Chapter 20

A nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the pavlik harness. which statement by the parents indicates that additional teaching is needed? select all that apply.

"The harness can be removed when the baby is awake." "The harness must be removed for diaper changes and for feeding."

A woman gave birth to a healthy term newborn about 2 hours ago. she asks the nurse about the appearance of her newborn's head. assessment reveals swelling of the head that extends across the midline. which response by the nurse would be appropriate?

"The swelling in your newborn's had is due to the head pressing against your cervix during labor and birth. It will go away on its own in a few days."

The nurse is assigned to care for a postpartum client with a deep vein thrombosis (dvt) who is prescribed anticoagulation therapy. which statement will the nurse include when providing education to this client?

"You need to avoid medications which contain acetylsalicylic acid."

What percentage of newborns are born with a complication or develop one shortly after birth?

10%

The incidence of sudden infant death syndrome (sids) peaks at what age?

2 to 4 months

A nurse is assessing the perineum of several postpartum clients using the reeda score. the nurse initiates interventions to minimize the risk for postpartum infection for the client with which score?

9

A postpartum woman is developing a thrombophlebitis in her right leg. which assessments would the nurse make to detect this?

Assess for pedal edema.

A late preterm newborn is born at:

Between 34 to 37 weeks

The nurse is providing care to a newborn with macrosomia who has sustained a midclavicular fracture. when reviewing the mother's labor and birth record, the nurse notes the following information: breech birth amniotomy apgar score: 7 at 1 minute; 8 at 5 minutes oxytocin augmentation which information would the nurse correlate with the newborn's current injury?

Breech birth

A client is experiencing postpartum hemorrhage shortly after the birth of the infant. which nursing intervention(s) would be appropriate for this client? select all that apply.

Encourage the client to breastfeed the infant, if she is breastfeeding. Begin uterine massage with both hands on the fungus of the uterus. Turn the client on the side and inspect the area under the buttocks for blood. Encourage increased fluid intake. Monitor vital signs every 15 minutes.

A neonate is diagnosed with erb's palsy after birth. the parents are concerned about their neonate's limp arm. the nurse explains the neonate will be scheduled to receive what recommended treatment for this condition first?

Immobilization of the shoulder and arm

When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications?

Morphine

Which nursing interventions are essential when caring for a newborn with macrosomia born to a mother with diabetes? select all that apply.

Obtain blood glucose reading, Obtain IV glucose for potential infusion, Assess for respiratory distress, and anticipate supplemental oxygen.

The nurse is caring for a neonate that is small for gestational age due to intrauterine growth restriction. which is the most common cause?

Oxygen and nutrient deficiency prior to birth.

The nurse is assisting in the newborn nursery with the completion of the ballard scoring system. which category is documented? select all that apply.

Posture, Arm recoil, Scarf sign, Heel to ear movement, and square window.

The nurse is caring for a newborn who is large-for-gestational-age (lga). which characteristics are documented as a contributing factor? select all that apply.

The mother has been previous large-for-gestational-age neonates. The mother has poorly controlled diabetes. Both parents are of a larger stature and size.

The nurse is most correct to assess for transient tachypnea of the newborn (ttn) in which neonate?

The neonate delivered by cesarean section

A nurse is caring for a newborn who was diagnosed with an imperforate anus. assessment reveals drooling, copious bubbles of mucus in mouth, rattling respirations, and abdominal distention. During feeding, the newborn coughs and becomes cyanotic. which action by the nurse would be appropriate?

clear the airway

A newborn requires resuscitation secondary to asphyxia. the resuscitation team frequently assesses the newborn's response and continues resuscitation efforts based on which assessment finding?

Heart rate of 70 beats/min

A perinatal nurse is working as a member of a local community health task force to address the impact of substance use during pregnancy. the group is to come up with recommendations for programs that will have a positive impact. after reviewing current research on the topic, on which area(s) will the group likely focus?

Heroin, alcohol, and cocaine.

When interacting with parents caring for their newborn in opioid withdrawal, which nursing action is most essential?

Instruct the parents with a nonjudgmental, caring attitude.

The nurse is assessing a male neonate using the ballard gestational age assessment tool. The neonate has the following characteristics: deep cracking skin, no vessels thinning lanugo creases on the plantar surface raised areola formed ear, instant recoil testes down, good rugae from the above characteristics, which can the nurse determine?

The neonate is a term newborn.