking and the time of feedings.

The correct answer is: The mother should not smoke in the same room her baby is in.

16. The nurse caring for a newborn checks the record to note clinical findings that occurred before her shift. Which finding related to the renal system would be of increased significance and require further action? Select one: a. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days. b. Breastfed infants will likely void more often during the first days after birth. c. The pediatrician should be notified if the newborn has not voided in 24 hours d. Brick dust or blood on a diaper is always cause to notify the physician.

The correct answer is: The pediatrician should be notified if the newborn has not voided in 24 hours

34. A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. Which response by the client alerts the nurse that psychosocial outcomes have not been met? a. The woman feels that her baby is more attractive and clever than any others. b. The woman has a partner or family members who react very positively about the baby. c. The woman excessively discusses her labor and birth experience. d. The woman has not given the baby a name.

The correct answer is: The woman has not given the baby a name.

25. A new father wants to know what medication was put into his infant's eyes and why it is needed. How does the nurse explain the purpose of the erythromycin (Ilotycin) ophthalmic ointment? Select one: a. This ointment prevents the infant's eyelids from sticking together and helps the infant see. b. Erythromycin (Ilotycin) ophthalmic ointment destroys an infectious exudate caused by Staphylococcus that could make the infant blind. c. Erythromycin (Ilotycin) prevents potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. d. This ophthalmic ointment prevents gonorrheal infection of the infant's eyes, potentially acquired from the birth canal.

The correct answer is: This ophthalmic ointment prevents gonorrheal infection of the infant's eyes, potentially acquired from the birth canal.

54. Which component of the sensory system is the least mature at birth? Select one: a. Smell b. Taste c. Hearing d. Vision

The correct answer is: Vision

112. A nurse notes that an Eskimo woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. While evaluating this client's behavior with her infant, what realization does the nurse make? Select one: a. The woman needs a referral to a social worker for further evaluation of her parenting behaviors once she goes home with the newborn. b. What appears to be a lack of interest in the newborn is, in fact, the cultural way of demonstrating intense love by attempting to ward off evil spirits. c. The woman is inexperienced in caring for a newborn. d. Extra time needs to be planned for assisting the woman in bonding with her newborn.

The correct answer is: What appears to be a lack of interest in the newborn is, in fact, the cultural way of demonstrating intense love by attempting to ward off evil spirits.

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

The correct answer is: When the cheek of the baby is touched, the newborn turns toward the side that is touched. An infant exhibits Rooting reflex when the neonate turns his head toward the direction of the stimulus and opens his mouth. Choice 2 is the Babinski reflex; Choice 3 is the Startle or Moro reflex; Choice 4 is the Tonic Neck reflex

68. Early this morning, an infant boy was circumcised using the PlastiBell method. Based on the nurse's evaluation, when will the infant be ready for discharge? Select one: a. When the bleeding completely stops b. When the PlastiBell plastic rim (bell) falls off c. When the infant voids d. When yellow exudate forms over the glans

The correct answer is: When the infant voids

6. What information should the nurse understand fully regarding rubella and Rh status? Select one: a. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for at least 1 month after vaccination b. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus. c. Rh immunoglobulin boosts the immune system and thereby enhances the effectiveness of vaccinations. d. Rh immunoglobulin is safely administered intravenously because it cannot harm a nursing infant.

The correct answer is: Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for at least 1 month after vaccination

31. Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? a. Progesterone b. Prolactin c. Estrogen d. Human placental lactogen

The correct answer is: prolactin

85. Which concerns regarding parenthood are often expressed by visually impaired mothers? Select one or more. a. needing extra time for parenting activities to accommodate the visual limitations. b. infant safety c. ability to care for the infant d. transportation.

The correct answers are: "needing extra time for parenting activities to accommodate the visual limitations" "infant safety" "transportation"

97. Which of the following statements indicates that a new mother needs additional teaching? Select all that apply: a. "I need to supervise my cat when she is in the same room as my baby." b. "I will place my baby on her back when she is sleeping." c. "I will not leave my baby on an elevated flat surface after she is able to turn over on her own." d. "I have asked my husband to install safety latches on the lower cabinets."

The correct answers are: "I need to supervise my cat when she is in the same room as my baby.", "I will not leave my baby on an elevated flat surface after she is able to turn over on her own."

56. General skin care for full-term infants includes which of the following? (Select all that apply.) Select one or more: a. Avoid daily bathing with soap. It is not necessary to bathe an infant daily. Daily bathing with soap can cause dry skin in the infant. The cleanser should be of neutral pH and free of additives such as fragrances that could be irritants. b. Use a cleanser with a neutral pH. c. Avoid fragrant soaps. It is not necessary to bathe an infant daily. Daily bathing with soap can cause dry skin in the infant. The cleanser should be of neutral pH and free of additives such as fragrances that could be irritants. d. Apply petrolatum-based ointments sparingly to dry skin, but avoid head and face.

The correct answers are: Avoid daily bathing with soap., Use a cleanser with a neutral pH., Avoid fragrant soaps., Apply petrolatum-based ointments sparingly to dry skin, but avoid head and face.

70. The perinatal nurse describes infant feeding cues to a new mother. These feeding cues include (select all that apply): Select one or more: a. Awake and alert b. Mouth movements c. Moving the hand to the mouth d. Yawning

The correct answers are: Awake and alert, Mouth movements, Moving the hand to the mouth The infant demonstrates readiness for feeding when he or she is awake and alert, makes hand-to-mouth or hand-to-hand movements, exhibits sucking or licking, exhibits rooting, and demonstrates increased activity with the arms and legs flexed and the hands in a fist.

27. Which statements concerning the benefits or limitations of breastfeeding are accurate? (Select all that apply.) Select one or more: a. Long-term studies have shown that the benefits of breast milk are only good while baby is breastfeeding. b. Breastfeeding increases the risk of childhood obesity. c. Breast milk changes over time to meet the changing needs as infants grow. d. Breast milk and breastfeeding may enhance cognitive development. e. Benefits to the infant include a reduced incidence of SIDS.

The correct answers are: Breast milk changes over time to meet the changing needs as infants grow., Breast milk and breastfeeding may enhance cognitive development., Benefits to the infant include a reduced incidence of SIDS.

59. A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. Which findings should the nurse include in the discussion? (Select all that apply.) Select one or more: a. Breast tenderness b. Fever and flulike symptoms c. Warmth in the breast d. Small white blister on the tip of the nipple

The correct answers are: Breast tenderness , Warmth in the breast, Fever and flulike symptoms

57. A first-time mother informs her nurse that she is concerned about infant abduction. The nurse should explain to the parents which of the following? (Select all that apply.) Select one or more:p a. Do not allow a person without proper unit specific hospital ID to take their baby. b. Encourage parents to accompany any person who removes their infant from the hospital room c. Instruct parents not to leave their newborn unattended at any time d. Inform parents that ID bands with matching identification numbers are placed on the parents and infant at birth to ensure identification of the correct infant with the correct parents

The correct answers are: Do not allow a person without proper unit specific hospital ID to take their baby., Encourage parents to accompany any person who removes their infant from the hospital room, Instruct parents not to leave their newborn unattended at any time, Inform parents that ID bands with matching identification numbers are placed on the parents and infant at birth to ensure identification of the correct infant with the correct parents

58. The let-down reflex occurs in response to the release of oxytocin. Which of the following can stimulate the release of oxytocin? (Select all that apply.) Select one or more: a. Emotional response to thinking about her baby b. Infant suckling c. Emotional response to hearing an infant crying d. Sexual activity

The correct answers are: Emotional response to thinking about her baby, Infant suckling, Emotional response to hearing an infant crying, Sexual activity The let-down reflex or milk ejection reflex results in milk being ejected into and through the lactiferous duct system. Oxytocin causes the alveoli to contract and forces milk into the duct system. Oxytocin is released in response to suckling and/or maternal emotional response to hearing a baby cry or thinking of her own baby. Let-down reflex also occurs during sexual arousal.

12. The nurse is caring for a postpartum woman who gave birth to a healthy, full-term baby girl. She has a 2-year-old son. She voices concern about her older child's adjustment to the new baby. Nursing actions that will facilitate the older son's adjustment to having a new baby in the house would include which of the following? (Select all that apply.) Select one or more: a. Explain to the mother that she can have her son visit her in the hospital. b. Teach her son how to change the baby's diapers. c. Assist her son in holding his new baby sister. d. Recommend that she spend time reading to her older son while he sits in her lap.

The correct answers are: Explain to the mother that she can have her son visit her in the hospital., Assist her son in holding his new baby sister. Younger children experience a sense of loss over no longer being the baby of the family while older children may have a sense of increased responsibility. Siblings should be introduced to the newest family member as soon as possible and spend time with his/her mother and new sibling during the postpartum hospitalization.

19. The postpartum mother asks the nurse why is it so important to prevent cold stress in her baby- can't she shiver to stay warm? What should the nurse include in their response? (Select all that apply) Select one or more: a. Yes, your baby can shiver; but it important that we prevent her from needing to so. b. If your baby gets too cold and we don't help her, her body will use a lot of oxygen to try and get warm, which can ultimately lead to decrease oxygen to her lungs and body causing respiratory problems. c. Your baby will eventually warm up on her own, but it is best if we keep the hat on her head. d. No, your baby cannot shiver; therefore, it is important to prevent her from losing body heat.

The correct answers are: If your baby gets too cold and we don't help her, her body will use a lot of oxygen to try and get warm, which can ultimately lead to decrease oxygen to her lungs and body causing respiratory problems., No, your baby cannot shiver; therefore, it is important to prevent her from losing body heat.

51. A G2 P2 woman who experienced a prolonged labor and prolonged rupture of membranes is at risk for metritis. Which of the following nursing actions are directed at decreasing this risk? (Select all that apply.) Select one or more: a. Instruct woman to increase her fluid intake b. Instruct woman to change her peri-pads after each voiding c. Instruct woman to ambulate in the halls four times a day d. Instruct woman to apply ice packs to the perineum

The correct answers are: Instruct woman to increase her fluid intake, Instruct woman to change her peri-pads after each voiding, Instruct woman to ambulate in the halls four times a day. Metritis is an infection of the endometrium, myometrium, and/or parametrial tissue. Risk factors include cesarean birth, prolonged rupture of membranes, prolonged labor, etc. Symptoms include elevated temp, lower abdominal pain, uterine tenderness, tachycardia, subinvolution. Metritis is generally treated with antibiotics based on culture results. Nursing actions include proper hand washing techniques, proper pericare/wipe front to back after urination, change peripad after each urination, early ambulation, rehydration, diet high in protein/vitamin C, and monitoring for symptoms.

76. The "Period of Purple Crying" is a program developed to educate new parents about infant crying and the dangers of shaking a baby. Each letter in the acronym "PURPLE" represents a key concept of this program. Which concepts are accurate? (Select all that apply.) Select one or more: a. U: unexpected b. L: extremely loud c. P: peak of crying and painful expression d. E: evening e. R: baby is resting at last

The correct answers are: P: peak of crying and painful expression, U: unexpected, E: evening

89. Which of the following nursing actions are directed at promoting bonding? (Select all that apply.) Select one or more: a. Providing opportunity for parents to hold their newborn as soon as possible following the birth. b. Providing opportunities for the couple to talk about their birth experience and about becoming parents. c. Promoting rest and comfort by keeping the newborn in the nursery at night. d. Providing positive comments to parents regarding their interactions with their newborn.

The correct answers are: Providing opportunity for parents to hold their newborn as soon as possible following the birth., Providing opportunities for the couple to talk about their birth experience and about becoming parents., Providing positive comments to parents regarding their interactions with their newborn.

10. If a woman is at risk for thrombus and is not ready to ambulate, which nursing intervention would the nurse use? (Select all that apply.) Select one or more: a. Having her flex, extend, and rotate her feet, ankles, and legs b. Putting her in antiembolic stockings (thromboembolic deterrent [TED] hose) and/or sequential compression device (SCD) boots c. Having her sit in a chair d. Immediately notifying the physician if a positive Homans sign occurs e. Promoting bed rest

The correct answers are: Putting her in antiembolic stockings (thromboembolic deterrent [TED] hose) and/or sequential compression device (SCD) boots, Having her flex, extend, and rotate her feet, ankles, and legs , Immediately notifying the physician if a positive Homans sign occurs

115. Pain should be regularly assessed in all newborns. If the infant is displaying physiologic or behavioral cues that indicate pain, then measures should be taken to manage the pain. Which interventions are examples of nonpharmacologic pain management techniques? (Select all that apply.) Select one or more: a. Skin-to-skin contact with the mother b. Acetaminophen c. Sucrose d. Nonnutritive sucking e. Swaddling

The correct answers are: Sucrose, Skin-to-skin contact with the mother , Swaddling, Nonnutritive sucking

53. Which of the following nursing actions are directed at assisting men in their transition to fatherhood? (Select all that apply.) Select one or more: a. Encourage the woman to take on the major responsibility for infant care. b. Talk to the couple about their expectations of the parenting role. c. Praise the father for his interactions with his infant. d. Provide information on infant care and behavior to both parents.

The correct answers are: Talk to the couple about their expectations of the parenting role., Praise the father for his interactions with his infant., Provide information on infant care and behavior to both parents. It is important to first have the couple discuss with each other their expectations of the fathering role. Once this has occurred, then the woman and nurse need to support the man in his role of infant care. Both parents need to receive information about infant care and infant behaviors, and both parents need to be praised for their interactions with their baby.

11. A parent who has a hearing impairment is presented with a number of challenges in parenting. Which nursing approaches are appropriate for working with hearing-impaired new parents? (Select all that apply.) Select one or more: a. Ascertaining whether the client can read lips before teaching b. Using devices that transform sound into light c. Assuming that the client knows sign language d. Speaking quickly and loudly e. Writing messages that aid in communication

The correct answers are: Using devices that transform sound into light, Ascertaining whether the client can read lips before teaching, Writing messages that aid in communication

62. The clinic nurse sees Xiao and her infant in the clinic for their 2-week follow-up visit. Xiao appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. She is carrying her son in the infant carrier and when asked to put him on the examining table, she holds him away from her body. The clinic nurse's most appropriate question to ask would be: Select one: a. "What has happened to you?" b. "Do you have help at home?" c. "Is there anything wrong with your son?" d. "Would you tell me about the first few days at home?"

The well-baby checkup that generally takes place 1 to 2 weeks following the hospital discharge may offer the first opportunity to assess the mother-baby dyad. In this setting, the nurse needs to be alert for subtle cues from the new mother, such as making negative comments about the baby or herself, ignoring the baby's or other children's needs, as well as the mother's physical appearance. In a private area, the nurse should take time to explore the new mother's feelings. A nonthreatening way to open the dialogue might be to say: "Tell me how the first few days at home have gone." This statement provides the new mother with an opportunity to share both positive and negative impressions. The correct answer is: "Would you tell me about the first few days at home?"