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Practice NUR 307 Exam 2

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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.

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 Created on:11/29/2018 Page 52 Detailed Answer Key medical 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. InCorrect 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 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 Correct Rationale: Apgar scoring is an assessment of five areas of newborn well-being: respiratory effort, heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for heart rate, muscle tone, and reflex irritability. The weak cry and acrocyanosis of the hands and feet score 1 each, for a total of 8. InCorrect Rationale: Apgar scoring is an assessment of five areas of newborn well-being: respiratory effort, heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for heart rate, muscle tone, and reflex irritability. The weak cry and acrocyanosis of the hands and feet score 1 each, for a total of 8

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. B. Ventrogluteal Rationale: The ventrogluteal muscle is used for some IM injections, but it is not the preferred site for injecting vitamin K into a newborn. C. Dorsogluteal Rationale: The dorsogluteal muscle in newborns is too small to receive an IM medication, and it is near the sciatic nerve. It is not recommended as an injection site in small children. D. Deltoid Rationale: The deltoid muscle in newborns is too small to receive an IM medication. It is not recommended as an injection site in small children

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." 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." Rationale: Created on:11/29/2018 Page 58 Detailed Answer Key medical Ill expect the plastic ring to fall off by itself within a week is a correct statement. With the Plastibell procedure, the plastic ring detaches in about 5 to 8 days. Ill apply petroleum jelly to his penis with diaper changes is an incorrect statement. With the Plastibell technique, no petroleum jelly is necessary. Ill wash his penis with warm water and mild soap each day is an incorrect statement. The client should not use soap or commercial cleansing wipes until the circumcision has healed, which takes at least 5 to 6 days. Ill call the doctor if I see any bleeding is a correct statement. The client should report any bleeding immediately. Ill make sure his diaper is loose in the front is a correct statement. Applying a loose diaper prevents pressure over the circumcision area.

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make? A. "It sounds like you are feeling sad that things didn't go as planned." B. "At least you know you have a healthy baby." . C. "Maybe next time you can have a vaginal delivery." D. "You can resume sexual relations sooner than if you had delivered vaginally."

-A. "It sounds like you are feeling sad that things didn't go as planned." Rationale: This response uses the therapeutic communication technique of restating to encourage the client to continue to communicate her feelings. B. "At least you know you have a healthy baby." Rationale: This nontherapeutic response is a stereotyped comment. It encourages the client to repress concerns and feelings. C. "Maybe next time you can have a vaginal delivery." Rationale: This nontherapeutic response is one that uses the communication technique of giving false reassurance. The nurse is making a promise she cannot honor. Created on:11/29/2018 Page 68 Detailed Answer Key medical D. "You can resume sexual relations sooner than if you had delivered vaginally." Rationale: The nurse is using the nontherapeutic communication technique of introducing an unrelated topic. It does not promote further statements by the client about her concerns.

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 appropriate? 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."

-A. "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. B. "The newborn is at risk for developing a TORCH infection." Rationale: TORCH is an acronym for certain maternal viral infections that can cross the placenta and affect the developing fetus. While rubella is one of the TORCH infections, exposure to one viral infection does not increase the risk of developing an additional viral infection. C. "The child might develop encephalitis, a complication of rubella." Rationale: Newborns exposed to the rubella virus during gestation are at increased risk to develop hearing loss, congenital cataracts, and cardiac anomalies, but not encephalitis. D. "Exposure to rubella will suppress the newborn's immune response." Rationale: Exposure to rubella does not affect the infant's immune response. All newborns are at a high risk for infection during the first few months of life due to a lower concentration of immunoglobins and a delayed response from white blood cells.

A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide? A. "The primary consideration is what type of incision was performed this time." B. "There are so many variables that you'll have to ask your obstetrician." C. "It's too soon for you to be worrying about this now." D. "A repeat cesarean birth is safer for both you and your baby."

-A. "The primary consideration is what type of incision was performed this time." Rationale: The most common type of incision during a cesarean birth is transverse, which is made across the lower, thinner part of the uterus. It is the primary criteria that permits a vaginal birth after a cesarean (VBAC). Other types of incisions increase the risk of uterine rupture. Additional criteria for VBAC include an adequate maternal pelvis, no uterine scars or history of rupture, the availability of a provider to monitor labor, and personnel to perform a cesarean birth if needed. B. "There are so many variables that you'll have to ask your obstetrician." Rationale: This nontherapeutic reply avoids addressing the client's concerns. A nurse in the labor and Created on:11/29/2018 Page 15 Detailed Answer Key medical delivery suite or the postpartum unit should be able to provide the client with information that answers her question. C. "It's too soon for you to be worrying about this now." Rationale: This nontherapeutic reply devalues the client's concerns and avoids addressing them. A nurse in the labor and delivery suite or the postpartum unit should be able to provide the client with information that answers her question. D. "A repeat cesarean birth is safer for both you and your baby." Rationale: Research has shown that, a vaginal birth after cesarean (VBAC) is safe for both the client and the fetus if specific criteria are met and labor is managed closely by nurses and health care providers.

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 responses? 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."

-A. "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. B. "Rice cereals can be a problem during lactation." Rationale: Common food allergies include wheat products, such as wheat cereal. C. "Foods you eat do not affect breast milk." Rationale: The flavor of breast milk can be altered by foods and spices in the diet. D. "The infant needing more sleep can indicate a food allergy." Rationale: Colic-like symptoms occur in infants with a family history of milk protein intolerance. Infants who are breastfed can exhibit fussiness and gastrointestinal distress as a response to foods and spices consumed by mothers

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. B. "Babies know instinctively how much of the nipple to take into their mouth." Rationale: The client should not rely on the newborn to perfect the breastfeeding technique. The client's knowledge and guidance of the newborn are needed for successful breastfeeding. C. "Your baby's mouth is rather small so she will only take part of the nipple." Rationale: The size of the newborn's mouth has some effect on the ability of the newborn to latch, as do the size of the nipple and the areola. There are general guidelines the client should use to promote successful breastfeeding. If the newborn sucks on only a portion of the nipple, nipple soreness is likely to develop. D. "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth." Rationale: Placing this much of the breast into the newborn's mouth might not be possible, and the client will feel discouraged and unsuccessful in attempting to latch the newborn.

A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first? A. A client who experienced a cesarean birth 4 hr ago and reports pain B. A client who has preeclampsia with a BP of 138/90 mm Hg C. A client who experienced a vaginal birth 24 hr ago and reports no bleeding D. A client who is scheduled for discharge following a laparoscopic tubal ligation

-A. A client who experienced a cesarean birth 4 hr ago and reports pain Rationale: Using Maslow's hierarchy of needs, assessment of pain and meeting the physiological needs of a surgical client are the priority nursing actions. B. A client who has preeclampsia with a BP of 138/90 mm Hg Rationale: A BP of 138/90 mm Hg is an expected finding in a client who has mild preeclampsia and this client does not need to be seen first. C. A client who experienced a vaginal birth 24 hr ago and reports no bleeding Rationale: A client who experienced a vaginal birth 24 hr ago and reports no bleeding is an expected finding and this client does not need to be seen first. D. A client who is scheduled for discharge following a laparoscopic tubal ligation Rationale: A client who is scheduled for discharge following a laparoscopic tubal ligation does not need to be seen first

A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply.) A. Apply breast milk to the nipples before each feeding. B. Place breast pads inside the nursing bra. C. Massage the breasts and nipples prior to feeding. D. Start breastfeeding with the nipple that is less sore. E. Change the infant's position on the nipples.

-A. Apply breast milk to the nipples before each feeding. B. Place breast pads inside the nursing bra. C. Massage the breasts and nipples prior to feeding. -D. Start breastfeeding with the nipple that is less sore. -E. Change the infant's position on the nipples. Rationale: Apply breast milk to the nipples before each feeding is correct.The application of colostrum and breast milk to the nipples moistens them and prepares them for breastfeeding. This can prevent and reduce nipple tenderness. Place breast pads inside the nursing bra is incorrect. Sore nipples should be exposed to the air as much as possible. The use of breast shells or cups inside the nursing bra is another option to reduce

A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus? A. At the level of the umbilicus B. 2 cm above the umbilicus C. One fingerbreadth above the symphysis pubis D. To the right of the umbilicus

-A. At the level of the umbilicus Rationale: Within 12 hr, the fundus should be palpable at the level of the umbilicus and then recede 1 to 2 cm each day. B. 2 cm above the umbilicus Rationale: The position of the fundus 2 cm above the umbilicus is an indication of subinvolution. C. One fingerbreadth above the symphysis pubis Rationale: The uterus would be palpated at a position between the umbilicus and symphysis pubis in a client who is approximately 1 week postpartum. D. To the right of the umbilicus Rationale: A uterine fundus that is deviated to the right or left of the umbilicus indicates the client has a full bladder.

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 Rationale: When an infant is stressed by cold exposure, oxygen consumption increases and pulmonary and peripheral vasoconstriction occurs. Metabolic demands for glucose increase. If the cold stress continues, hypoglycemia and metabolic acidosis can result. B. Shivering Rationale: The shivering mechanism in newborns is rarely operable. Newborns respond to cold by increasing muscle and metabolic activity and through metabolizing brown fat. C. Basal metabolic rate reduction Rationale: If the newborn becomes chilled, he will increase his basal metabolic rate in an attempt to generate heat. This results in an increased consumption of oxygen and blood glucose. D. Brown fat production Rationale: Infants are born with stores of brown fat, which they utilize during the first few weeks of life to produce heat. Brown fat is unique to the newborn and can increase heat production by 100%

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? A. Document the findings and continue to monitor the client. B. Notify the client's provider. C. Increase the frequency of fundal massage. D. Encourage the client to empty her bladder.

-A. Document the findings and continue to monitor the client. period. Small clots are common. The nurse should document the findings and continue to monitor the client. B. Notify the client's provider. Rationale: These are expected findings, so there is no need to notify the provider. C. Increase the frequency of fundal massage. Rationale: These are expected findings and the fundus is already firm. Increasing the frequency of fundal massage is not indicated at this time. D. Encourage the client to empty her bladder. Rationale: These are expected findings, and the fundus is firm at the midline. If the fundus was deviated, this would be an indication of a distended bladder and the client should be encouraged to void to prevent uterine atony.

A nurse is instructing a female client about how to check basal temperature in order to determine if the client is ovulating. The nurse should instruct the client to check her temperature at which of the following times? A. Every morning before arising B. On days 13 to 17 of her menstrual cycle C. 1 hour following intercourse D. Before going to bed every night

-A. Every morning before arising Rationale: To measure basal temperature, the client must take her temperature every morning at the same exact time before getting out of bed. The client must try not to move too much, as any activity can raise the body temperature slightly. B. On days 13 to 17 of her menstrual cycle Rationale: The client should take her basal temperature every day of the month to accurately map the decrease in temperature that occurs at ovulation and the subsequent elevation in temperature that occurs until menses begin. C. 1 hour following intercourse Rationale: Measuring the temperature after intercourse would not be accurate, as any activity can raise the body temperature slightly . D. Before going to bed every night Rationale: Measuring the temperature after a full day's activity would not be accurate, as any activity can raise the body temperature slightly.

A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase? A. Expressions of excitement B. Lack of appetite C. Focus on the family unit and its members D. Eagerness to learn newborn care skills

-A. Expressions of excitement Rationale: Expressing excitement and being talkative are characteristic of this phase. B. Lack of appetite Rationale: A lack of appetite is not a characteristic of maternal postpartum adjustment. C. Focus on the family unit and its members Rationale: A focus on the family unit and its members is a finding in the interdependent, letting go phase of maternal postpartum adjustment. D. Eagerness to learn newborn care skills Rationale: A desire to learn newborn care is a finding in the dependent-independent, taking hold phase of maternal postpartum adjustment

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 partners

-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. B. Mosquito bites Rationale: Mosquito bites are not associated with TSS. C. Travel to foreign countries Rationale: Travel to foreign countries is not associated with TSS. D. Multiple sexual partners Rationale: Multiple sexual partners is not associated with TSS

A nurse is preparing to administer an injection of Rho (D) immunoglobulin. The nurse should understand that the purpose of this injection is to prevent which of the following newborn complications? A. Hydrops fetalis B. Hypobilirubinemia C. Biliary atresia . D. Transient clotting difficulties

-A. Hydrops fetalis Rationale: Hydrops fetalis is the most severe form of Rh incompatibility and can be prevented by the administration of Rho (D) immunoglobulin. B. Hypobilirubinemia Rationale: Hyperbilirubinemia, not hypobilirubinemia, is a hemolytic disorder of the newborn that occurs as a result of Rh incompatibility. C. Biliary atresia Rationale: Biliary atresia is a congenital structural anomaly in the newborn and is not prevented by the administration of Rho (D) immunoglobulin. D. Transient clotting difficulties Rationale: Galactosemia is a cause of hemolytic jaundice in the newborn and is not prevented by the administration of Rho (D) immunoglobulin

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. Created on:11/29/2018 Page 90 Detailed Answer Key medical B. Increased deposits of fat in the chest and shoulder area Rationale: Increased fat deposits in the chest and shoulder area increase the risk of shoulder dystocia at delivery. C. Brachial plexus injury Rationale: A brachial plexus injury causes the arm to hang limply at the newborn's side. It is typically the result of a difficulty delivery. D. Increased blood viscosity Rationale: Increased blood viscosity is due to polycythemia, which increases the risk of developing hyperbilirubinemia

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. B. Hypomagnesemia Rationale: Newborns of mothers who have diabetes are at risk for hypomagnesemia, but this is not the nurse's priority focus of care. C. Hyperbilirubinemia Rationale: Newborns of mothers who have diabetes are at risk for hyperbilirubinemia, but this is not the Created on:11/29/2018 Page 74 Detailed Answer Key medical nurse's priority focus of care. D. Hypocalcemia Rationale: Newborns of mothers who have diabetes are at risk for hypocalcemia, but this is not 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. B. Decreased blood pressure in the arms with increased 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. C. Increased blood pressure in both the arms and 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. D. Decreased blood pressure in both the arms and 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 planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care? A. Initiate a controlled low-protein diet. B. Educate parents on blood glucose monitoring. C. Administer thyroid hormone replacement. . D. Obtain a blood sample for blood type.

-A. Initiate a controlled low-protein diet. Rationale: PKU is managed by eliminating phenylalanine from the diet. It is found in most natural food proteins, such as milk and infant formulas. A special low-protein, amino-acid formula that is low in phenylalanine is initiated and included in the plan of care. B. Educate parents on blood glucose monitoring. Rationale: Blood glucose monitoring is needed for the client who has a new diagnosis of diabetes. Therefore, educating parents on blood glucose monitoring is not an appropriate action to include in the plan of care. C. Administer thyroid hormone replacement. Rationale: Thyroid hormone replacement is necessary for the client who has a new diagnosis of hypothyroidism. Therefore, administering thyroid hormone replacement is not an appropriate action to include in the plan of care. D. Obtain a blood sample for blood type. Rationale: Obtaining a blood sample for blood type is not indicated for newborns who have PKU. Therefore, it is not an appropriate action to include in the plan of care

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.

-A. 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. B. Promote maternal-infant bonding. Rationale: Although promoting maternal-infant bonding is important, there is a higher priority during the preoperative phase of care. C. Educate the parents about the defect. Rationale: Although parental education is important, there is a higher priority during the preoperative phase of care. D. Provide age-appropriate stimulation. Rationale: Although providing age-appropriate stimulation is important, there is a higher priority during the preoperative phase of care.

A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of lactated Ringer's with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification? A. Methylergonovine 0.2 mg IM now. B. Insert an indwelling urinary catheter. C. Administer oxygen by nonrebreather mask at 5 L/min. D. Obtain laboratory study of prothrombin and partial thromboplastin time.

-A. Methylergonovine 0.2 mg IM now. Rationale: Methylergonovine is contraindicated in the client with a blood pressure greater than 140/90 mm Hg. This prescription requires clarification. B. Insert an indwelling urinary catheter. Rationale: Insertion of an indwelling urinary catheter is an appropriate prescription for the client who has a hypotonic uterus. C. Administer oxygen by nonrebreather mask at 5 L/min. Rationale: Administration of oxygen by a nonrebreather mask at 5 L/min is an appropriate prescription for the client who has a hypotonic uterus. D. Obtain laboratory study of prothrombin and partial thromboplastin time. Rationale: Laboratory studies include prothrombin time, partial thromboplastin time, complete blood count with platelet count, fibrinogen, fibrin split products, blood type, and antibody screen for the client who has a hypotonic uterus

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. 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. B. Hold the newborn vertically allowing one foot to touch the table surface. Rationale: This position is used to elicit the stepping reflex. The newborn should respond by alternating flexion and extension of his feet, as if he was walking. C. Place a finger at the base of the newborn's toes. Rationale: This action elicits the plantar grasp reflex. The expected response is that the newborn's toes will curl downward. D. Turn the newborn's head quickly to one side. Rationale: This action elicits the tonic neck reflex. The expected response is that the newborn will extend the arm and leg on the side where the head was turned, while the opposite arm and leg will flex

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. B. Preterm delivery Rationale: A preterm newborn is defined as one born prior to the completion of 37 weeks of gestation, regardless of the birth weight. Small for gestational age refers to newborns whose weight falls below the 10th percentile on intrauterine growth curves. C. Fetal hyperinsulinemia Rationale: Fetal hyperinsulinemia is the result of high levels of maternal glucose crossing the placenta. This would result in increased growth and fat deposits in the fetus. D. Perinatal asphyxia Rationale: Newborns who are small for gestational age are at risk for perinatal asphyxia due to chronic hypoxia, but this is not a cause of the condition.

A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP? A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. B. Observe an area of redness on the breast of a client who is 1 day postpartum. C. Monitor vital signs during admission of a client who has gestational hypertension. D. Change the perineal pad of a client who just transferred from labor and delivery.

-A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. Rationale: Providing comfort measures is an appropriate task that can be delegated to the AP since it does not require nursing judgment. B. Observe an area of redness on the breast of a client who is 1 day postpartum. Rationale: Assessment of a client's breast is a task that cannot be delegated to the AP because this requires professional nursing knowledge. C. Monitor vital signs during admission of a client who has gestational hypertension. Rationale: Initial nursing assessment during the admission of a client who has an alteration in blood pressure cannot be delegated to the AP because this requires professional nursing knowledge. D. Change the perineal pad of a client who just transferred from labor and delivery. Rationale: Created on:11/29/2018 Page 79 Detailed Answer Key medical Initial nursing assessment of the perineal pad of a client following delivery cannot be delegated to the AP because this requires professional nursing knowledge

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. B. Hypothermia Rationale: Hypothermia in a newborn can lead to both respiratory distress and hypoglycemia. While it is important to monitor for this, there is another assessment that is the priority. C. Accidental lacerations Rationale: Accidental lacerations can be inflicted with the scalpel during a cesarean birth. They are typically superficial and rarely need sutures. While it is important to assess for the presence of these, there is another assessment that is the priority. D. Acrocyanosis. Rationale: Acrocyanosis is a bluish discoloration of the hands and feet and is an expected finding in the first 24 hours following delivery. There is another assessment that is the priority.

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. 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. Rationale: Take the newborn for a ride in the car is correct. Movement and rhythmic noise are soothing to newborns. Keep the newborn in the center of a large crib is incorrect. Newborns prefer small, warm, close spaces similar to the intrauterine environment. Carry the newborn in a front or back pack is correct. Carrying the newborn in a front or back carrier provides the comfort of close contact and gentle movement that is soothing to newborns. Swaddle the newborn in a receiving blanket is correct. Swaddling simulates the intrauterine environment, position-wise, and provides security to the newborn. Allow the newborn to continue crying is incorrect. Responsiveness to crying fosters trust as the newborn associates comfort with the caregiver

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.

-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. 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. 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. Rh incompatibility only occurs when the client's blood does not contain Rh factor (Rh negative) but the fetal blood does contain Rh factor (Rh positive). C. The client has a history of receiving a transfusion with Rh-negative blood. Rationale: Receiving a transfusion of Rh-negative blood would not cause sensitization of the client's blood against Rh factor. D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells. Rationale: Anti-A and anti-B antibodies can cause fetal blood cell destruction when there is an ABO incompatibility. This type of incompatibility is related to the client/fetal blood type, not the presence of Rh factor.

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 B. Large ears C. Muscular hypertonicity -D. Protruding tongue E. Low birth weight Rationale: Transverse palmar creases is correct. A common characteristic of newborns who have Trisomy 21 is transverse palmar creases. Large ears is incorrect. A common characteristic of newborns who have Trisomy 21 is small ears. Muscular hypertonicity is incorrect. A common characteristic of newborns who have Trisomy 21 is muscular hypotonicity. Protruding tongue is correct. A common characteristic of newborns who have Trisomy 21 is protruding tongue. Low birth weight is incorrect. Newborns who have Trisomy 21 do not demonstrate the common characteristic of low birth weight

A nurse is caring for a client who is 6 hr postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse? A. "It determines if kernicterus will occur in the newborn." Rationale: Kernicterus is the irreversible chronic result of acute bilirubin encephalopathy. While the presence of Rh antibodies in the client's blood increases the risk of jaundice and acute bilirubin encephalopathy in the newborn, it does not determine if these disorders will occur. B. "It detects Rh-negative antibodies in the newborn's blood." Rationale: If the client is Rh-negative, her blood is lacking Rh factor. Rh antibodies are only produced in response to the unexpected presence of Rh factor, not its absence. A newborn who has Rh positive blood has Rh factor so would not produce antibodies against it. -C. "It detects Rh-positive antibodies in the mother's blood." Rationale: An indirect Coombs test determines the presence of Rh antibodies. If the client has Rh-negative blood, she does not produce Rh factor. Exposure to Rh positive blood, such as from an Rh factor positive fetus, could trigger the client to begin producing antibodies against Rh factor. These antibodies can cross the placenta and harm an Rh-positive fetus. D. "It determines the presence of maternal antibodies in the newborn's blood." Rationale: A direct Coombs test measures the present of maternal antibodies in the newborn's blood

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 Rationale: Antihypertensives do not interfere with the effectiveness of COCs when taken simultaneously. -B. Anticonvulsants Rationale: Anticonvulsants when taken simultaneously with COCs can decrease their effectiveness. The anticonvulsants included are: phenytoin, phenobarbital, carbamazepine, oxcarbazepine, topiramate, and primidone. C. Antioxidants Rationale: Antioxidants do not interfere with the effectiveness of COCs when taken simultaneously. D. Antiemetics Rationale: Antiemetics do not interfere with the effectiveness of COCs when taken simultaneously

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 your 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 a concern, but strabismus is easily treated with patching."

A. "I will call your primary care provider to report your concerns." Rationale: This is an inappropriate response by the nurse because it does not address the client's feelings of concern. B. "I will take your baby to the nursery for further examination." Rationale: It is not necessary for the nurse to complete additional examination of the newborn. This also does not address the client's concerns. -C. "This occurs because newborns lack muscle control to regulate eye movement." Rationale: This addresses the client's concerns because it provides information that addresses her concerns. The eyes of newborns are structurally incomplete and muscle control is not fully developed for 3 months. D. "This is a concern, but strabismus is easily treated with patching." Rationale: This is an inappropriate statement by the nurse because it offers unwarranted reassurance The nurse is making an assumption that that should be addressed by the provider.

A nurse in a prenatal clinic is teaching a group of clients about nutrition requirements during lactation. Which of the following statements should the nurse make? A. "Calcium intake should be at least 2,000 mg per day." B. "Zinc intake should be at least 12 mg per day." C. "The recommended intake of folic acid remains the same as for pregnant women." D. "The recommended intake of iron increases."

A. "Calcium intake should be at least 2,000 mg per day." Rationale: The calcium requirement during lactation for women over age 19 is 1,000 mg, which is the same as during pregnancy and for nonpregnant female clients of the same age. -B. "Zinc intake should be at least 12 mg per day." Rationale: Zinc intake should be increased to 12 mg per day during lactation, which is above the recommended levels for pregnancy and nonpregnant female clients over age 19. C. "The recommended intake of folic acid remains the same as for pregnant women." Rationale: Folic acid requirements are 500 mcg per day during lactation, as compared to a recommended intake of 600 mcg during pregnancy. D. "The recommended intake of iron increases." Rationale: Iron requirements do not increase during lactation. They remain 9 mg per day for female clients over age 19

A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as an indication of inhibition of parental attachment? A. "He's got my husband's nose, that's for sure." B. "I don't need a baby bath demonstration. I know how to do it." C. "I wish he had more hair. I will keep a hat on his head until he grows some." D. "Do you think you could keep him in the nursery for the next feeding so I can get some sleep?"

A. "He's got my husband's nose, that's for sure." Rationale: Identification of family characteristics is a sign of healthy attachment. B. "I don't need a baby bath demonstration. I know how to do it." Rationale: The client might have experience bathing a newborn. The nurse should obtain additional information regarding the reason for the client not wanting this learning experience before assuming this is inhibited parental attachment. -C. "I wish he had more hair. I will keep a hat on his head until he grows some." Rationale: This client statement expresses disappointment in the newborn's appearance and a need to hide what the client perceives as an undesirable feature. This is an indication of inhibited parental attachment. D. "Do you think you could keep him in the nursery for the next feeding so I can get some sleep?" Rationale: A client can experience fatigue and a need for sleep following labor and delivery. The nurse should validate the client's concerns before concluding that the client is manifesting inhibited parental attachment

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."

A. "I should start solid foods when my baby is 3 months old." Rationale: The American Academy of Pediatrics recommends that the introduction of solid foods should not begin until after 4 months of age, and preferably not until 6 months of age. Created on:11/29/2018 Page 66 Detailed Answer Key medical B. "I should introduce cow's milk when my baby is 9 months old." Rationale: Cow's milk lacks adequate nutrients an infant needs to grow. Therefore, it is recommended that cow's milk should not be introduced until the infant is 12 months old. -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. D. "I should wait to begin fluoride supplements until my baby is 4 months of age." Rationale: Commercial iron-fortified formula has all the fluoride an infant needs for the first 6 months of life. Fluoride supplements should not begin until 6 months of age and only for infants if the local water supply is not fluoridated

.A nurse is teaching a client who is breastfeeding about dietary recommendations. Which of the following statements by the client indicates understanding of the teaching? A. "I will decrease my daily fiber intake." B. "I'll make sure I reduce salt in my diet." C. "I'll eat more protein at each meal." D. "I will consume more vitamin D-rich foods."

A. "I will decrease my daily fiber intake." Rationale: During lactation, clients should consume about 4 g more of fiber per day than nonpregnant, nonlactating women. B. "I'll make sure I reduce salt in my diet." Rationale: Unless the client has an underlying disorder that requires sodium restriction, this is not necessary during lactation. Recommended sodium intake for nonpregnant, pregnant, and lactating female clients during the childbearing years is 1.5 to 2.3 g/day. -C. "I'll eat more protein at each meal." Rationale: During lactation, clients should consume about 25 g of additional protein per day, which is more than what is required by nonpregnant and nonlactating female clients. D. "I will consume more vitamin D-rich foods." Rationale: The recommended intake of vitamin D is 5 mcg/day, which is the same for nonpregnant, pregnant, and lactating female clients

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."

A. "I will keep my baby's head elevated while he is feeding." Rationale: A semi-reclining position is appropriate for bottle feeding. B. "I will allow my baby to burp several times during each feeding." Rationale: Newborns swallow air during feeding and should be offered the opportunity to burp several times during each feeding. -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. D. "My baby will have soft, formed yellow stools." Rationale: A newborn who is bottle-fed typically has soft, formed yellow stools and they can occur with each feeding. The frequency of stools will decline as the newborn adapts to feeding

A nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. Which of the following responses should the nurse provide? A. "I'll feed him today. Maybe tomorrow you can try it." B. "Oh, this isn't difficult. You'll be fine doing this." C. "You can learn to feed him; I wasn't comfortable the first time I fed a baby either." D. "Feeding an infant can feel a little intimidating at first, but I'll stay and help you."

A. "I'll feed him today. Maybe tomorrow you can try it." Rationale: This is a close-ended nontherapeutic response that might eliminate the client's anxiety momentarily, but it does not provide an opportunity for the client to express her anxiety or to learn an essential skill. B. "Oh, this isn't difficult. You'll be fine doing this." Rationale: This is an example of a nontherapeutic response that offers false reassurance. The nurse cannot assume the client has the knowledge to feed the newborn correctly. C. "You can learn to feed him; I wasn't comfortable the first time I fed a baby either." Rationale: This nontherapeutic response illustrates the technique of changing the topic to one that reflects a personal issue of the nurse, rather than focusing on the client's issues. -D. "Feeding an infant can feel a little intimidating at first, but I'll stay and help you." Rationale: The nurse, while recognizing and acknowledging the client's apprehension, offers assistance and a sense of presence, with the intention of boosting client confidence.

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching? A. "I'll let my baby drain one breast at each feeding." B. "I'll try drinking an herbal tea to reduce the engorgement." C. "I'll apply cold compresses 20 minutes before each feeding." D. "I'll feed my baby every 2 hours."

A. "I'll let my baby drain one breast at each feeding." Rationale: The client should have her newborn drain both breasts at each feeding to soften them. If the newborn can only drain one breast, the client should pump the other breast to soften it. B. "I'll try drinking an herbal tea to reduce the engorgement." Rationale: Herbal remedies should be reviewed with the provider to determine those that are safe to use when breastfeeding. C. "I'll apply cold compresses 20 minutes before each feeding." Rationale: There is no evidence to support the use of cold compresses to relieve breast engorgement. If a client prefers the application of cold compresses to manage the discomfort of engorgement, it should be applied after each feeding. -D. "I'll feed my baby every 2 hours." Rationale: Breast engorgement is relieved by emptying both breasts. The client might be able to accomplish this with more frequent feedings. Otherwise, she can pump her breasts after breastfeeding to ensure optimal emptying.

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." D. "This is erythema toxicum, which is a transient condition."

A. "Mongolian spots can be found on the skin of many newborns." Rationale: Mongolian spots are bluish-black areas of pigmentation more commonly noted on the back and buttocks. -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. C. "This is a cephalhematoma, which can occur spontaneously." Rationale: A cephalohematoma is a collection of blood between the skull and periosteum and does not 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." Rationale: Erythema toxicum is a transient skin rash that can occur during the first 3 weeks of life. It is thought to be an inflammatory response and no treatment is required

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."

A. "Most new mothers feel somewhat anxious about things like this." Rationale: With this response, the nurse is using the nontherapeutic communication technique of passing judgment about the client's feelings. It discourages the client from making further comments. B. "There's nothing for you to worry about. Newborns often breathe this way." Rationale: With this response, the nurse is using the nontherapeutic communication technique of offering false reassurance. It does not encourage the client to express her concerns. C. "Why do you think there is something wrong with that?" Rationale: With this response, the nurse is using the nontherapeutic communication technique of challenging the client for an explanation. It ends further statements of client concern. -D. "Let's sit here together and observe your baby while you feed him." Rationale: With this response, the nurse is using the therapeutic communication techniques of focusing and physical attending.

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." One in 1,000 newborns has a significant hearing loss. 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." D. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles."

A. "There is no need to worry about that. Most forms of hearing loss are not inherited." Rationale: The nurse is giving the client false reassurance, a nontherapeutic communication technique. One in 1,000 newborns has a significant hearing loss. B. "Look at how she looks as you when you speak. That's a good sign." Rationale: The nurse is giving the client false reassurance, a nontherapeutic communication technique, by equating what might be reflexive or unintentional behavior with hearing. One in 1,000 newborns has a significant hearing loss. -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. D. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles." Rationale: This is an unreliable way to test hearing

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? A. Administer vitamin K. B. Dry the skin. C. Administer eye prophylaxis. D. Place an identification bracelet.

A. Administer vitamin K. Rationale: Administration of vitamin K is important, but it can be delayed until the newborn is held by the mother and is breastfed. There is another, more important nursing action. •-B. Dry the skin. Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother's abdomen, and a cap applied to the newborn's head to prevent cold stress. The newborn responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory distress. Based on Maslow's hierarchy of needs, this is the most important nursing action after securing the airway. C. Administer eye prophylaxis. Rationale: Administration of eye prophylaxis should occur within the first hour after birth. There is another. more important nursing action. D. Place an identification bracelet. Rationale: Correct identification of the newborn is important, but it can be delayed, as long as it is completed prior to the mother and newborn leaving the delivery room. There is another, more important nursing action.

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."

A. "You are so young. Are you ready for the responsibilities of a sexual relationship?" Rationale: This response is an example of the nontherapeutic communication technique of probing and is likely to make the client feel defensive or to withdraw from seeking help with contraception. B. "Because of your age, I think that a barrier method would be the best choice." Rationale: This response is an example of the nontherapeutic communication technique of passing judgment. The nurse implies that she knows what is best for the client and does not take the client's concerns or preferences into consideration. -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. D. "A provider can help you with that after a physical examination." Rationale: By referring the client to a provider, the nurse ends further communication with the client about her concerns.

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if 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 grandchild 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, you can take the infant."

A. "You may carry your grandchild to the room." Rationale: This is not an appropriate response. Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting a newborn to leave the nursery. B. "You can push the baby to the room in a wheeled bassinet." Rationale: This is not an appropriate response. Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting a newborn to leave the nursery. -C. "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. D. "If you show me your photo identification, you can take the infant." Rationale: This is not an appropriate response. Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting a newborn to leave the nursery.

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."

A. "You might want to offer water supplements between feedings." Rationale: This is not an explanation for weight loss. Water supplements are not recommended at this time. The nurse should review the newborn's pattern of breast feeding, the mother's breast feeding technique, and factors that can influence decreased milk production. B. "It is due to the newborn's loss of the influence of the maternal hormones." Rationale: This is not an explanation for weight loss. Breastfed newborns typically lose 5% to 6% of body weight before gaining weight. A delayed period of weight gain might be due to a slower transition from early breast milk to mature milk. C. "This might be related to your baby having 3 stools a day." Rationale: This is not an explanation for weight loss. The newborn who is being breastfed typically has 3 or more stools per day during the first few weeks. -D. "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 is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make? A. "You need to take pain medications so you are more comfortable." B. "We can time your pain medication so that you have an hour or two before the next feeding." C. "All medications are found in breast milk to some extent." D. "You have the option of not taking pain medication if you are concerned."

A. "You need to take pain medications so you are more comfortable." Rationale: This answer does not address the client's concern about taking pain medication while breastfeeding. -B. "We can time your pain medication so that you have an hour or two before the next feeding." Rationale: This answer provides the client an option that allows for administration of pain medication but minimizes the effect it will have on the newborn while breastfeeding. C. "All medications are found in breast milk to some extent." Rationale: This answer does not provide an option for the client that addresses the impact of pain medication on the newborn during breastfeeding. D. "You have the option of not taking pain medication if you are concerned." Rationale: This answer does not provide an option for the client to enhance her comfort while breastfeeding her newborn.

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take? A. Assist the client into a comfortable position. B. Observe the perineum for signs of crowning. C. Have the client pant during the next contractions. D. Help the client to the bathroom to void.

A. Assist the client into a comfortable position. Rationale: A comfortable position will not affect the client's need to push. B. Observe the perineum for signs of crowning. Rationale: At 7 cm of cervical dilation, it is too soon to observe for crowning. -C. Have the client pant during the next contractions. Rationale: Panting is rapid, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation. Observe for hyperventilation and have the client exhale slowly through pursed lips. D. Help the client to the bathroom to void. Rationale: Emptying the bladder does not alter the client's urge to push

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." Rationale: Burping the baby will not ensure the newborn is getting enough breast milk. D. "Your baby should sleep at least 6 hours between feedings." Rationale: A newborn should eat at least every 4 hr at night; however, length of sleep between feedings is not an indicator that the infant is getting enough breast milk.

A. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." Rationale: Babies will typically sleep after a feeding, making this an unreliable indicator that the newborn is getting enough breast milk. B. "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. C. "Your baby should burp after each feeding." Rationale: Burping the baby will not ensure the newborn is getting enough breast milk. D. "Your baby should sleep at least 6 hours between feedings." Rationale: A newborn should eat at least every 4 hr at night; however, length of sleep between feedings is not an indicator that the infant is getting enough breast milk.

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. A newborn who is 24 hr post-delivery and has not voided Rationale: First voiding usually occurs within 24 to 48 hr following delivery. B. A newborn who is 18 hr post-delivery and has acrocyanosis Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, can persist for 24 hr following delivery. C. A newborn who is 24-hr post-delivery and has not passed meconium Rationale: Passage of meconium usually occurs within 12 to 48 hr post-delivery. -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. 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

A. Absent bowel sounds Rationale: Visible gastric peristaltic waves moving from the left to the right are a clinical manifestation of pyloric stenosis. B. Increased sodium levels Rationale: Vomiting causes a depletion of fluid and electrolytes; therefore, a decrease in serum sodium levels is a clinical manifestation of pyloric stenosis. -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. D. Golf ball-sized mass over the left quadrant Rationale: An olive-shaped mass palpable right of the umbilicus is a clinical manifestation of pyloric stenosis.

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 t. D. Asymmetric thigh folds

A. Absent plantar reflexes Rationale: Absence of any newborn reflexes indicate a neurological problem, not a musculoskeletal one. B. Lengthened thigh on the affected side Rationale: With DDH, the thigh on the affected side is shorter than the thigh on the unaffected side. This is known as Galeazzi sign. C. Inwardly turned foot on the affected side Rationale: A foot that turns inward can be the result of fetal positioning or due to a congenital condition known as talipes equinovarus or club foot. -D. Asymmetric thigh folds Rationale: Gluteal and thigh skin folds that are not equal and symmetric is a sign of DDH

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

A. Acrocyanosis of hands and feet Rationale: Acrocyanosis is monitored as part of the Apgar and newborn physical assessment but is not a component of gestational age assessment. B. Anterior fontanel soft and level Rationale: The anterior fontanel is palpated as part of newborn physical assessment but is not a component of gestational age assessment. -C. Plantar creases cover 2/3 of sole Rationale: Observing the presence of creases on the plantar surface is one of the components of a gestational age assessment. D. Vernix caseosa in inguinal creases Rationale: Vernix caseosa in inguinal creases is a normal newborn finding but not a component of gestational age assessment

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.) 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 C. Short, soft fingernails D. Abundant lanugo E. Vernix in the folds and creases Rationale: Cracked, peeling skin is correct. Physical findings that indicate postmaturity in a newborn (gestational age of qreater than 42 weeks) include cracked, peeling skin.Positive Moro reflex is correct.Reflexes that are present in a postmature newborn are the same as those that are present in a mature newborn. These reflexes include a positive Moro reflex.Short, soft fingernails is incorrect.Short, soft fingernails are not characteristic of the postmature newborn. They appear long and are hard. Abundant lanugo is incorrect. Abundant lanugo is seen in preterm (gestational age of less than 37 weeks) newborns. Vernix in folds and creases is incorrect. Vernix in the folds and creases is seen in mature, term newborns.

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications? A. Anaphylactoid syndrome of pregnancy B. Disseminated intravascular coagulation C. Preeclampsia D. Puerperal infection

A. Anaphylactoid syndrome of pregnancy Rationale: Anaphylactoid syndrome of pregnancy, due to an amniotic fluid embolism, typically occurs within 30 min after birth and is manifested by sudden, acute onset of hypoxia, hypotension, cardiac arrest, and coagulopathy. -B. Disseminated intravascular coagulation Rationale: Clinical manifestations of disseminated intravascular coagulation (DIC) include oozing from intravenous access and venipuncture sites; petechiae, especially under the site of the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of bruising; and hematuria. C. Preeclampsia Rationale: Preeclampsia is typically seen in the antepartum period and is manifested by elevated blood pressure, hyperactive reflexes, proteinuria, and edema. D. Puerperal infection Rationale: Puerperal or postpartum infection is identified by the presence of a fever of 380 C (100.40 F) or higher on 2 consecutive days of the first 10 postpartum days and can include endometritis, wound infections, urinary tract infections, and mastitis

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. .

A. Apply mineral oil to the nipples between feedings. Rationale: The client should apply purified lanolin to the nipples after feedings. B. Keep the nipples covered between breastfeeding sessions. Rationale: The client should expose sore nipples to the air as much as possible. C. Increase the length of time between feedings. Rationale: Decreasing the frequency of feedings does not prevent sore nipples or allow time for healing. -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 planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care? A. Apply warm, moist heat to the client's lower extremities. B. Massage the client's posterior lower legs. C. Place pillows under the client's knees when resting in bed. D. Have the client ambulate.

A. Apply warm, moist heat to the client's lower extremities. Rationale: Warm, moist heat helps relieve the discomfort of thrombophlebitis, but it does not prevent it. B. Massage the client's posterior lower legs. Rationale: Massage of the legs does not prevent blood clot formation, and can dislodge a clot that is present and undetected. C. Place pillows under the client's knees when resting in bed. Rationale: Flexing the client's knees by placing pillows under them causes blood to pool in the lower extremities and increases the risk of thrombophlebitis. -D. Have the client ambulate. Rationale: Venous stasis is a major cause of thrombophlebitis. To prevent clot formation, have the client ambulate as soon as she can after delivery and as often as possible.

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.

A. Ask another nurse to verify the heart rate. Rationale: Unless the nurse has doubts about measuring the newborn's apical heart rate, there is no need to ask another nurse to verify this finding. -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. C. Call the provider to further assess the newborn. Rationale: Based on this finding, there is no need to call the provider to assess the newborn. D. Prepare the newborn for transport to the NICU. Rationale: Based on this finding, there is no need to prepare the newborn for transport to the NICU.

A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first? A. Assess client's blood pressure. B. Assess the bladder for distention. C. Massage the client's fundus. D. Prepare to administer a prescribed oxytocic preparation.

A. Assess client's blood pressure. Rationale: Blood pressure is not a reliable indicator of impending shock from hemorrhage because compensatory mechanisms prevent a significant drop in blood pressure until the client has lost 30 to 40% of her blood volume. B. Assess the bladder for distention. Rationale: While a distended bladder can displace the uterus and interfere with contractions, this is not the first action the nurse should take. -C. Massage the client's fundus. Rationale: The initial management of excessive uterine bleeding is firm massage of the uterine fundus. This action stimulates contraction of the uterine muscles, which constrict the maternal uterine blood vessels. D. Prepare to administer a prescribed oxytocic preparation. Rationale: If manual massage of the uterine fundus does not increase contractility and slow bleeding, it would then be appropriate to empty the bladder and administer a continuous IV infusion of oxytocin.

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse? A. Assist the family to identify prior use of positive coping skills in family crises. . B. Ask the client if she has considered harming her newborn. C. Anticipate a prescription by the provider for an antidepressant. D. Reinforce postpartum and newborn care discharge teaching.

A. Assist the family to identify prior use of positive coping skills in family crises. Rationale: Assisting the family to identify the use of coping mechanisms at a time of family crisis is important, but it is not the first action the nurse should consider. -B. Ask the client if she has considered harming her newborn. Rationale: When using the nursing process in caring for a client, the first action should focus on assessment of the client's mood, ability to concentrate, thought processes, and if the client has had thoughts of self-harm or of injuring her newborn. C. Anticipate a prescription by the provider for an antidepressant. Rationale: Created on:11/29/2018 Page 67 Detailed Answer Key medical Although it is likely that the client will need medication therapy, there are other actions that the nurse should consider first in using the nursing process. D. Reinforce postpartum and newborn care discharge teaching. Rationale: It is appropriate to reinforce discharge teaching that focuses on the postpartum period and care of a newborn, but this is not the priority action by the nurse at this time

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 does not promote the newborn to latch. D. Stepping

A. Babinski Rationale: The Babinski reflex is elicited by stroking upward along the lateral edge of the sole of the newborn's foot. This reflex does not promote the newborn to latch. -B. 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. C. Moro Rationale: The Moro reflex is elicited by striking the surface next to the newborn to startle him. This reflex does not promote the newborn to latch. D. Stepping Rationale: The stepping reflex is elicited by holding the newborn vertically with one foot in contact with a surface. The newborn will make leg movements that look like walking. This reflex does not promote the newborn to latch

A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform? A. Bladder distention B. Pulse rate C. Respiratory rate . D. Color of lochia

A. Bladder distention Rationale: A sitz bath does not result in bladder distention, but it can assist a client to void who is experiencing urinary retention. -B. Pulse rate Rationale: A sitz bath causes vasodilation; therefore, the nurse should monitor the client's pulse rate. Orthostatic hypotension can occur upon standing causing the client to feel faint. C. Respiratory rate Rationale: A sitz bath should not alter the client's respiratory rate. D. Color of lochia Rationale: The color, characteristics, and quantity of lochia are related to uterine tone. They do not assess a client's tolerance of a sitz bath

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

A. Caput succedaneum Rationale: Caput succedaneum is edema of the presenting part of the newborn's head due to pressure during labor. The edema extends across the suture lines of the skull. -B. Cephalhematoma Rationale: A cephalhematoma is a swelling, indicating bleeding under the subcutaneous tissues of the newborn's scalp. The collection of blood is beneath the periosteum of the cranial bone and therefore does not cross the suture line. C. Molding Rationale: Molding is a temporary misshaping of the fetal head due to overlapping cranial bones at the suture lines to accommodate the passage of the fetal head through the birth canal. D. Pilonidal dimple Rationale: Pilonidal dimple can be observed when assessing the vertebral column and can be associated with spina bifida

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

A. Copious vernix Rationale: A newborn who is postmature lacks vernix. B. Scant scalp hair Rationale: A newborn who is postmature commonly has profuse scalp hair. C. Increased subcutaneous fat Rationale: A newborn who is postmature lacks subcutaneous fat. D. Dry, cracked skin Rationale: A newborn who is postmature has dry, cracked skin.

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

A. Cyanosis with crying 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. Therefore, cyanosis is not a clinical manifestation of a large patent ductus arteriosus. -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. C. Weak pulses 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. Therefore, bounding pulses is a clinical manifestation of a large patent ductus arteriosus. D. Chronic hypoxemia 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. Therefore, chronic hypoxemia is not a clinical manifestation of a large patent ductus arteriosus

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

A. Displays a social smile Rationale: An infant that is 2 months old is able to display a social smile. -B. Follows movements of objects with eyes Rationale: A 1-month-old infant is able to follow movements with their eyes. C. Reacts to sounds by turning head Rationale: An infant that is 3 months old is able to turn their head to locate sounds. D. Makes babbling sounds Rationale: An infant that is 3 months old is able to make a babbling sound

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action? A. Elevate the client's legs. B. Position the client on her side. C. Administer oxygen via face mask. D. Increase the infusion rate of the IV fluid.

A. Elevate the client's legs. Rationale: Elevating the client's legs might help relieve maternal hypertension, but there is a higher priority action. -B. Position the client on her side. Rationale: Late decelerations stem from decreased blood perfusion to the placenta or compression of the placenta. A position change should increase perfusion or decrease compression, and it is the first intervention the nurse should try. The greatest risk to the client is fetal hypoxia, so the priority action is the one that has the best chance of improving fetal perfusion. C. Administer oxygen via face mask. Rationale: Administering oxygen can help increase the oxygen concentration of whatever blood does get to the placenta, but there is a higher priority action. D. Increase the infusion rate of the IV fluid. Rationale: Increasing the rate of fluid infusion is an appropriate intervention for late decelerations, but there is a higher priority action.

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take? A. Encourage the client to perform Kegel exercises. B. Encourage the client to move to the left lateral position. C. Ask the client to rate her pain. D. Assist the client to the bathroom to void.

A. Encourage the client to perform Kegel exercises. Rationale: Kegel exercises help to restore pelvic muscle tone that is often lost during pregnancy and birth. B. Encourage the client to move to the left lateral position. Rationale: Encouraging the client to lie on her side can decrease discomfort from an episiotomy or perineal laceration. C. Ask the client to rate her pain. Rationale: Created on:11/29/2018 Page 53 Detailed Answer Key medical Many women experience discomfort during the postpartum period. However, the fundal assessment is not an expected finding and needs further investigation. -D. Assist the client to the bathroom to void. Rationale: A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage.

A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest? A. Flex her knee while resting. B. Massage the area. C. Elevate her leg. D. Apply cold compresses.

A. Flex her knee while resting. Rationale: The client should avoid sharp flexion of the knee because it inhibits venous return. B. Massage the area. Rationale: The client should not massage the leg because it could turn a clot into an embolus. -C. Elevate her leg. Rationale: The client should elevate her leg to encourage venous return and to relieve pain. D. Apply cold compresses. Rationale: The client should apply moist heat to the affected area

A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect? A. Fundus soft, 1 cm to the right of the umbilicus B. Fundus firm, at the level of the umbilicus C. Fundus present, to the left of the umbilicus D. Fundus soft, 2 cm above the umbilicus

A. Fundus soft, 1 cm to the right of the umbilicus Rationale: A soft or boggy fundus indicates that the uterine muscle is not contracted. A fundal location that is not midline often indicates the client has a full bladder. -B. Fundus firm, at the level of the umbilicus Rationale: Within 12 hours after birth, the fundal tone is expected to be firm and the location is typically palpated midline and at the level of the umbilicus. C. Fundus present, to the left of the umbilicus Rationale: The fundal tone, location, and placement all need to be assessed and monitored to prevent the occurrence of hemorrhage. D. Fundus soft, 2 cm above the umbilicus Rationale: The fundus should be palpated as firm, indicating that it is contracted. Additionally, the expected location is at or below the level of the umbilicus.

A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications? A. Hearing loss B. Intrauterine growth restriction C. Type 1 diabetes mellitus D. Congenital heart defects

A. Hearing loss Rationale: Hearing loss in the newborn is related to congenital rubella syndrome and cytomegalovirus infection during pregnancy. -B. Intrauterine growth restriction Rationale: Clients who smoke place their newborns and themselves at risk for diverse complications, including fetal intrauterine growth restriction, placental abruption, placenta previa, preterm delivery, and fetal death. C. Type 1 diabetes mellitus Rationale: A newborn's risk for development of type 1 diabetes mellitus is associated with a family history of diabetes and an autoimmune process. D. Congenital heart defects Rationale: Congenital alterations in the newborn, such as ventricular septal defects and central nervous system malfunctions, are associated with maternal alcohol abuse

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

A. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months Rationale: This is not the appropriate vaccine and immune globulin schedule for a newborn whose mother is positive for the hepatitis B surface antigen. B. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen Rationale: This is not the appropriate vaccine and immune globulin schedule for a newborn whose mother is positive for the hepatitis B surface antigen. -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. D. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days Rationale: This is not the appropriate vaccine and immune globulin schedule for a newborn whose mother is positive for the hepatitis B surface antigen

A nurse is caring for a client who is breastfeeding her newborn and asks the nurse about the changes she should make in her diet. Which of the following dietary changes should the nurse suggest? A. Increase her caloric intake by 600 kcal/day. B. Increase her fluid intake to 2.5 L/day. C. Reduce her intake of iron. D. Avoid shellfish.

A. Increase her caloric intake by 600 kcal/day. Rationale: During the first 6 months of breastfeeding, the client should consume 330 more kcal/day, and 400 more during the second 6 months. B. Increase her fluid intake to 2.5 L/day. Rationale: During lactation, the client should increase her fluid intake to 3.8 L/day. -C. Reduce her intake of iron. Rationale: Recommendations for some nutrients, such as iron and folic acid, are less during lactation than during pregnancy. Because maternal blood volume decreases after childbirth, the client's need for these nutrients also diminishes. D. Avoid shellfish. Rationale: To maintain adequate levels of some vitamins and minerals, such as vitamin D and zinc, the client should include shellfish and other seafood in her diet

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.

A. Iron facilitates development of vision in infants. Rationale: Vitamin A is important for development of vision. B. Iron facilitates growth of bones in infants. Rationale: Calcium facilitates bone mineralization and growth. -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. D. Iron is poorly absorbed in infants. Rationale: The whey proteins in human milk and infant formulas have iron-binding capacities that allow for adequate absorption and storage of iron

A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time? A. Massage the fundus. . B. Insert a urinary catheter. C. Have the client urinate. D. Administer an analgesic.

A. Massage the fundus. Rationale: The client's fundus is firm, so there is no indication for massage. B. Insert a urinary catheter. Rationale: Catheterization might be necessary if the client is unable to void after implementing additional measures to promote urination. -C. Have the client urinate. Rationale: A full bladder displaces the uterine fundus and elevates it above the level of the umbilicus. This can lead to uterine atony and excessive bleeding. Having the client urinate allows the uterus to return to midline and remain below the umbilicus. D. Administer an analgesic. Rationale: Unless the client reports pain, there is no indication to administer an analgesic.

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis? A. Moderate amount of dark red lochia with a bloody odor . B. A localized area of breast tenderness C. Pelvic pain D. Hematuria .

A. Moderate amount of dark red lochia with a bloody odor Rationale: Foul-smelling, profuse lochia indicates endometritis. B. A localized area of breast tenderness Rationale: Localized breast tenderness along with fever and malaise are symptoms of mastitis. Created on:11/29/2018 Page 86 Detailed Answer Key medical -C. Pelvic pain Rationale: Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain. D. Hematuria Rationale: Hematuria is an indication of a urinary tract infection.

A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate? A. Moderate lochia rubra B. Fundus three fingerbreadths above the umbilicus C. Moderate swelling of the labia D. Blood pressure 130/84 mm Hg

A. Moderate lochia rubra Rationale: Moderate lochia rubra is an expected finding 8 hr following delivery and does not correlate with a full bladder. -B. Fundus three fingerbreadths above the umbilicus Rationale: A full bladder can raise the level of uterine fundus and possibly deviate it to the side. C. Moderate swelling of the labia Rationale: Swelling in the perineal area is an expected finding following a vaginal delivery and does not correlate with a full bladder. D. Blood pressure 130/84 mm Hg Rationale: The client's blood pressure after delivery does not correlate with a full bladder

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

A. Moist skin Rationale: Newborns who are SGA have loose, dry skin. B. Protruded abdomen Rationale: Newborns who are SGA have a sunken abdomen. C. Gray umbilical cord Rationale: Newborns who are SGA have a thin, yellowish umbilical cord that appears dull and is dry. -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 planning care for a 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.

A. Monitor I&O. Rationale: All newborns require monitoring to ensure adequate I&O. This is not the priority intervention for this client at this time. B. Monitor axillary temperature. Rationale: All newborns require temperature monitoring to prevent cold stress. This is not the priority intervention for this client at this time. -C. 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. D. Monitor weight. Rationale: All infants require weight measurement, and ongoing monitoring is important for infants who are SGA. This is not the priority intervention for this client at this time.

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 Rationale: An L/S ratio of 2:1 is an indication of fetal lung maturity. D. Nonstress test is reactive

A. Phosphatidylglycerol (PG) absent Rationale: The absence of PG is an indication that the fetal lungs have not reached maturity. B. Biophysical profile score of 8 Rationale: A biophysical profile score of 8 indicates fetal well-being, but does not determine 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. D. Nonstress test is reactive Rationale: A reactive nonstress test indicates fetal well-being, but does not determine if the fetal lungs have reached maturity

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 Rationale: Newborns who have hydrocephalus will have widened suture lines and full or bulging fontanels due to pressure from the increased amount of cerebral spinal fluid. B. Dilated scalp veins Rationale: Manifestations of hydrocephalus in newborns include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement. C. Hypertension Rationale: Hydrocephalus increases pressure within the central nervous system, not within the cardiovascular system. Signs of increased pressure in the CNS include irritability, lethargy, and vomiting. Created on:11/29/2018 Page 87 Detailed Answer Key medical D. A backward sloping appearance of the forehead. Rationale: This finding is associated with microcephaly, in which the newborn's head is smaller due to inadequate brain growth

A. Over-riding suture lines Rationale: Newborns who have hydrocephalus will have widened suture lines and full or bulging fontanels due to pressure from the increased amount of cerebral spinal fluid. -B. Dilated scalp veins Rationale: Manifestations of hydrocephalus in newborns include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement. C. Hypertension Rationale: Hydrocephalus increases pressure within the central nervous system, not within the cardiovascular system. Signs of increased pressure in the CNS include irritability, lethargy, and vomiting. Created on:11/29/2018 Page 87 Detailed Answer Key medical D. A backward sloping appearance of the forehead. Rationale: This finding is associated with microcephaly, in which the newborn's head is smaller due to inadequate brain growth

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 inflammatory disease of the gastrointestinal mucosa. C. Need for placement of a gastrostomy tube that would require long-term gavage feedings. D. Intraventricular hemorrhage

A. Overstimulation Rationale: Cues to overstimulation in preterm newborns include gaze aversion, hiccuping, gagging, vomiting, and uncoordinated movement of all their limbs. -B. Necrotizing enterocolitis Rationale: Premature newborns who are formula fed are much more likely to contract this acute inflammatory disease of the gastrointestinal mucosa. C. Need for placement of a gastrostomy tube Rationale: Gastrostomy tubes are used for newborns who have neurological or congenital malformations that would require long-term gavage feedings. D. Intraventricular hemorrhage Rationale: A germinal matrix or intraventricular hemorrhage occurs in the lateral ventricles of the brain. Manifestations include a full anterior fontanel, change in activity level, and decreased muscle tone.

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 by quickly and thoroughly drying the infant D. Maintaining ambient room temperature at 24° C (75° F)

A. Placing the newborn on a warm surface Rationale: This action decreases the loss of heat from a warm body to a cooler surface in direct contact. This process is called conduction. B. Preventing air drafts Rationale: This action decreases the loss of heat from a warm body to a cooler solid surface in close proximity but not in direct contact. This process is called radiation. Air drafts increase the effect of radiation. -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 D. Maintaining ambient room temperature at 24° C (75° F) Rationale: This action decreases the loss of body heat to the cooler ambient air. This process is called convection.

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions? A. Postpartum infection B. Hypertension C. Postpartum hemorrhage D. Thromboembolic events

A. Postpartum infection Rationale: Methylergonovine has no anti-infective properties. B. Hypertension Rationale: An adverse effect of methylergonovine is hypertension. This medication is contraindicated for the client who has hypertension or cardiac disease. -C. Postpartum hemorrhage Rationale: Methylergonovine is an oxytocic medication. It causes uterine contractions, which control postpartum bleeding. D. Thromboembolic events Rationale: Methylergonovine has no anticoagulant properties.

A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications? A. Puerperal infection . B. Retained placental fragments C. Thrombophlebitis D. Uterine atony

A. Puerperal infection Rationale: Endometritis is the most common cause of postpartum infections. B. Retained placental fragments Rationale: Placental retention due to poor separation is common in very preterm births. C. Thrombophlebitis Rationale: The major causes of thromboembolic disease in the pregnant client are venous stasis and hypercoagulation. -D. Uterine atony Rationale: A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of uterine atony

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action? A. Recheck the client's temperature in 4 hr. B. Administer glucocorticoids intramuscularly. when preterm birth is threatened. D. Prepare the client for emergency cesarean section.

A. Recheck the client's temperature in 4 hr. Rationale: The client's temperature should be checked at least every 2 hours after rupture of membranes. B. Administer glucocorticoids intramuscularly. Rationale: Antenatal glucocorticoids are indicated for all women between 24 and 34 weeks of gestation when preterm birth is threatened. -C. Assess the odor of the amniotic fluid. Rationale: Chorioamnionitis is an infection of the amniotic cavity that presents with maternal fever, tachycardia, increased uterine tenderness, and foul-smelling amniotic fluid. D. Prepare the client for emergency cesarean section. Rationale: While clients who have chorioamnionitis are more likely to have a dysfunctional labor, it is not an indication for an emergent cesarean section.

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%.

A. Remove the hood every hour for 10 min to facilitate bonding. Rationale: Supplemental oxygen must be provided if the hood is removed to minimize significant fluctuations in oxygenation. B. Insert an orogastric tube for decompression of the stomach. Rationale: Insertion of an orogastric tube is indicated with the use of continuous positive airway pressure therapy. C. Place the newborn in Trendelenburg position. Rationale: Trendelenburg position should be avoided because it increases intracranial pressure and reduces lung capacity. -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 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

A. Sternal notch Rationale: Using this landmark can result in an incorrect measurement of chest circumference. -B. Nipple line Rationale: The nurse should measure the newborn's chest circumference at the nipple line. C. Xiphoid process Rationale: Using this landmark can result in an incorrect measurement of chest circumference. D. Fifth intercostal space Rationale: Using this landmark can result in an incorrect measurement of chest circumference.

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.

A. Suction the nose with a bulb syringe. Rationale: Suctioning the secretions from the nose is important, but it is not the first action the nurse should take. Touching the nares with the tip of the bulb syringe might make the newborn gasp and inhale secretions from the mouth. -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. C. Use a suction catheter with low negative pressure. Rationale: It might become necessary to remove secretions that interfere with respiratory effort using a mechanical suction system, but this is not the first action the nurse should take. D. Turn the newborn on his side. Rationale: Positioning a newborn with excessive secretions on the side with a rolled blanket supporting the back is important to help prevent aspiration, but it is not the first action the nurse should take.

A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make? A. The client is exhibiting early indications of mastitis. B. Additional interventions are not indicated at this time. C. Application of a heating pad to the breasts is indicated. D. The client should be advised to remove her nursing bra. Rationale: Wearing a nursing bra helps reduce discomfort due to engorgement

A. The client is exhibiting early indications of mastitis. Rationale: Clinical manifestations of mastitis include chills, fever, malaise, and a localized area of breast tenderness. -B. Additional interventions are not indicated at this time. Rationale: For this postpartum day, the client's fundal location and lochia characteristics are within the expected reference range. Breast engorgement is typical, as this is the time when the breasts begin producing milk. Frequent breastfeeding and routine care can help relieve engorgement. C. Application of a heating pad to the breasts is indicated. Rationale: Heat increases blood flow and can, therefore, increase congestion in breasts that are already engorged. A heating pad should not be offered. However, a warm shower before breastfeeding can help relieve engorgement. D. The client should be advised to remove her nursing bra. Rationale: Wearing a nursing bra helps reduce discomfort due to engorgement

A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? A. The client is not experiencing a rubella infection at this time. indicate the presence or absence of a rubella infection B. The client is immune to the rubella virus. C. The client requires a rubella vaccination at this time. Rationale: Rubella vaccination during pregnancy is contraindicated because of possible injury to the developing fetus. D The client requires a rubella immunization following delivery.

A. The client is not experiencing a rubella infection at this time. Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus. It does not indicate the presence or absence of a rubella infection B. The client is immune to the rubella virus. Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus. C. The client requires a rubella vaccination at this time. Rationale: Rubella vaccination during pregnancy is contraindicated because of possible injury to the developing fetus. -D The client requires a rubella immunization following delivery. Rationale: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month.

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

A. Two veins and one artery Rationale: This is not the correct combination of vessels. B. One artery and one vein Rationale: This is not the correct combination of vessels. •-C. Two arteries and one vein Rationale: The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta. D. Two arteries and two veins Rationale: This is not the correct combination of vessels.

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 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.

A. Wash the cord daily with mild soap and water. Rationale: The client should be instructed to wash the skin around the base of the cord, not the cord stump, with mild soap and water. B. Cover the cord with the diaper. Rationale: The parent should fold the edge of the diaper downward to avoid exposing the cord stump to urine and feces in the diaper. C. Apply petroleum jelly to the cord stump. Rationale: Circumcision care, not cord care, might include the application of petroleum jelly to the penis. -D. Give a sponge bath until the cord stump 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 is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make? A. Within 2 days B. In 3 to 5 days Rationale: By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast C. In 6 to 8 days D. In about 10 days

A. Within 2 days Rationale: In this time frame, most clients who are breastfeeding are still producing colostrum. -B. In 3 to 5 days Rationale: By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk C. In 6 to 8 days Rationale: Day 6 to 8 is not the usual time frame for the onset of breast milk production. D. In about 10 days Rationale: Breast milk transitions to mature milk in about 10 days, but clients do produce breast milk before that time

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.

Rationale: Preterm newborns lack motor development that allows for muscle flexion. A prone position or the use of a sling promotes flexion. B. Use fingertips when calming the newborn. Rationale: The use of both hands is the most effective calming technique, especially when repositioning the newborn's extremities close to his body. -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. D. Keep the newborn in a well-lit nursery. Rationale: To promote sleep-wake cycles, newborns should be protected from light at night by dimming nursery illumination, placing a cover over the incubator, or positioning a mask over the eyes

20. 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. B. Products of conception will be present in vaginal bleeding. Rationale: The products of conception are surgically removed during a D&C C. Increased intake of zinc-rich foods is recommended. Rationale: The client is encouraged to consume foods high in iron and protein to replace red blood cells and repair uterine tissue. D. Aspirin may be taken for cramps. Rationale:Aspirin for pain management of cramps should be avoided because of its anticoagulant property. NSAIDS, such as ibuprofen, are recommended as they are an antiprostaglandin agent and reduce the discomfort of cramping.

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 to cry. D. Cut the umbilical cord.

•-A. Clear the respiratory tract. Rationale:Clearing the airway of the infant is the first action the nurse should take immediately following delivery. B. Dry the infant off and cover the head. Rationale: Drying the infant and covering the head should be done shortly after the delivery, but it is not the first action the nurse should take. C. Stimulate the infant to cry. Rationale: Stimulating the infant to cry should be done shortly after the delivery, but it is not the first action the nurse should take. D. Cut the umbilical cord. Rationale: Cutting the umbilical cord should be done shortly after the delivery, but it is not the first action the nurse should take.

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