Chapter 67 ATI and NCLEX

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed?

"I will breastfeed, especially for the first 6 weeks postpartum."

The nurse instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed?

"I will flush the eyes after instilling the ointment"

A nurse is assiting with data collection of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1,100 g. Which of the following findings should the nurse expect? (Select all that apply) (3)

1. Lanugo 2. Weak grasp reflex 3. Translucent skin - Characteristics of a preterm newborn include the presence of abundant lanugo - A weak grasp reflex is characteristic of a preterm newborn - Skin that is thin, smooth, shiny, and translucent is a finding in a preterm newborn

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? (Select all that apply) (3)

1. Monitor the skin temperature closely 2. Reposition the newborn every 2 hours 3. Cover the newborn's eyes with shields or patches

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medicaiton if which findings are noted during the assessment? (Select all that apply) (2)

1. Respirations of 10 breaths/minute 2. Urine output of 20 mL in an hour

A nurse is assisting with data collection of a postterm newborn. Which of the following findings should the nurse expect? (Select all that apply) (3)

1. Thin with loose skin 2. Meconium staining of umbilical cord 3. Long finger nails

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse should tell the mother that which is a sign of infection?

A mosit cord with discharge

A nurse is preparing to administer prophylactice eye ointment to a newborn to prevent opthalmia neonatorum. Which of the following medications should the nurse anticipate administering?

Erythromycin - One medication of choice for opthalmia neonatorum is erythromycin opthalmic ointment 0.5%. This antibiotic provides prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis

The nurse notes hypotonia, irritablity, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS

Abnormal palmar creases

A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should assign the newborn which of the following classfications?

Appropriate for gestational age - This newborn is classified as appropriate for gestational age because the weight is between the 10th and 90th percentile

A nurse is caring for a newborn. Which of the following actions by the newborn indicates readiness to feed?

Attempts to place his hand in his mouth - Readiness-to-feed cues include the newborn making hand-to-mouth and hand-to-hand movements, sucking moitons, rooting, and mouthing

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment?

Blood pressure

The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priorty? - Connecting the resuscitation bag to the oxygen outlet - Turn on the apnea and cardiorespiratory monitors - Set up the intravenous line with 5% dextrose in water - Set the radiant warmer control temperature at 36.5 C (97.6F)

Connecting the resuscitation bag to the oxygen outlet

The nurse is assigned to assist with caring for a neonate born to a mother who is immunodeficiency virus (HIV)-positive. The nurse understands that which should be included in the plan of care?

Maintaining standard precautions at all times while caring for the neonate

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs?

Naloxone

A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse shoudl make which statement to the client?

"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."

A nurse is discussing neonatal abstinence syndrome with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicate understanding?

"The newborn will have a continuous high-pitched cry." - A continuous high-pitched cry is often an indication of CNS disturbances in a newborn who has neonatal abstinence syndrome

A nurse is caring for a client who is in the early postpartum period and is very excited and talkative. the nurse is having difficulty completing the postpartum data colleciton. Which of the following actions should the nurse take?

Give the client time to express her feelings? - The nurse should recognize that the client in is the taking-in phase, which begins immediately following birth and lasts a few hours to a couple of days

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse contacts the primary health care provider (PHCP) who prescribed the medicaiton if which condition is documented in the client's medical history?

Peripheral vascular disease

A nurse notes that the father appears nervous when the mother asks him to help care for the newborn. Which of the following actions should the nurse take to promote father-newborn bonding?

Reinforce education about newborn care when the father is present - Nursing interventions to promote paternal bonding include reinforcing education about newborn care and encouraging the fatehr to take a hands-on approach

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?

Sunken fontanels - The greatest risk to this client is injury from dehydration. Sunken fontane;s is the prioroty finding

The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn?

Tachypnea and retractions

A nurse is reinforcing teaching with a new mother on bathing a newborn. The newborn has a bluish marking across the lower back. Which of the following statements shouldthe nurse make concerning the variation?

"This is frequently seen in newborns of African American, Asian, or Native American origin." - Mongolian spots are commonly found over the lumbosacral area of newborns who are of African American, Asian, or Native American origin.

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client?

"You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

A nurse is assisting with the care of a client who is at 42 weeks gestation and in labor. The clietn asks the nurse what should she expect because her baby is postmature. Which of the following statements should the nurse make?

"Your baby's skin will have a leathery appearance." - Leathery, cracked, and wrinkled skin is seen in a newborn who is postmature due to placental insufficiency

A nurse is collecting data from a newborn following birth. Which of the following findings indicate the newborn is adapting to extrauterine life? (Select all that apply) (2)

1. Apnea for 10-second periods 2. Obligate nasal breathing - Periods of apnea lasting less than 15 seconds are an expected finding - Newborns are considered obligate nasal breathers

A nurse is reinforcing teaching about breastfeeding with the mother of a newborn. Which of the following actions indicates understanding of the teaching?

When latched on, the infant's nose, cheek, and chin are touching the mother's breast - Effective latching-on includes the infant's nose, cheek and chin touching the mother's breast

The nurse is assisting in caring for a postterm neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter?

Blood glucose level

A nurse is evaluating the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following actions?

Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward - The Moro reflex is elicited by holding the newborn in a semi-sitting position and then allowing the head and trunk to fall backward

The nurse is preparing to administer beractant to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route?

Intratracheal

A nurse is reinforcing teaching about proper techniques for bottle feeding with a new mother. Which of the following instructions should the nurse provide?

Keep the nipple full of formula throughout the feeding. - The nipple should always be kept full of formula to prevent the newborn from sucking air in during the feeding.

A nurse is returning a newborn to his mother following circumcision. Which of the following actions should the nurse take to ensure safety of the newborn?

Match the mother's idenitfication band with the newborn's band. - Each time the newborn is taken to the mother, the mother's identification band should be verified against the newborn's identificaiton band

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes and the mother asks the nurse why this is done. The nurse shoudl give which response to the client?

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care?

The process of keeping the cord clean and dry will decrease bacterial growth

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 responses should the nurse make?

"Your son is exhibiting an expected behavior to having a new sibling." - The nurse should reassure the mother that this is an expected behavior for a sibling to exhibit. - Regression can effect toileting and the sibling's sleep routine. - The nurse should also inform the mother that sibling adaptation can include other negative behaviors (seeking attention, frequent complains, showing hostility toward the baby)

A nurse is caring for a client ho is 1 day postpartum. The nurse is checking for maternal adaptation and bonding with the newborn. For which of the following client behaviors should the nurse intervene? (Select all that apply) (2)

1. Demonstrates apathy when the newborn cries 2. Views the newborn's behavior as uncooperative during diaper changing

A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? Select all that apply (3)

1. Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days 2. Change the diaper every 4 hours or more often to inspect the penis for drainage or infection 3. Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for wchi adverse effects of this medication? (Select all that apply) (3)

1. Flushing 2. Depressed respirations 3. Extreme muscle weakness

A nurse is discussing circumcision with a newly hired nurse. Which of the following conditions should the nurse identify as contraindications? (Select all that apply.) (3)

1. Hypospadias 2. Family history of hemophilia 3. Epispadias

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? (Select all that apply) (2)

1. Uterine hyperstimulation 2. Late decelerations of the fetal heart rate

After birth the nurse prevents hypothermia as a result of evaporation by performing which action?

Drying the baby with a warm blanket

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention?

Begin with the eyes and face

Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?

Being affected by Rh incompatibility

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication?

Betamethasone

A nurse on a postpartum unit is planning to promote bonding with the family and siblings of a newborn. Which of the following actions should the nurse take?

Encourage the parents to explore the newborn's features. - The nurse should encourage the parents to explore their newborn, noting the baby's unique features and qualities, to promote parental adaptation.

A nurse is collecting data from a newborn and observes small white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions?

Epstein pearls - Eptstein's pearls are small white nodules that appear on the roof of a newborn's mouth