Unit 3 Exam
A nurse is caring for an infant who has hydrocephalus. Which of the following manifestations should the nurse expect to find? A. proteinuria B. dilated scalp veins C. hypertension D. pulsatile fontanels
B
A nurse is preparing to administer vitamin K injection to a newborn. Which of the following responses should the nurse make to the newborn's parent regarding why this medication is given? A. "It assists with blood clotting." B. "It promotes maturation of the bowel." C. "It is a preventative vaccine." D. "It provides immunity."
A
A nurse is providing discharge teaching for a nonlactating client. Which if the following instructions should the nurse include in the teaching? A. "Wear a supportive bra continuously for the first 72 hours." B. "Pump your breast every 4 hours to relieve discomfort." C. "Use breast shells throughout the day to decrease milk supply." D. "Apply warm compresses until milk suppression occurs."
A
A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will place my baby on his back when it is time for him to sleep." B. "I will keep my baby's crib close to the heat vents to keep him warm." C. "I will use an infant carrier when I drive to places close to my house." D. "I will tie my baby's pacifier around his neck with a piece of yarn."
A
A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's lower back. The nurse should include which of the following information in the teaching? A. "This is more commonly seen in newborns who have dark skin." B. "This is a finding indicating hyperbilirubinemia." C. "This is a forcep mark from an operative delivery." D. "This is related to prolonged birth or trauma during delivery."
A
A nurse places the 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. thermogenesis D. brown fat production
A
Immediately after a cesarean delivery, a nurse is caring for a newborn who weighs 5,160 g (11 lb 6 oz) and whose mother has diabetes mellitus. The priority data collection for this newborn is for A. hypoglycemia B. hypomagnesemia C. hyperbilirubinemia D. hypocalcemia
A
A nurse is discussing risk factors for UTIs with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? SATA A. epidural anesthesia B. urinary bladder catheterization C. frequent pelvic examinations D. history of UTIs E. vaginal birth
A, B, C, D
A nurse is caring for a postpartum client 8hr after delivery. Which of the following factors places the client at risk for uterine atony? SATA A. magnesium sulfate infusion B. distended bladder C. oxytocin infusion D. prolonged labor E. small for gestational age newborn
A, B, D
A nurse is caring for a postpartum client who delivered their third infant 2 days ago. Which of the following manifestations could indicate postpartum depression? SATA A. fatigue B. insomnia C. euphoria D. flat affect E.delusions
A, B, D
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 help lessen discomfort during breastfeeding? SATA A. apply breast milk to her nipples before each feeding B. alternate breasts at the beginning of each feeding C. let the newborn sleep for long periods so the nipples can heal D. start breastfeeding with the nipple that is less sore E. change the infant's position on the nipples
A, B, D, E
A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? SATA A. demonstrates apathy when the newborn cries B. touches the newborn and maintains close physical proximity C. views the newborn's behavior as uncooperative during diaper changing D. identifies and relates newborn's characteristics to those of family members E. interprets the newborn's behavior as meaningful and a way of expressing needs
A, C
A nurse is called to the birthing rooms to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1000 g. Which of the following are expected findings in this newborn? SATA A. lanugo B. long nails C. weak grasp reflex D. translucent skin E. plump face
A, C, D
A nurse on the postpartum unit is assessing a client who is being admitted with suspected DVT. Which of the following clinical findings should the nurse expect? SATA A. calf tenderness to palpation B. mottling of the affected extremity C. elevated temperature D. area of warmth E. reports of nausea
A, C, D
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? SATA A. precipitous delivery B. obesity C. inversion of the uterus D. oligohydramnois E. retained placental fragments
A, C, E
A nurse is taking a newborn to a parent following a circumcision. Which of the following actions should the nurse take for security purposes? A. ask the parent to state their full name B. look at the name on the newborn's bassinet C. match the parent's identification band with the newborn's band D. compare name on the bassinet and room number
C
A nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. Which of the following information should the nurse include? SATA A. use a perineal squeeze bottle to cleanse the perineum B. sit on the perineum while resting in bed C. apply a topical anesthetic cream or spray to the perineum D. wipe the perineum thoroughly with a back-and-forth motion E. apply cold or ice packs to the perineum
A, C, E
A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? SATA A. hypospadias B. hydrocele C. family history of hemophilia D. hyperbilirubinemia E. epispadias
A, C, E
A nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? A. "The circumcision will heal within a couple of days." B. "I should remove the yellow mucus that will form." C. "I will clean the penis with each diaper change." D. "I will give him a tub within a couple of days."
C
A nurse is providing discharges instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings? A. scant, nonodorous white vaginal discharge B. uterine cramping during breastfeeding C. sore nipple with cracks and fissures D. decreased response with sexual activity
C
A nurse is reinforcing teaching to a new mother regarding the purpose of administering vitamin K to her newborn following delivery. The nurse explains that the purpose of administering vitamin K is to prevent which of the following? A. infection B. potassium deficiency C. bleeding D. hyperbilirubinrmia
C
A nurse is reviewing car seat safety with the parents of a newborn. Which of the following instructions should the nurse include in the teaching regarding car seat position? A. front seat, rear-facing B. front seat, forward-facing C. back seat, rear-facing D. back seat, forward-facing
C
A nurse is on the postpartum unit is caring for a group of clients with the assistive personnel. Which of the following tasks should the nurse plan to delegate the AP? A. provide a sitz bath to a client with a fourth-degree laceration who is 2 days postpartum B. observe an area of redness on the breast of a client who is 1 day postpartum C. monitor VS of a client being admitted with gestational hypertension D. change the perineal pad of a client who just transferred from labor and delivery
A
A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? A. moderate lochia rubra B. excessive lochia serosa C. light lochia rubra D. scant lochia serosa
A
A nurse is planning care for an infant that has been diagnosed with phenylketonuria. Which of the following is an appropriate action for the nurse to take? A. initiate a controlled diet eliminating protein B. educate parents on blood glucose monitoring C. administer thyroid hormone replacement D. obtain a blood sample for blood type
A
A nurse is preparing to administer Rho immunoglobulin (RhoGAM). An Rh incompatibility can lead to which of the following? A. hydrops fetalis B. hypobilirubinemia C. congenital hypothermia D. transient clotting difficulties
A
A nurse is preparing to administer vitamin K by intramuscular injection to a newborn. Into which of the following muscles should the nurse inject the medication? A. vastus lateralis B. ventrogluteal C. dorsogluteal D. deltoid
A
A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min, respiratory rate of 36/min, well flexed extremities, responding to stimuli with a cry, and blue hands and feet. Which of the following is the Apgar score the nurse should assign to the newborn? A. 7 B. 8 C. 9 D. 10
9
A client who is postpartum and is breastfeeding her newborn asks the nurse about dietary precautions. The client states food allergies "run in her family." The nurse should tell the mother to avoid A. peanuts B. asparagus C. lamb D. blueberries
A
A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she inquires about the finding? A. "This will resolve within 3 to 6 weeks without treatment." B. "This will resolve on its own within 3 to 4 days." C. "The provider might drain this area with a syringe." D. "This is expected at birth so you don't need to worry about it."
A
A nurse is assessing a newborn 1 hr after birth. Which of the following assessment findings should the nurse report to the provider? A. jaundice of the sclera B. respiratory rate 50/min C. acrocyanosis D. blood glucose 60 mg/dL
A
A nurse is caring for a client immediately after delivery. After assuring a patent airway, which action would be the nurse's priority in the care of the infant? A. dry the infant and place him in a radiant warmer B. administer vitamin K IM C. perform complete physical assessment and document findings D. implement identification procedures
A
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 is an expected finding during this period? A. expression of excitement B. lack of appetite C. focuses on the family unit and its members D. eagerness to learn newborn skills
A
A nurse is caring for a client who has DIC. Which of the following antepartum complications should the nurse understand is a risk factor for this condition? A. preeclampsia B. thrombophlebitis C. placenta previa D. hyperemesis gravidarum
A
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? A. increasing pulse and decreasing bp B. dizziness and increasing RR C. cool, clammy skin, and pale mucous membranes D. altered mental status and LOC
A
A nurse is caring for a newborn who is premature at 30 weeks of gestation. Which of the following findings should the nurse expect? A. abundant lanugo B. good flexion C. heel creases covering the bottom of the feet D. dry, parchment-like skin
A
A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A. oxygen saturation B. body temperature C. serum bilirubin D. heart rate
A
A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make? A. "Apply cold compresses between feedings." B. "Take a warm shower right after feedings." .C. " Apply breast milk to the nipples and allow them to air dry." D. "Use the various infant positions for feedings."
A
A nurse is caring for a newborn who was born at 38 weeks of gestation, weigh 3200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following? A. low birth weight B. appropriate for gestational age C. small for gestational age D. large for gestational age
B
A nurse is caring for a newborn. Which of the following actions by the newborn indicates readiness to feed? A. spits up clear mucus B. attempts to place their hand in their mouth C. turns the head toward sounds D. lies quietly with their eyes open
B
A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication from the oxygen therapy? A. atelectasis B. retinopathy C. interstitial emphysema D. necrotizing entercolitis
B
A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following actions should the nurse take? A. come back when they client is more cooperative B. give the client time to express feelings C. tell the client they need to be quiet so the assessment can be completed D. redirect the client's focus so that they will become quiet
B
A nurse is assessing a client who is 14 hr postpartum has a third-degree perineal laceration. The client's temperature is 37.8 C (100 F), and her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movements since delivery. Which of the following actions should the nurse take? A. notify the provider about the elevated temperature B. assist the client to empty her bladder C. administer a bisacodyl suppository D. massage the client's fundus
B
A nurse is assessing a newborn who is 12 hr old and notes mild jaundice of the face and trunk, Which of the following actions should the nurse take? A. administer phytonadione IM B. obtain a stat prescription for a bilirubin level C. obtain a bagged urine specimen D. perform a gestational age assessment
B
A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions as the cause of the uterine atony? A. poor involution B. urinary retention C. hemorrhage D. infection
B
A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina. Which of the following statements should the nurse make? A. "You might have retained placental fragments in your uterus." B. "Blood pools in the vagina when you are lying in bed." C. "You might have a damaged blood vessel." D. "The amount of blood flow will increase during the first few days after giving birth."
B
A nurse is assisting a client who is 8 hour 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 finger breaths above the umbilicus C. moderate swelling of the labia D. blood pressure 130/84 mm Hg
B
A nurse is assisting 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. The nurse should document this finding as A. caput succedaneum B. cephlahematoma C. molding D. cradle cap
B
A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? A. reinforce the need to take antipschotics as prescribed B. ask the client if they have thoughts of harming themselves or their infant C. monitor the infant for indications of failure to thrive D. review the client's medical record for a history of bipolar disorder
B
A nurse is caring for a client who is 2 days postpartum. The client states, "My 4 year old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? A. "Your son was probably not ready for toilet training and should wear training pants." B. "Your son is showing an adverse sibling response." C. " Your son may need counseling." D. "You should try sending your son to preschool to resolve the behavior."
B
A nurse is caring for a client who is pregnant and has iron-deficiency anemia. To enhance the client's iron absorption, which of the following beverages should the nurse recommend? A. milk B. orange juice C. tea D. hot chocolate
B
A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1 to 2 hr delivery? A. naloxone B. erythromycin ophthalmic ointment C. poractant alpha D. rotavirus immunization
B
A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse take first? A. perform a detailed physical assessment B. place the newborn directly on the client's chest C. give the newborn vitamin K IM D. administer erythromycin ophthalmic ointment
B
A nurse is caring for a newborn who is premature in the NICU. Which of the following actions should the nurse take to promote development? A. rapidly advance oral feedings B. position the naked newborn on the parent's bare chest C. provide frequent periods of visual and auditory stimulation D. discourage the use of pacifiers
B
A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? A. "I will need to use contraception for 3 months before considering pregnancy." B. "I need a second vaccination at my postpartum visit." C. " I was given the vaccine because my baby is O-positive." D. " I will be tested in 3 months to see if I have developed immunity."
B
A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? A. A client who has an episotomy that is erythematous and has extended into a third-degree laceration. B. A client who does not wash their hands between perineal care and breastfeeding. C. A client who is not breastfeeding and is using measures to suppress lactation. D. A client who has a cesarean incision that is well-approximated with no drainage.
B
A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching? A. stand under a hot shower with your breasts exposed B. place ice packs on your breasts C. wear a loose-fitting, comfortable bra D. limit fluid intake to 1 L per day
B
A nurse is reinforcing teaching to a group of postpartum clients about nutritional requirements during lactation. The nurse recommends increased intake of which of the following nutrients? A. calcium B. zinc C. folic acid D. iron
B
A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "The newborn will have decreased muscle tone." B. "The newborn will have a continuous high-pitched cry." C. "The newborn will sleep for 2-3 hours after a feeding." D. "The newborn will have mild tremors when disturbed."
B
A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection? A. a client who experienced a precipitous labor less than 3 hours in duration B. a client who has premature rupture of membranes and prolonged labor C. A client who delivered a large for gestational age infant D. a client who had a boggy uterus that was not well-contracted
B
A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following manifestations? SATA A. paranoia that their infant will be harmed B. concerns about lack of income to pay bills C. anxiety about assuming a new role as a parent D. rapid decline in estrogen and progesterone E. feeling of inadequacy as a new parent
B, C, D, E
A newborn was not dried completely after birth. This places the infant at risk for which of the following types of heat loss? A. conduction B. convection C. evaporation D. radiation
C
A nurse is assessing a 12 hour newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take? A. perform chest percussion B. place the newborn in a prone position C. continue routine monitoring D. request a prescription for supplemental oxygen
C
A nurse is assessing a 4-hour old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take? A. apply an oxygen hood over the newborn's head and neck B. check the newborn's temperature using a temporal thermometer C. place the naked newborn on the mother's care chest and cover both with a blanket D. give the newborn glucose water between feedings
C
A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration? A. continuous lochia flow and a flaccid uterus B. report of increasing pain and pressure in the perineal area C. a slow trickle of bright vaginal bleeding and a firm fundus D. a gush of rubra lochia when the nurse massages the uterus
C
A nurse is caring for a client who is postpartum and requires RhoGAM. Before administering it, the nurse should verify that the A. client is Rh positive and the newborn is Rh positive B. client is Rh negative and the newborn is Rh negative C. client is Rh negative and the newborn is Rh positive D. client is Rh positive and the newborn is Rh negative
C
A nurse is caring for a client who is receiving oxytocin IV following a normal vaginal delivery. To evaluate the effectiveness of this medication, the nurse needs to check the client's A. urinary output B. blood pressure C. fundal consistency D. pulse rate
C
A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. Which of the following actions should the nurse implement? A. apply Gelfoam powder to the site B. place the newborn in the prone position C. apply petroleum gauze to the site D. avoid changing the diaper until the first voiding
C
A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? A. conjunctivitis B. bronze skin discoloration C. sunken fontanels D. maculopapular skin rash
C
A nurse is completing a newborn gestational age assessment. Which of these findings is recorded as part of this assessment? A. acrocyanosis of hands and feet B. anterior fontanel soft and level C. plantar creases cover 2/3 of sole D. vernix caseosa in inguinal creases
C
A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? A. ofloxacin B. nystatin C. erythromycin D. ceftriaxone
C
A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest? A. sit-ups B. pelvic tilt excercises C. kegel exercises D. abdominal crunches
C
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? A. "Limit the amount of time the infant nurses on each breast." B. "Nurse the infant only on the unaffected breast until resolved." C. "Completely empty each breast at each feeding or use a pump." D. "Wear a tight-fitting bra until lactation has ceased."
C
A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? A. burp the newborn at the end of the feeding B. hold the newborn close in a supine position C. keep the nipple full of formula through the feeding D. refrigerate any unused formula
C
A nurse is testing the reflexes of a newborn to assess neurologic maturity. Which of the following reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? A. rooting B. moro C. tonic neck D. babinski
C
A nurse is 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 of 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 ID, you can take the infant."
C
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? A. evidence of a possible vaginal hematoma B. an indication of a cervical or perineal laceration C. a normal postural discharge of lochia D. abnormally excessive lochia rubra flow
C
A nurse is completing an assessment. Which of the following data indicates the newborn is adapting to extrauterine life? SATA A. expiratory grunting B. inspiratory nasal flaring C. apnea for 10-second periods D. obligatory nose breathing E. crackles and wheezing
C, D
A nurse is reviewing formula preparation with parents who plan to bottle-feed their newborn. Which of the following information should the nurse include in the teaching? SATA A. use a disinfectant wipe to clean the lid of the formula can B. store prepared formula in the refrigerator up to 72 hours C. place used bottles in the dishwasher D. check the nipple for appropriate flow of formula E. use tap water to dilute concentrated formula
C, D, E
A nurse is reviewing discharge teaching with a client who has a UTI. Which of the following statements by the client indicates understanding of the teaching? SATA A. "I will perform perineal care and apply a perineal pad in a back-to-front direction." B. "I will drink grape juice to make urine more acidic." C. "I will drink large amounts of fluids to flush the bacteria from my urinary tract." D. "I will go back to breastfeeding after I have finished taking the antibiotic." E. "I will take Tylenol for any discomfort."
C, E
A client who is postpartum and is breastfeeding her newborn tells the nurse that her nipples are sore. Which of the following interventions should the nurse suggest to the client? A. apply a light coating of mineral oil to the nipples between feedings B. keep the nipples covered in between breastfeeding sessions C. increase the time between feedings until the nipples are less sore D. change the newborn's position on the nipples with each feeding
D
A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to their parent. Which of the following actions should the nurse use to promote parent-infant bonding? A. hand the parent the newborn, and suggest that they change the diaper B. ask the parent why they are so anxious and nervous C. tell the parents that they will grow accustomed to the newborn D. provide education about infant care when the parent is present
D
A nurse in the delivery room is planning to promote parent-infant bonding to a client who just delivered. Which of the following is the priority action by the nurse? A. encourage the parents to touch and explore the neonate's features B. limit noise and interruption in the delivery room C. place the neonate at the client's breast D. position the neonate skin-to-skin on the client's chest
D
A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following statements indicates to the nurse the client needs further instruction? A. "I can continue to breastfeed." B. "I will still need to have my provider perform a rubella titer check with my next pregnancy." C. "I cannot receive the rubella immunization during my pregnancy." D. "I can conceive any time I want after 10 days."
D
A nurse is assessing a newborn for congenital hip dysplasia. Which of the following findings should the nurse expect? A. legs that are shorter than the arms B. temperature of one leg differing from that of the other C. symmetrical gluteal folds D. limited abduction of one hip
D
A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these manifestations? A. postpartum fatigue B. postpartum psychosis C. letting-go phase D. postpartum blues
D
A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? A. hold the newborn vertically under arms and allow one foot to touch table B. stimulate the pads of the newborn's hands with stroking or massage C. stimulate the soles of the newborn's feet on the outer lateral surface of each foot D. hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward
D
A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? A. terbutaline B. nifedipine C. magnesium sulfate D. methylergonovine
D
A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make? A. "Your baby will have excess body fat." B. "Your baby will have flat areola without breast buds." C. " Your baby's heels with easily move to his ears." D. "Your baby's skin will have a leathery appearance."
D
A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority? A. initiating breastfeeding B. performing the initial bath C. giving vitamin K injection D. covering the newborn's head with a cap
D
A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? A. chills shortly after delivery B. fundus at umbilicus level C. urinary output 3000 mL per 12 hour D. pulse rate 110 bpm
D
A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? A. mongolian spots B. milia spots C. erythema toxicum D. epstein's pearls
D
A nurse is giving instructions to a parent about how to breastfeed their newborn. Which of the following actions by the parent indicates understanding of the teaching? A. The parent places a few drops of water on their nipple before feeding B. The parent gently removes their nipple from the infant's mouth to break the suction C. When they are ready to breastfeed, the parent gently strokes the newborn's neck with a finger D. when latched on, the infant's nose, cheek, and chin are touching the breast
D
A nurse is planning care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? A. apply cold compresses to the affected extremity B. massage the affected extremity C. allow the client to ambulate D. measure leg circumferences
D
A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take? A. offer the newborn glucose water between feedings B. keep the newborn's eye patches on during feedings C. apply barrier ointment to the newborn's perianal region D. use a photometer to monitor the lamp's energy
D
A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I must drink milk every day in order to assure good quality breast milk." B. "Drinking lots of fluids will increase my breast milk production." C. "After the first few weeks, my nipples will toughen up and breastfeeding won't hurt." D. "It is normal for my baby to sometimes feed every hour for several hours in a row."
D
A nurse is providing teaching to the parents of a newborn about bottle feeding. Which of the following instructions should the nurse include in the teaching? A. dilute ready-to-feed formula if the newborn is gaining weight too quickly B. prop the bottle with a blanket for the last feeding of the day C. discard unused refrigerated formula after 72 hr D. boil water for powdered formula for 1 to 2 min
D
A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching? A. apply the diaper tightly over the circumcision area B. remove the yellow exudate with each diaper change C. use prepackaged commercial wipes to clean the circumcision site D. encourage nonnutritive sucking for pain relief
D
A nurse is reviewing breastfeeding positions with the parent of a newborn. Which of the following positions should the nurse discuss? A. over the shoulder B. supine C. chin supported D. cradle
D
A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? A. cover the cord with a small gauze square B. trickle clean water over the cord with each diaper change C. apply hydrogen peroxide to the cord twice a day D. keep the diaper folded below the cord
D
