Thermoregulation and Newborn Complications (2.4)

A nurse sees another health team member cover an infant with a blanket to prevent heat loss. What heat loss mechanism is being minimized by this action? A) Radiation B) Conduction C) Active transport D) Fluid vaporization

A

The nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn? Select all that apply. A) Pallor B) Irritability C) Hypotonia D) Ineffective sucking E) Excessive birth weight

A, B, C, D

A nurse is caring for a client who is 4 hours postpartum with postpartum hemorrhage. Which nursing diagnosis has the highest priority? A) Knowledge Deficit related to lack of information about signs of postpartum hemorrhage B) Fluid Volume Deficit related to blood loss secondary to uterine atony C) Fatigue related to anemia from postpartum bleeding D) Activity Intolerance related to enforced bed rest to control postpartum bleeding

B

A nurse in the newborn nursery is monitoring an infant for jaundice related to ABO incompatibility. What blood type does the mother usually have to cause this incompatibility? A) A B) B C) O D) AB

C

A breastfeeding woman develops mastitis. She tells the nurse that she will just feed her baby formula instead of breastfeeding. What is the best nursing response? A) Emptying the breast is important to prevent abscess B) A tight breast binder or bra will help reduce engorgement C) Continue to drink extra fluids while weaning D) Breastfeeding can continue while her temperature is normal

A

A woman who has postpartum bipolar II disorder is most likely to demonstrate which of the following? A) Hyperactivity and poor judgment alternating with tearfulness and guilt. B) Intermittent feelings of letdown or frustration with the baby and her life. C) Gradual reduction of interest in her surroundings and family. D) Prolonged difficulty feeling close to the the infant.

A

Three days after birth, a breast-feeding newborn becomes jaundiced. The parents bring the infant to the clinic, and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL (100 mcmol/L). The nurse explains that the infant has physiologic jaundice. What is the cause of this benign condition? A) Immature liver function B) An inability to synthesize bile C) An increased maternal hemoglobin level D) A high hemoglobin and low hematocrit level

A

What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate? A) Encouraging more frequent breastfeeding during the first 2 days B) Instituting phototherapy for 30 minutes every 6 hours for 3 days C) Substituting formula feeding for breastfeeding on the second day D) Supplementing breastfeeding with glucose water during the first day

A

The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? Select all that apply. A) The nurse keeps the newborn covered in warm blankets. B) The nurse keeps the newborn under the radiant warmer. C) The nurse places the newborn on the mother's abdomen. D) The nurse measures the newborn's temperature regularly. E) The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

A, B, C

Signs and symptoms of postpartum depression include which of the following? Select all that apply. A) Sleep disturbance B) Uncontrolled crying C) Delusions D) Feelings of guilt and/or worthlessness E) Appetite disturbance

A, B, D, E

Phototherapy is prescribed for a preterm neonate with hyperbilirubinemia. Which nursing intervention is appropriate to reduce the potentially harmful side effects of the phototherapy? A) Covering the trunk to prevent hypothermia B) Using shields on the eyes to protect them from the light C) Massaging vitamin E oil into the skin to minimize drying D) Turning after each feeding to reduce exposure of each surface area

B

A newborn is experiencing cold stress while being admitted to the nursery. Which nursing goal has the highest immediate priority? A) Minimize shivering B) Prevent hyperglycemia C) Limit oxygen consumption D) Prevent metabolism of fat stores

D

The nurse is presenting information about hyperthermia to a group of nursing students. Which activities put a client at risk for this condition? A) Snowmobiling B) Skiing in the winter C) Hiking Alaskan mountains D) Performing strenuous activity in high humidity

D

The nurse assesses for what client symptoms that indicate hyperthermia? Select all that apply. A) Vasodilation B) Dry and flushed skin C) Pale and cyanotic skin D) Decreased capillary refill E) Decreased urinary output

A, B, E

The nurse is testing newborns' heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? Select all that apply. A) Preterm infant B) Infant with Down syndrome C) Small-for-gestational-age infant D) Large-for-gestational-age infant E) Appropriate-for-gestational-age infant

A, C, D

The nurse knows that postpartum clients are at increased risk of thromboembolic disease because of which of the following risk factors? Select all that apply. A) Cesarean birth B) Birth of a male child C) Obesity D) Cigarette smoking E) Asthma F) Diabetes mellitus

A, C, D, F

While reviewing the health history of a newborn with suspected jaundice, the nurse recalls that some risk factors place infants at a higher risk for developing jaundice. Which conditions are risk factors for jaundice? Select all that apply. A) Infection B) Female sex C) Prematurity D) Breast-feeding E) Formula feeding F) Maternal diabetes

A, C, D, F

The nurse is assessing the victims of a disaster brought in to the emergency department for signs of hypothermia. Which statements made by the nurse indicate accurate awareness about the conditions associated with hypothermia? Select all that apply. A) "Shivering is the body's first attempt to conserve heat." B) "Wet clothing increases evaporative heat loss twice as much as normal." C) "Hypothermia can often be misdiagnosed as it mimics other disorders." D) "Near drowning increases evaporative heat loss to 25 times greater than normal." E) "Older adults are less prone to hypothermia due to medications that alter body defenses."

C, D

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). Which clinical finding confirms this complication? A) Muscle irritability within 1 hour of birth B) Neurologic signs during the first 24 hours C) Jaundice that develops in the first 12 to 24 hours D) Jaundice that develops between 48 and 72 hours after birth

C

The nurse is assigned to care for an infant in the newborn nursery who is 24 hours old. During assessment the nurse becomes concerned that the baby is jaundiced. The nurse knows that jaundice first becomes visible in a newborn when serum bilirubin reaches what level? A) 1 to 3 mg/dL (17.1 to 51.3 µmol/L) B) 2 to 4 mg/dL (34.2 to 68.4 µmol/L) C) 5 to 7 mg/dL (85.5 to 119.7 µmol/L) D) 8 to 10 mg/dL (136.8 to 171 µmol/L)

C

The nurse is aware that because of excess blood loss during delivery, the woman is at risk for hypovolemic shock. What is one of the earliest signs that hypovolemic shock is occurring? A) Woman is anxious and confused B) Decrease in urinary output C) Tachycardia D) Increased respiratory rate

C

Which nursing measure is appropriate to prevent thrombophlebitis in the recovery period following a cesarean birth? A) Roll a bath blanket and place it firmly behind the knees B) Encourage a diet high in iron C) Assist the woman in performing leg exercises every 2 hours D) Ambulate the woman as soon as her vital signs are stable

C

Which of the following is a sign of thrombophlebitis? A) visible vericose veins B) negative Homan's sign C) local swelling, tenderness, warmth, and redness D) fatigue with ambulation

C

Which woman is at greater risk for early postpartum hemorrhage? A) Gravida 1 who delivered a 7-pound baby boy B) Gravida 3 who delivered a 5-pound baby girl C) Gravida 1 who delivered 38-week twins D) Gravida 2 who delivered 32-week infant

C

A mother asks the neonatal nurse why her infant must be monitored so closely for hypoglycemia when her type 1 diabetes was in excellent control during the entire pregnancy. How should the nurse best respond? A) "A newborn's glucose level drops after birth, so we're being especially cautious with your baby because of your diabetes." B) "A newborn's pancreas produces an increased amount of insulin during the first day of birth, so we're checking to see whether hypoglycemia has occurred." C) "Babies of mothers with diabetes do not have large stores of glucose at birth, so it's difficult for them to maintain the blood glucose level within an acceptable range." D) "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."

D

A nurse is caring for a mother and neonate. What is the priority nursing action to prevent heat loss in the neonate immediately after birth? A) Bottle feeding immediately after birth B) Dressing the newborn in a shirt and gown immediately C) Bathing the newborn in warm water as soon as possible D) Putting the naked newborn on the mother's skin and covering the infant with a blanket

D

How should the nurse screen the newborn of a diabetic mother for hypoglycemia? A) Testing for glucose tolerance B) Drawing blood for a serum glucose determination C) Arranging for a fasting blood glucose determination D) Testing heel blood with the use of a glucose-oxidase strip

D

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent? A) Radiation B) Convection C) Conduction D) Evaporation

D

The nurse is assessing a woman who delivered 1 hour ago. She notes that the uterus is boggy. What should the FIRST intervention be for this patient? A) Notify the physician B) Massage the uterus until firm C) Administer oxytocin D) Empty the woman's bladder

B

The nurse is caring for a patient who is 48 hours post cesarean section. On assessment the nurse notes the patient is dyspneic with chest pain, tachycardia, and an O2 saturation of 89%. What is the nurse's initial response? A) Initiate a second IV line of a hypotonic solution B) Raise the head of the bed and administer oxygen C) Insert a catheter to monitor urine output D) Lower the head of the bed and elevate the legs

B

The nurse knows that late postpartum hemorrhage can be prevented by what? A) Administering broad-spectrum antibiotics B) Inspecting the placenta after delivery C) Manually removing the placenta D) Pulling on the umbilical cord to hasten the delivery of the placenta

B

A nurse is caring for a preterm neonate with physiologic jaundice who requires phototherapy. What is the physiologic mechanism of this therapy? A) Stimulates the liver to dispose of the bilirubin B) Breaks down the bilirubin into a conjugated form C) Facilitates the excretion of bilirubin by activating vitamin K D) Dissolves the bilirubin, allowing it to be excreted by the skin

B

A steady trickle of bright red blood from the vagina in the presence of a firm fundus is indicative of which of the following? A) Uterine atony B) Laceration of the genital tract C) Perineal hematoma D) Infection of the uterus

B

Jaundice develops in a newborn 72 hours after birth. How should the nurse best explain the probable cause of this jaundice to the parents? A) An allergic response to the feedings B) The physiologic destruction of fetal red blood cells C) A temporary bile duct obstruction commonly found in newborns D) The seepage of maternal Rh-negative blood into the neonate's bloodstream

B

Rho(D) immune globulin (RhoGAM) is prescribed for an Rh-negative client who has just given birth. Before giving the medication, the nurse verifies the newborn's Rh factor and reaction to the Coombs test. Which combination of newborn Rh factor and Coombs test result confirms the need to give Rho(D) immune globulin? A) Rh positive with a positive Coombs result B) Rh positive with a negative Coombs result C) Rh negative with a positive Coombs result D) Rh negative with a negative Coombs result

B

A client who is 4 weeks postpartum has irregular bleeding of lochia rubra with her fundus measured at 1 cm below the umbilicus. Based on these findings, what medication would the nurse anticipate the healthcare provider ordering for this client? A) methylergonovine maleate B) oxycodone C) ibuprofen D) carboprost

A

A nurse is assessing a client 2 hours postpartum. Her blood pressure is 98/60, pulse is 90, and she has saturated two pads in the last hour. What should be the immediate nursing action? A) Massage fundus until firm B) Increase the rate of the intravenous infusion C) Notify the healthcare provider D) Obtain an order to catheterize the client

A

A nurse is caring for a 48-hour-postpartum client who complains of urinary frequency and dysuria. Her temperature is 100.2°F, pulse 72, respirations 18, and blood pressure 108/72. What is the MOST appropriate nursing intervention? A) Obtain a clean-catch urine specimen B) Administer antibiotics C) Obtain a catheterized urine specimen for culture and sensitivity D) Administer anti-inflammatory medication for discomfort

A

A woman has an 8 lb 9 oz baby after an 18-hour labor that required a low-forceps delivery. Her membranes were ruptured for 15 hours. Based on these facts, what patient teaching should be emphasized? A) Reporting foul smelling lochia B) Delaying intercourse for at least 6 weeks C) Eating a diet that is high in iron D) Losing weight over at least a 6 month period

A

After assessing a client's reports, the nurse confirms that the client has moderate hypothermia. What should be the nurse's immediate intervention? Select all that apply. A) Administering heated oxygen gas B) Positioning the client in supine position C) Administering high carbohydrate liquids D) Applying external heat with heating blankets E) Performing cardiopulmonary bypass technique

A, B, D

A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000-gram infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse massages the woman's fundus and has her void, but her fundus remains difficult to find and the rubra remains heavy. What is the nurse's next action? A) Leave the room to call the physician B) Stay in the room and call for assistance C) Recheck vital signs in 2 hours D) Try to express clots from the uterus

B

The nurse is caring for a client with hypothermia. What should be the nurse's priority of care? A) Administering electrolytes B) Monitoring body temperature C) Increasing the room's temperature D) Removing the client from cold environment

D

The nurse notes that a client has mild hypothermia based on what body temperature? A) 29 °C B) 30 °C C) 33 °C D) 35 °C

D

What temperature indicates the presence of postpartum infection? A) 99.6 degrees F in the first 48 hours B) 100 degrees F for 2 days postpartum C) 100.4 degrees F in the first 24 hours D) 100.8 degrees F on the third postpartum day

D

Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? A) Postpartum depression B) Postpartum psychosis C) Postpartum bipolar disorder D) Postpartum blues

D