exam 2

15. A woman who is 12 weeks postpartum presents with the following behavior: she reports severe mood swings and hearing voices, believes her infant is going to die, she has to be reminded to shower and put on clean clothes, and she feels she is unable to care for her baby. These behaviors are associated with which of the following? a. Postpartum blues b. Postpartum depression c. Postpartum psychosis d. Maladaptive mother-infant attachment

ANS: C a. Postpartum blues usually occurs within the first few weeks of the postpartum period. Women experiencing postpartum blues will have mild mood swings, and they can take care of themselves as well as their baby. b. Women with PPD are predominately depressed and do not have mood swings. c. Postpartum psychosis is associated with a break from reality reflected in the woman hearing voices. d. The symptoms reported are reflective of a psychiatric disorder beyond maladaptive attachment.

12. A postpartum nurse has received an exchange report on the four following mother-baby couplets. Based on the provided information, which couplet should the nurse first assess? a. A 25-year-old G2P1 woman who is 36 hours postbirth and is having difficulty breastfeeding her baby girl. Her fundus is firm at the umbilicus, and lochia is moderate to scant. b. A 16-year-old G1P0 who will be discharged in the afternoon. It was reported that she refers to her baby boy as "it" and that she requested to have her baby stay in the nursery so she could sleep. c. A 32-year-old G5P4 woman who delivered a 4500 gram baby boy 2 hours ago after a 20 hour labor that was augmented. It was reported that her fundus is 2 cm above umbilicus with moderate lochia. d. A 28-year-old G2P1 woman who delivered a 3800 gram baby girl by elective cesarean birth. She had spinal anesthesia and was given intrathecal preservative-free morphine for post

ANS: C a. The priority need for this woman is breastfeeding assistance which does not require immediate attention. b. The data indicate that the woman is experiencing a delay in bonding and that social services should become involved. This needs to be done prior to discharge but does not require immediate attention. c. This woman is at risk for hemorrhage (large baby, prolonged labor, augmented labor, high parity, and immediate postpartum). This woman needs to be assessed first to determine whether the fundus is firm and if lochia is within normal limits. d. Based on data provided, this woman is stable, but should be assessed second.

A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly license nurse indicate understanding of the teaching?

"The newborn will have a continuous high-pitched cry"

A nurse is teaching a newly licensed nurse how to bathe a newborn and observes bluish marking across the newborn's lower back. The nurse should include which of the following information in the teaching?

"This is frequently seen in newborns who have dark skin"

A nurse is caring for a client who is at 42 weeks gestation and in labor. The client 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"

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. "Apply cold compresses between feedings." Cold compresses applied to the breasts after the feedings can help with breast engorgement.

A nurse is providing discharge teaching for a nonlactating client. Which of 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. "Wear a supportive bra continuously for the first 72 hours. The nurse should instruct the client to wear a well‑fitting support bra continuously for the first 72 hr.

Which of the following strategies can decrease the frequency of hot flashes related to perimenopause? Select all that apply A. Avoiding alcohol drinks B. Avoiding hot teas C. Avoiding foods high in fat D. Avoiding cold rooms

A. Avoiding alcohol drinks B. Avoiding hot teas

A nurse on the postpartum unit is performing a physical assessment of a client who is being admitted with a suspected deep‑vein thrombosis (DVT). Which of the following clinical findings should the nurse expect? (Select all that apply.) A. Calf tenderness to palpation B. Mottling of the affected extremity C. Elevated temperature D. Area of warmth E. Report of nausea

A. Calf tenderness to palpation C. Elevated temperature D. Area of warmth A client report of calf tenderness to palpation is an expected finding in a client who has a DVT Elevated temperature is an expected finding in a client who has a DVT. An area of warmth over the thrombus is an expected finding in a client who has a DVT.

A nurse is caring for a client who is 1 hr postpartum following a vaginal birth and experiencing uncontrollable shaking. The nurse should understand that the shaking is due to which of the following factors? (Select all that apply.) A. Change in body fluids B. Metabolic effort of labor C. Diaphoresis D. Decrease in body temperature E. Decrease in prolactin levels

A. Change in body fluids B. Metabolic effort of labor A shift in body fluids during the first 2 hr puerperium can cause a postpartum chill. The work of labor can cause a postpartum chill during the first 2 hr puerperium.

A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and mother‑infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply.) A. Demonstrates apathy when the infant cries B. Touches the infant and maintains close physical proximity C. Views the infant's behavior as uncooperative during diaper changing D. Identifies and relates infant's characteristics to those of family members E. Interprets the infant's behavior as meaningful and a way of expressing needs

A. Demonstrates apathy when the infant cries C. Views the infant's behavior as uncooperative during diaper changing This behavior demonstrates a lack of interest in the infant and impaired maternal‑infant bonding. A client's view of her infant as being uncooperative during diaper changing is a sign of impaired maternal‑infant bonding.

A nurse is discussing risks factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? (Select all that apply). A. Epidural anesthesia B. Urinary bladder catheterization C. Frequent pelvic examinations D. History of UTIs E. Vaginal birth

A. Epidural anesthesia B. Urinary bladder catheterization C. Frequent pelvic examinations D. History of UTIs Epidural anesthesia is a risk factor for a UTI. Urinary bladder catheterization is a risk factor for a UTI. A history of frequent pelvic examinations is a risk factor for a UTI. A history of UTIs is a risk factor for developing UTIs.

A nurse is caring for a postpartum client who delivered her third infant 2 days ago. The nurse recognizes that which of the following findings are suggestive of postpartum depression? (Select all that apply.) A. Fatigue B. Insomnia C. Euphoria D. Flat affect E. Delusions

A. Fatigue B. Insomnia D. Flat affect Fatigue is a finding suggestive of postpartum depression. Insomnia is a finding suggestive of postpartum depression. A flat affect is a finding suggestive of postpartum depression.

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 blood pressure B. Dizziness and increasing respiratory rate C. Cool, clammy skin, and pale mucous membranes D. Altered mental status and level of consciousness

A. Increasing pulse and decreasing blood pressure A rising pulse rate and decreasing blood pressure are often the first indications of inadequate blood volume.

A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. She notes the pad to be 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 blood loss C. Light lochia rubra D. Scant lochia serosa

A. Moderate lochia rubra The client has moderate lochia rubra containing small clots, which is an expected finding for the second day postpartum.

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? (Select all that apply.) A. Precipitous delivery B. Obesity C. Inversion of the uterus D. Oligohydramnios E. Retained placental fragments

A. Precipitous delivery C. Inversion of the uterus E. Retained placental fragments Rapid, precipitous delivery is a risk factor for postpartum hemorrhage. Inversion of the uterus in a risk factor for postpartum hemorrhage. Retained placental fragments is a risk factor for postpartum hemorrhage.

A nurse is caring for a client who has disseminated intravascular coagulation (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. Preeclampsia DIC can occur secondary in a client who has preeclampsia.

A nurse is caring for a client who has mastitis. Which of the following is the typical causative agent of mastitis? A. Staphylococcus aureus B. Chlamydia trachomatis C. Klebsiella pneumonia D. Clostridium perfringens

A. Staphylococcus aureus Staphylococcus aureus, Escherichia coli, and streptococcus are usually the infecting agents that enter the breast due to sore or cracked nipples, which results in mastitis.

An ambulatory care nurse is discussing health promotion behaviors with her client. Her client is a 48 year old asian woman who has been divorced for 5 years and has a new male partner. Both the woman and her partner are smokers. The teaching plan for this client based on her risk factors include: Select all that apply A. Warning signs of heart attack and stroke B. Need for yearly pelvic exam that includes a chlamydia test C. Need for pneumococcal vaccine now and in 10 years D. Need for tetanus and diphtheria vaccine every 5 years

A. Warning signs of heart attack and stroke B. Need for yearly pelvic exam that includes a chlamydia test C. Need for pneumococcal vaccine now and in 10 years

The serosa stage of lochia usually occurs between day __________ and __________ and the lochia is a __________ or __________ color, and the amount is normally __________.

ANS: 1 - 4; 10; pink; brown; scant Lochia rubra (first stage) occurs during the first 3 days postpartum. Lochia rubra is bright red blood and is moderate to scant. Lochia alba (third stage) begins around the tenth day. The lochia is yellow to white in appearance and is scant in amount.

The postpartum period is the first __________ weeks following childbirth.

ANS: 6 Postpartum is the 6-week period of time following childbirth. It is a time of rapid physiological changes within the woman's body as it returns to a prepregnant state.

12. Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb. 13 oz. daughter. She experiences severe cramps with breastfeeding. The perinatal nurse best describes this condition as: a. Afterpains b. Uterine hypertonia c. Bladder hypertonia d. Rectus abdominis diastasis

ANS: A Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Patients often describe the sensation as a discomfort similar to menstrual cramps.

10. The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, "I don't expect to have any more kids, but I hate the thought of being sterile." Which of the following contraceptive methods would be best for the nurse to recommend to this client? a. Intrauterine device b. Contraceptive patch c. Bilateral tubal ligation d. Birth control pills

ANS: A An intrauterine device (IUD) is an excellent contraceptive method for women who have had at least one delivery, are in a monogamous relationship, and wish to have long-term contraception. The contraceptive patch is not recommended for women over 35 or for women who smoke. A bilateral tubal ligation is a sterilization procedure. Birth control pills are not recommended for women over 35 or for women who smoke.

9. The nurse is providing discharge counseling to a woman who is breastfeeding her baby. The nurse advises the woman that if she experiences unilateral breast inflammation, she should do which of the following? a. Apply warm soaks to the reddened area. b. Consume an herbal galactagogue. c. Bottle feed the baby during the next day. d. Take expressed breast milk to the laboratory for analysis.

ANS: A The client may be developing mastitis. She should apply warm soaks to the area. There is no need for a galactagogue. It is essential that the client continue to breastfeed. If she were to stop feeding, she could develop a breast abscess. Unless ordered by the physician, the milk need not be cultured.

14. A 37-year-old gravid 8 para 7 woman was admitted to the postpartum unit at 2 hours postbirth. On admission to the unit, her fundus was U/U, midline, and firm, and her lochia was moderate rubra. An hour later, her fundus is midline and boggy, and the lochia is heavy with small clots. Based on this assessment data, the first nursing action is: a. Massage the fundus of the uterus. b. Assist the woman to the bathroom and reassess the fundus. c. Notify the physician or midwife. d. Start IV oxytocin therapy as per standing orders.

ANS: A a. Correct. Based on the assessment data that the uterus is midline and boggy, the woman is experiencing uterine atony. b. Assisting the woman to the bathroom would be a nursing action if the uterus was not midline. c. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage. d. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage.

1. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following actions should the nurse perform? a. Supervise all infant care. b. Maintain client on strict bed rest. c. Restrict visitation to her partner. d. Carefully monitor toileting

ANS: A a. It is essential that a client diagnosed with postpartum (PP) psychosis not be left alone with her infant. b. There is no need for a client with PP psychosis to be on strict bed rest. c. Visitation is not usually restricted to the woman's partner. d. There is no need to monitor the client's toileting.

13. Which of the following is an indication for the administration of methylergonovine? a. Boggy uterus that does not respond to massage and oxytocin therapy b. Woman with a large hematoma c. Woman with a deep vein thrombosis d. Woman with severe postpartum depression

ANS: A a. Methylergonovine (methergine) is ordered for PPH due to uterine atony or subinvolution. It is used when massage and oxytocin therapy have failed to contract the uterus. b. Hematoma occurs when blood collects within the connective tissues of the vagina or perineal areas related to a vessel that ruptured and continues to bleed. Methylergonovine stimulates contraction of the smooth muscle of the uterus and would not have an effect on the vaginal or perineal areas. c. Heparin is usually prescribed for treatment of thrombosis. d. Methylergonovine is prescribed for treatment of uterine atony.

7. A woman is 2 days postpartum from a normal vaginal delivery over an intact perineum of a 3000-gram baby. Where would the nurse expect to palpate the client's fundus? a. At the umbilicus b. 2 cm below the umbilicus c. 2 cm above the symphysis d. At the symphysis

ANS: B Expected location for 6 to 12 hours postpartum. The firm fundus should be 2 cm below the umbilicus. This is an abnormal finding and may be related to subinvolution of the uterus. Expected location for 6 days postpartum.

3. During a postpartum assessment, the nurse notes that the uterus is midline and boggy. The immediate nursing action is:a. To notify the patient's midwife or physician b. Massage the fundus until firm and reevaluate within 30 minutes c. Give Syntocinon as per orders d. Assist the patient to the bathroom and ask her to void

ANS: B If the uterus does not respond to massage, then the nurse would give Syntocinon and notify the primary health provider. The first nursing action for a boggy uterus is to massage the fundus. If the uterus does not respond to massage, then the nurse would give Syntocinon and notify the primary health provider. You would assist the woman to the bathroom if the uterus is boggy and displaced to the side.

11. The perinatal nurse demonstrates for the student nurse the correct technique of postpartum uterine palpation. Support for the lower uterine segment is critical, as without it, there is an increased risk of: a. Uterine edema b. Uterine inversion c. Incorrect measurement d. Intensifying the patient's level of pain

ANS: B Placing the hand over the base of the uterus does not cause uterine edema. The uterine fundus is palpated by placing one hand on the base of the uterus immediately above the symphysis pubis and the other hand at the level of the umbilicus. The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. It should feel like a firm, globular mass located at or slightly above the umbilicus during the first hour after birth. The uterus should never be palpated without supporting the lower uterine segment. Failure to do so may result in uterine inversion and hemorrhage. Measurement is the same with or without the hand supporting the lower uterine segment. Not supporting the lower uterine segment has no effect on the level of pain felt by the patient.

1. A 25 year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to: a. Explain that this is normal for second-time moms. b. Assess the location and firmness of the fundus. c. Change her pad and return in 1 hour and reassess. d. Give her 10 units of oxytocin as per standing order.

ANS: B The nurse should not inform the patient that this is normal until she has assessed for the degree and potential cause of bleeding. It is important to first assess for uterine atony or displaced uterus from full bladder. If the uterus is firm and midline, then the nurse should change the pad and return within 30 minutes to assess the amount of lochia. The nurse would give oxytocin if the uterus is boggy and does not respond to uterine massage.

16. During change of shift report, the nurse hears the following information on a newly delivered client: 27 years old, married, G4 P3, 8 hours postspontaneous vaginal delivery over 3º laceration, vitals—110/70, 98.6ºF, 82, 18, fundus firm at umbilicus, moderate lochia, ambulated to bathroom to void three times for a total of 900 mL, breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? a. Fluid volume deficit b. Impaired skin integrity c. Impaired urinary elimination d. Ineffective breastfeeding

ANS: B There is nothing in the scenario that indicates that this client has had a significant blood loss. The client has a 3º laceration. A nursing diagnosis of impaired skin integrity is appropriate. The client is voiding well. There is no indication of impaired urinary elimination. The client is feeding q 2 h. There is no indication of impaired breastfeeding.

2. Which of the following sites is priority for the nurse to assess when caring for a breastfeeding client, G8 P5, who is 1 hour postdelivery? a. Nipples b. Fundus c. Lungs d. Rectum

ANS: B a. Her nipples should be assessed, but this is not the priority assessment. b. This client is a grand multipara. She is high risk for uterine atony and postpartum hemorrhage. The nurse should monitor her fundus very carefully. c. Her lungs should be assessed bilaterally, but this is not the priority assessment. d. Her rectum should be assessed for hemorrhoids, but this is not the priority assessment.

Mastitis is an inflammation of the __________.

ANS: Breast Mastitis is an inflammation or infection of the breast. This can occur when bacteria enter the breast through cracks around the nipple area

2. Which of these medications is commonly used to control postpartum bleeding related to uterine atony? a. Magnesium sulfate b. Phytonadione c. Oxytocin d. Warfarin

ANS: C Magnesium sulfate is commonly used for PIH and preterm labor. It is a smooth muscle relaxant and can cause the uterus to relax. Phytonadione (vitamin K) is important for clotting but will not cause the uterus to contract. Oxytocin is commonly used to control postpartum bleeding related to uterine atony. Warfarin is an anticoagulant and will increase the risk of hemorrhage.

13. A 35-year-old G1 P0 postpartum woman is Rh0(D)-negative and needs Rh0(D) immune globulin to be administered. The most appropriate dose that the perinatal nurse would expect to be ordered would be: a. 120 ug b. 250 ug c. 300 ug d. 350 ug

ANS: C Nonsensitized women who are Rh0(D)-negative and have given birth to an Rh(D)-positive infant should receive 300 ug of Rh0(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations, depending on the extent of hemorrhage and exchange of maternal-fetal blood, a larger dose of RhoGAM may be indicated.

6. A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery. Which of the following actions indicates that the nurse is performing the assessment correctly? a. The nurse measures the fundal height in relation to the symphysis pubis. b. The nurse monitors the client's central venous pressure. c. The nurse assesses the client's perineum for edema and ecchymoses. d. The nurse performs a sterile vaginal speculum exam.

ANS: C The fundal height should be measured in relation to the umbilicus. The central venous pressure is not monitored during postpartum assessments. The nurse should assess the perineum for signs of edema and ecchymoses. If a speculum exam were needed, a physician or midwife would perform the procedure. Speculum exams are rarely needed postpartum.

8. Which of the following clients is most likely to complain of afterbirth pains during her postpartum period? a. G1 P0, diagnosed with preeclampsia b. G2 P0, group B streptococci in the vagina c. G3 P2, gave birth to a 4100-gram baby d. G4 P1, diagnosed with preterm labor

ANS: C This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. This client is a multipara and she delivered a macrosomic baby. She is likely to complain of severe afterbirth pains. Although this client is a gravida 4, she is a para 1. The nurse would not expect her to complain excessively of afterbirth pains.

4. On day four following the birth of an average size baby, the nurse would expect the fundus to be at: a. 1 cm below umbilicus b. 2 cm below umbilicus c. 3 cm below umbilicus d. 4 cm below umbilicus

ANS: D Correct. The uterus on the average descends 1 centimeter per day.

15. The perinatal nurse teaches the postpartum woman about the normal process of diuresis that she can expect to occur approximately 6 to 8 hours after birth. A decrease in which of the following hormones is primarily responsible for the diuresis? a. Prolactin b. Progesterone c. Oxytocin d. Estrogen

ANS: D Maternal diuresis occurs almost immediately after birth and urinary output reaches up to 3000 mL each day by the second to fifth postpartum days. After childbirth, a decrease in the level of estrogen naturally occurs and contributes to the diuresis.

5. A nurse is preparing to administer RhoGam to a client who delivered a fetal demise. Which of the following must the nurse check before giving the injection? a. Verify that the direct Coombs test results are positive. b. Check that the fetus was at least 28 weeks' gestation. c. Make sure that the client is at least 3 days postdelivery. d. Confirm that the client is Rh negative.

ANS: D The direct Coombs test is irrelevant, and because the baby has died, the Coombs will likely not be performed. RhoGam should be given no matter how old the fetus was. RhoGam must be administered before 72 hours postpartum. RhoGam is contraindicated for clients who are Rh+ (positive). The nurse must confirm that any client receiving RhoGam is Rh negative.

14. Heather, a postpartum woman who experienced a spontaneous vaginal birth 12 hours ago, describes a headache that is worsening. Heather was given two regular strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. Several friends and family members are presently visiting Heather. The nurse notes that Heather's pain relief during labor consisted of a single dose of an IM narcotic. The most appropriate nursing action at this time is to: a. Notify Heather's health-care provider about Heather's headache. b. Dim the lights in Heather's room so that she is able to get some rest. c. Ask Heather's visitors to leave now to decrease Heather's environmental stimuli. d. Ask Heather where she is experiencing this headache and to identify the pain score that best describes the intensity of the pain.

ANS: D The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort in order to provide interventions in a timely manner and enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0 to 10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale.

3. A client is 1 hour postpartum from a vacuum delivery over a midline episiotomy of a 4500-gram neonate. Which of the following nursing diagnoses is appropriate for this mother? a. Risk for altered parenting b. Risk for imbalanced nutrition: less than body requirements c. Risk for ineffective individual coping d. Risk for fluid volume deficit

ANS: D a. Although the baby is macrosomic, there is no evidence that this mother is high risk for altered parenting. b. This woman's baby is macrosomic—there is no indication that this woman is consuming a diet that is less than body requirements. c. There is no evidence that this mother is high risk for altered coping. d. This client is high risk for fluid volume deficit. Women who deliver macrosomic babies are high risk for uterine atony, which can lead to heavy flow of lochia.

The postpartum nurse is caring for a couple who experienced an unplanned emergency cesarean birth. The nurse observes the following behaviors: Parents are gently touching their newborn. Mother is softly singing to her baby. Father is gazing into his baby's eyes. Based on this data, the correct nursing diagnosis is altered parent-infant bonding related to emergency cesarean birth. Cesarean birth can place the parents at risk for bonding, but based on the observed interaction with their newborn, the parents display positive signs of bonding. (T/F)

ANS: False

True/False The clinic nurse recognizes that the longer an infant is formula fed, the greater is the immunity and resistance the infant will develop against bacterial and viral infections.

ANS: False One of the primary benefits of breastfeeding, not formula feeding, is the decreased incidence of bacterial and viral infections as a result of passive immunity, including the transfer of maternal antibodies.

Bonding is bidirectional from parent to infant and infant to parent. (T/F)

ANS: False Bonding is unidirectional from parent to infant. Attachment is bidirectional.

37. The gray, blue, or purple areas on the buttocks of a neonate are referred to as __________.

ANS: Mongolian spots Mongolian spots are blue/gray areas on the buttocks that are frequently seen in darker-skinned neonates.

38. __________ is a vasomotor response to decreased body temperature after birth

ANS: Mottling Mottling is a benign transient pattern of pink and white blotches on the skin in response to a cold environment

True/False It is a common custom for traditional Chinese women to bottle feed their infants until their milk comes in.

ANS: True It is common for traditional Chinese women to bottle feed until their milk comes in.

A hematoma is the collection of blood beneath the intact skin layer following an injury to a blood vessel. T/F

ANS: True A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. At the time of injury, pressure necrosis and inadequate hemostasis occur.

30. The nurse assessing a newborn for heat loss is aware that nonshivering thermogenesis utilizes the newborn's stores of brown adipose tissue (BAT) to provide heat in the cold-stressed newborn. (T/F)

ANS: True Brown adipose tissue, also known as "brown fat," is a unique highly vascular fat found only in newborns. BAT derives its name from the rich abundance of blood vessels, cells, and nerve endings that cause it to appear dark in color. The masses of brown fat cells accelerate triglyceride metabolism, triggering a process that produces heat.

Eye movements are an example of newborn/infant style of communication. (T/F)

ANS: True Crying, cooing, facial expressions, eye movements, cuddling, and arm and leg movements are all examples of newborn/infant style of communication.

Metritis is an infection that usually starts at the placental site. T/F

ANS: True Metritis is an infection of the endometrium that usually starts at the placental site and spreads to encompass the entire endometrium.

Abruptio placenta is a risk factor for amniotic fluid embolism. T/F

ANS: True Risk factors for amniotic fluid embolism include induction of labor, maternal age over 35, operative delivery, placenta previa, abruptio placenta, polyhydramnios, eclampsia, and cervical or uterine lacerations

The perinatal nurse teaches the postpartum woman that the most critical time to achieve effectiveness from the application of ice packs to the perineum is during the first 24 hours following birth. (T/F)

ANS: True To reduce perineal swelling and pain that result from bruising, ice packs may be applied every 2 to 4 hours. Patients obtain the most relief when ice packs are applied within the first 24 hours after childbirth

9. Approximately 8 hours ago, Juanita, a 32-year-old G1 P0, gave birth after 2 ½ hours of pushing. She required an episiotomy and an assisted birth (forceps) due to the weight and size of her baby (9 lb. 9 oz.). The perinatal nurse is performing an assessment of Juanita's perineal area. A slight bulge is palpated and the presence of ecchymoses to the right of the episiotomy is noted. The area feels "full" and is approximately 4 cm in diameter. Juanita describes this area as "very tender." The most likely cause of these signs and symptoms is: a. Hematoma formation b. Sepsis in the episiotomy site c. Inadequate repair of the episiotomy d. Postpartum hemorrhage

ANS: a A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. The most common sign or symptom of a hematoma is unremitting pain and pressure. Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as "full."

6. The perinatal nurse recognizes that a risk factor for postpartum depression is: a. Inadequate social support b. Age >35 years c. Gestational hypertension d. Regular schedule of prenatal care

ANS: a Recognized risk factors for postpartum depression include an undesired or unplanned pregnancy, a history of depression, recent major life changes such as the death of a family member, moving to a new community, lack of family or social support, financial stress, marital discord, adolescent age, and homelessness.

15. The perinatal nurse is assisting the student nurse with completion of documentation. The laboring woman has just given birth to a 2700 gram infant at 36 weeks' gestation. The most appropriate term for this is: a. Preterm birth b. Term birth c. Small for gestational age infant d. Large for gestational age infant

ANS: a a. A preterm infant is an infant with gestational age of fewer than 36 completed weeks. b. Term births are infants born between 37 and 40 weeks. c. SAG infants at 36 weeks weigh less than 2000 grams. d. LAG infants at 36 weeks weigh over 3400 grams.

10. A 42-week gestation neonate is admitted to the NICU (neonatal intensive care unit). This neonate is at risk for which complication? a. Meconium aspiration syndrome b. Failure to thrive c. Necrotizing enterocolitis d. Intraventricular hemorrhage

ANS: a a. Although there is nothing in the scenario that states that the amniotic fluid is green tinged, post-term babies are high risk for meconium aspiration syndrome. b. Post-term babies often gain weight very quickly. c. Preterm, not post-term, babies are high risk for necrotizing enterocolitis. d. Preterm, not post-term, babies are high risk for intraventricular hemorrhages.

13. The laboratory reported that the L/S ratio (lecithin/sphingomyelin) results from an amniocentesis of a gravid client with preeclampsia are 2:1. The nurse interprets the result as which of the following? a. The baby's lung fields are mature. b. The mother is high risk for hemorrhage. c. The baby's kidneys are functioning poorly. d. The mother is high risk for eclampsia

ANS: a a. An L/S ratio of 2:1 usually indicates that the fetal lungs are mature. b. L/S ratios are unrelated to maternal blood loss. c. L/S ratios are unrelated to fetal renal function. d. L/S ratios are unrelated to maternal risk for becoming eclamptic.

22. The nursery nurse notes the presence of diffuse edema on a baby girl's head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edema has disappeared. The nurse documents the following condition in the infant's chart. a. Caput succedaneum b. Cephalhematoma c. Subperiosteal hemorrhage d. Epstein pearls

ANS: a a. Caput succedaneum is diffuse edema that crosses the cranial suture lines and disappears without treatment during the first few days of life. b. Cephalhematoma, a more serious condition, results from a subperiosteal hemorrhage that does not cross the suture lines. It appears as a localized swelling on one side of the infant's head and persists for weeks while the tissue fluid is slowly broken down and absorbed. c. Cephalhematoma, a more serious condition, results from a subperiosteal hemorrhage that does not cross the suture lines. It appears as a localized swelling on one side of the infant's head and persists for weeks while the tissue fluid is slowly broken down and absorbed. d. Epstein pearls are whitish, hardened nodules on the gums or roof of the mouth.

1. A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of vitamin K, the nurse will: a. Explain to the parents the action of the medication and answer their questions. b. Remove the neonate from the room so the parents will not be distressed by seeing the injection. c. Completely undress the neonate to identify the injection site. d. Replace needle with a 21 gauge 5/8 needle.

ANS: a a. It is important to always explain to parents what and why a procedure is being done on the newborn. b. It is best to give parents an option to be with their newborn when giving injections. c. It is best to keep the newborn covered as much as possible to reduce heat loss. d. A 25 gauge 5/8 needle is used for giving injections to full-term neonates.

5. Which of the following breath sounds are normal to hear in the neonate during the first few hours postbirth? a. Scattered crackles b. Wheezes c. Stridor d. Grunting

ANS: a a. It is normal to hear scattered crackles during the first few hours. This is due to retained amniotic fluid that will be absorbed through the lymphatic system. b. This may indicate difficulty in breathing. c. This may indicate respiratory obstruction. d. This may indicate respiratory distress.

8. An infant admitted to the newborn nursery has a blood glucose level of 55 mg/dL. Which of the following actions should the nurse perform at this time? a. Provide the baby with routine feedings. b. Assess the baby's blood pressure. c. Place the baby under the infant warmer. d. Monitor the baby's urinary output.

ANS: a a. This blood glucose level is normal. The nurse should provide routine nursing care. b. There is no apparent need to assess this baby's blood pressure. c. There is no apparent need to place the baby under the infant warmer. d. There is no apparent need to monitor the baby's output.

12. A baby boy was just born to a mother who had positive vaginal cultures for group B streptococci. The mother was admitted to the labor room 30 minutes before the birth. For which of the following should the nursery nurse closely observe this baby? a. Grunting b. Acrocyanosis c. Pseudostrabismus d. Hydrocele

ANS: a a. This infant is high risk for respiratory distress. The nurse should observe this baby carefully for grunting. b. Acrocyanosis is a normal finding. c. Pseudostrabismus is a normal finding. d. Hydrocele should be reported to the neonatologist. It is not, however, an emergent problem, and it is not related to group B streptococci colonization in the mother.

10. The nurse is about to elicit the rooting reflex on a newborn baby. Which of the following responses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

ANS: a a. This is a description of the rooting reflex. b. This is a description of the Babinski reflex. c. This is a description of the Moro reflex. d. This is a description of the tonic neck reflex.

2. To accurately measure the neonate's head, the nurse places the measuring tape around the head: a. Just above the ears and eyebrows b. Middle of the ear and over the eyes c. Middle of the ear and over the bridge of the nose d. Just below the ears and over the upper lip

ANS: a a. This is the standard measurement for the diameter of the head. b. This is not the standard measurement for the diameter of the head. c. This is not the standard measurement for the diameter of the head. d. This is not the standard measurement for the diameter of the head.

12. A nurse is assisting a physician during a baby's circumcision. Which of the following demonstrates that the nurse is acting as the baby's patient care advocate? a. The nurse requests that oral sucrose be ordered as a pain relief measure. b. The nurse restrains the baby on the circumcision board. c. The nurse wears a surgical mask during the procedure. d. The nurse provides the physician with an iodine solution for cleansing the skin.

ANS: a a. This response is correct. Because the baby is unable to ask for pain medication for the procedure, the nurse is advocating for the child. b. The restraint is used to keep the baby from moving during the procedure, a safety precaution. c. The nurse is using aseptic technique during the procedure when he or she wears a mask. d. The nurse is using aseptic technique during the procedure when he or she gives the physician iodine solution for the procedure.

Painful nipples are a major reason why women stop breastfeeding. A primary intervention to decrease nipple irritation is: a. Teaching proper techniques for latching-on and releasing of suction b. Applying hot compresses to breast prior to feeding c. Instructing woman to express colostrum or milk at the end of the feeding session and rub it on her nipples d. Air drying nipples for 10 minutes at the end of the feeding session

ANS: a Feedback a. Correct. All of the answers are correct, but problems with latching-on are a primary cause of nipple irritation. b. All of the answers are correct, but problems with latching-on are a primary cause of nipple irritation. c. All of the answers are correct, but problems with latching-on are a primary cause of nipple irritation. d. All of the answers are correct, but problems with latching-on are a primary cause of nipple irritation.

Which of the following positions for breastfeeding is preferred for a 2-day post-cesarean-birth woman? a. Lying down on side b. Sitting c. Cradle d. Cross-cradle

ANS: a Feedback a. Having the woman lying on her side to breastfeed prevents pressure on her abdomen and the pain that can result from the pressure. b. In this position, the baby is on the woman's abdomen, and this can be painful for the woman. c. In this position, the baby is on the woman's abdomen, and this can be painful for the woman. d. In this position, the baby is on the woman's abdomen, and this can be painful for the woman.

The nurse is advising parents of a full-term neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? a. Put the car seat facing forward only after the baby reaches 20 pounds. b. The infant car seat should be placed facing the rear seat in the front seat of the car. c. A fist should fit between the straps of the seat and the baby's body. d. Seat belt adjusters should always be used to support infant car seats.

ANS: a Feedback a. It is unsafe for infants to be facing forward until they have reached 20 pounds, even if they are over 1 year of age. b. The baby should be facing the rear of the back seat and not the front seat. c. The straps of the car seat should fit snugly, allowing only two fingers to be inserted between them and the baby. d. Seat belt adjusters that are being sold as adding to a car seat have not been shown to be safe.

A mother of a 10-day-old infant calls the clinic and reports that her baby is having loose, green stools. The mother is breastfeeding her infant. Which of the following is the best nursing action? a. Instruct the woman to bring her infant to the clinic. b. Instruct the woman to decrease the amount of feeding for 24 hours and to call if the stools continue to be loose. c. Explain that this is a normal stool pattern. d. Instruct the woman to eat a bland diet for the next 24 hours and call back if the stools continue to be loose and green.

ANS: a Feedback a. The loose, green stools indicate that the baby is having diarrhea. The infant needs to be evaluated by the primary health provider, because prolonged diarrhea can lead to dehydration and electrolyte imbalance. b. The baby is having diarrhea. Decreasing the amount of feeding can further dehydrate the baby. c. This is not a normal stool pattern; the baby is having diarrhea. d. This neonate needs to be evaluated first, before determining a treatment plan.

The nurse is teaching the parents of a female baby how to change a baby's diapers. Which of the following should be included in the teaching? a. Always wipe the perineum from front to back. b. Remove any vernix caseosa from the labia folds. c. Put powder on the buttocks every time the baby stools. d. Weigh every diaper in order to assess for hydration.

ANS: a Feedback a. To decrease risk of infection from bacteria from the rectum, the perineum of female babies should always be cleansed from front to back. b. Vernix is a natural lanolin that will be absorbed over time. Actively removing the vernix can irritate the baby's skin. c. Powder is not recommended for use on babies. When mixed with urine, powders can produce an irritating paste. d. The number of wet diapers per day should be counted to assess hydration, but weighing diapers of full-term, healthy neonates is not necessary.

A neonatal nurse caring for newborns knows that the best time for a mother to first attempt breastfeeding is during which one of the following stages of activity? a. First period of reactivity b. First period of inactivity and sleep c. Second period of reactivity d. Second period of inactivity and sleep

ANS: a The best stage for initiating breastfeeding is the first period of active, alert wakefulness that the infant displays immediately after birth, which may last from 30 minutes to 2 hours.

The postpartum nurse caring for a 20-year-old G1 P0 woman who 3 hours ago delivered a healthy full-term infant, observes the woman who is lightly touching her baby girl with her fingertips but who seems to be uncomfortable holding her baby close to her body. Which of the following is an accurate interpretation of these observed behaviors? a. The woman is in the initial stage of maternal touch. b. The woman is in the taking-in phase. c. The woman is having difficulty in bonding with her baby. d. The woman needs to be medicated for pain.

ANS: a These are classical signs of the initial stage of Rubin's maternal touch.

The nurse is developing a plan of care for a client who is in the "taking-in" phase after delivering a healthy baby boy. Which of the following should the nurse include in the plan? a. Provide the client with a nutritious meal. b. Teach baby care skills like diapering. c. Discuss the pros and cons of circumcision. d. Counsel her regarding future sexual encounters.

ANS: a a. Mothers are very hungry immediately after delivery. The nurse should provide the client with food.

A 16-year-old woman delivers a healthy, full-term male infant. The nurse notes the following behaviors 2 hours after the birth: Woman holds baby away from her body; woman refers to baby as "he"; woman verbalizes she wanted a baby girl; woman requests that baby be placed in the bassinet so she can eat her lunch. The most appropriate nursing diagnosis for this woman is: a. At risk for impaired parenting related to disappointment with baby as evidenced by verbalizing she wanted a girl b. At risk for impaired parenting related to nonnurturing behaviors as evidenced by holding baby away from body c. At risk for impaired mother-infant attachment as evidenced by woman requesting baby being placed in bassinet d. At risk for impaired mother-infant attachment related to disappointment as evidenced by calling baby "he"

ANS: a a. The potential is for impaired parenting related to disappointment in the gender of the baby.

1. A neonate is born at 33 weeks' gestation with a birth weight of 2400 grams. This neonate would be classified as: a. Low birth weight b. Very low birth weight c. Extremely low birth weight d. Very premature

ANS: a a. Neonates with a birth weight of less than 2500 grams but greater than 1500 grams are classified as low birth weight. b. Neonates with birth weight less than 1500 grams but greater than 1000 grams are classified as very low birth weight. c. Neonates with birth weight less than 1000 grams are classified as extremely low birth weight. d. Neonates born less than 32 weeks' gestation are classified as very premature.

A woman who gave birth 2 hours ago has a temperature of 37.9°C. Select all of the immediate nursing actions. a. Have patient drink two glasses of fluid over the next hour. b. Explain to the patient that she needs to rest and assist her into a comfortable position. c. Medicate the patient with 500 mg of acetaminophen as per orders. d. Call the patient's physician or midwife to report the elevated temperature.

ANS: a, b A mild temperature elevation within a few hours of birth can be related to dehydration and exhaustion. Acetaminophen is given if the temperature remains elevated after the woman has been hydrated and rested. The physician or midwife is notified if temperature remains elevated after initial interventions.

The clinic nurse teaches expectant mothers about the differences between breast milk and commercially prepared infant formulas. When compared to commercially prepared formulas, breast milk has (select all that apply): a. More carbohydrates b. Less protein c. Fewer nutrients d. Less cholesterol

ANS: a, b Human breast milk contains more carbohydrates, less protein, and more cholesterol than cow's milk or infant formulas. Commercially prepared infant formulas use vegetable oils which are void of cholesterol.

Which of the following actions can decrease the risk for a postpartum infection? (Select all that apply.) a. Diet high in protein and vitamin C b. Increased fluid intake c. Ambulating within a few hours after delivery d. Washing nipples with soap prior to each breastfeeding session

ANS: a, b, c Protein and vitamin C assist with tissue healing. Rehydrating a woman after delivery can assist with decreasing risk for infections. Early ambulation decreases risk for infection by promoting uterine drainage. The woman should not wash her breasts with soap because soap can dry the tissue and increase the woman's risk for tissue breakdown

Which of the following are primary risk factors for subinvolution of the uterus? (Select all that apply.) a. Fibroids b. Retained placental tissue c. Metritis d. Urinary tract infection

ANS: a, b, c Uterine fibroids can interfere with involution. Retained placental tissue does not allow the uterus to remain contracted. Infection in the uterus is a risk factor for subinvolution. UTI does not interfere with involution of the uterus.

25. A healthy, full-term baby is scheduled for a circumcision. Nursing actions prior to the procedure include which of the following? (Select all that apply.) a. Obtain written consent from the mother. b. Administer acetaminophen PO 1 hour before procedure per MD order. c. Feed the neonate glucose water 30 minutes before the procedure. d. Obtain the neonate's protime.

ANS: a, b, c a. Circumcision is a surgical procedure and requires written consent signed by the parent. b. Administration of acetaminophen is a method of pain management for the newborn. c. Glucose water is a method of pain management for the newborn. d. It is not a standard protocol to obtain a protime prior to circumcision.

A G2 P1 woman who experienced a prolonged labor and prolonged rupture of membranes is at risk for metritis. Which of the following nursing actions are directed at decreasing this risk? (Select all that apply.) a. Instruct woman to increase her fluid intake b. Instruct woman to change her peri-pads after each voiding c. Instruct woman to ambulate in the halls four times a day d. Instruct woman to apply ice packs to the perineum

ANS: a, b, c a. Maintaining adequate hydration can decrease a person's risk for infection. b. Lochia is a media for bacterial growth, so it is important to frequently change the peri-pads. c. Ambulation can decrease the risk of infection by promoting uterine drainage. d. Ice pack therapy is directed at decreasing edema of the perineum and promoting comfort. It has no effect on metriosis.

20. Nursing actions that decrease the risk of skin breakdown include which of the following? (Select all that apply.) a. Using gelled mattresses b. Using emollients in groin and thigh areas c. Using transparent dressings d. Drying thoroughly

ANS: a, b, c a. Use of gelled mattresses decreases the risk of pressure sores. b. Use of emollients reduces the risk of irritation from urine. c. Use of transparent dressings reduces the risk of friction injuries. d. Drying thoroughly is important in maintaining body heat.

The perinatal nurse describes infant feeding cues to a new mother. These feeding cues include (select all that apply): a. Vocalizations b. Mouth movements c. Moving the hand to the mouth d. Yawning

ANS: a, b, c The infant demonstrates readiness for feeding when he or she begins to stir, bobs the head against the mattress or mother's neck or shoulder, makes hand-to-mouth or hand-to-hand movements, exhibits sucking or licking, exhibits rooting, and demonstrates increased activity with the arms and legs flexed and the hands in a fist.

25. A nurse is completing the initial assessment on a neonate of a mother with type I diabetes. Important assessment areas for this neonate include which of the following? (Select all that apply.) a. Assessment of cardiovascular system b. Assessment of respiratory system c. Assessment of musculoskeletal system d. Assessment of neurological system

ANS: a, b, c, d a. Neonates of mothers with type I diabetes are at higher risk for cardiac anomalies. b. Neonates of mothers with type I diabetes are at higher risk for RDS due to a delay in surfactant production related to high maternal glucose levels. c. Neonates of mothers with type I diabetes are usually large and are at risk for a fractured clavicle. d. Neonates of mothers with type I diabetes are at higher risk for neurological damage and seizures due to neonatal hyperinsulinism.

26. A first-time mother informs her nurse that another staff member came in and wanted to take her baby to the nursery. The mother refused to let the woman take her baby because the staff member did not have a picture ID. The nurse should do which of the following? (Select all that apply.) a. Praise the mother for not allowing a person without proper ID to take her baby. b. Check with the nursery to see if a staff member was recently in the patient's room. c. Notify security of an unauthorized person in the unit. d. Alert staff of the incident.

ANS: a, b, c, d a. Parents are instructed not to allow anyone who does not have proper identification to take their newborn from their room. b. Check and see if there is a staff member who is not wearing picture ID. c. This incident needs to be reported to security. Usually the unit is locked, and there are security checks for unauthorized persons on the unit. d. All staff on the different shifts need to be alerted so they can watch for unauthorized persons on the unit.

23. Which of the following are common assessment findings of postmature neonates? (Select all that apply.) a. Dry and peeling skin b. Abundant vernix caseosa c. Hypoglycemia d. Thin, wasted appearance

ANS: a, b, c, d a. Vernix caseosa covers the fetus's body around 17 to 20 weeks' gestation; as pregnancy advances, the amount of vernix decreases. Vernix prevents water loss from the skin to the amniotic fluid; as the amount of vernix decreases, an increasing amount of water is lost from the skin. This contributes to the dry and peeling skin seen in postmature neonates. b. Vernix caseosa covers the fetus's body around 17 to 20 weeks' gestation; as pregnancy advances, the amount of vernix decreases. c. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fat stores and glycemic stores. This results in the thin and wasted appearance of the neonate and risk for hypoglycemia during the first few hours post-birth. d. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fat stores and glycemic stores. This results in the thin and wasted appearance of the neonate and risk for hypoglycemia during the first few hours post-birth.

Which of the following nursing actions can assist a man in his transition to fatherhood? (Select all that apply.) a. Ask the man to share his ideas of what it means to be a father. b. Demonstrate infant care such as diapering and feeding. c. Engage couple in a discussion regarding each other's expectations of the fathering role. d. Provide the man with information on infant care.

ANS: a, b, c, d Each of these actions can assist the father in his transition. It is important for the man to be able to learn and practice infant care skills in a nonthreatening environment. It is also important for the man to be able to openly talk about his feelings regarding fatherhood and for the couple to identify mutual expectations of the fathering role.

24. A nurse is caring for a 40 weeks' gestation neonate. The neonate is 12 hours post-birth and has been admitted to the NICU for meconium aspiration. The nurse recalls that the following are potential complications related to meconium aspiration (select all that apply): a. Obstructed airway b. Hyperinflation of the alveoli c. Hypoinflation of the alveoli d. Decreased surfactant proteins

ANS: a, b, d a. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. b. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. c. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. d. The presence of meconium in the lungs can also cause a chemical pneumonitis and inhibit surfactant production.

Which of the following factors place a new mother at risk for parenting? (Select all that apply.) a. She is 17 years old. b. Family income is below the average income. c. Her parents live in the same city and are perceived as helpful. d. She dropped out of school at age 13.

ANS: a, b, d Adolescent parents may have a more difficult transition to parenthood because they have not made the transition to adulthood. Financial concerns can hamper the transition to parenthood because the focus of attention may be on where to get money to pay for daily living expenses versus on the care of their newborn. Decreased ability to read and comprehend information regarding child care may hamper the ability to gain knowledge about the care of their child.

Which of the following nursing actions are directed at promoting bonding? (Select all that apply.) a. Providing opportunity for parents to hold their newborn as soon as possible following the birth. b. Providing opportunities for the couple to talk about their birth experience and about becoming parents. c. Promoting rest and comfort by keeping the newborn in the nursery at night. d. Providing positive comments to parents regarding their interactions with their newborn.

ANS: a, b, d Parent bonding can be delayed by prolonged periods of separation from their child. The other three actions support parent bonding with their newborn.

18. A nurse is caring for a 2-day-old neonate who was born at 31 weeks' gestation. The neonate has a diagnosis of respiratory distress syndrome (RDS). Which of the following medical treatments would the nurse anticipate for this neonate? (Select all that apply.) a. Exogenous surfactant b. Corticosteroids c. Continuous positive airway pressure (CPAP) d. Bronchodilators

ANS: a, c a. This is a common medical treatment for RDS. b. Corticosteroids are given to women in preterm labor to decrease the risk of RDS. c. CPAP is used to assist neonates with RDS. d. Bronchodilators are given to neonates with bronchopulmonary dysplasia (BPD).

Nursing actions focused at reducing a postpartum woman's risk for cystitis include which of the following? (Select all that apply.) a. Voiding within a few hours post-birth b. Oral intake of a minimum of 1000 mL per day c. Changing peri-pads every 3 to 4 hours or more frequently as indicated d. Reminding the woman to void every 3 to 4 hours while awake

ANS: a, c, d Early voiding helps flush bacteria from the urethra. Voiding every 3 to 4 hours will decrease the risk of bacterial growth in the bladder. Soiled peri-pads are a media for bacterial growth. It is recommend that a postpartum woman drink a minimum of 3000 mL/day to help dilute urine and promote frequent voiding.

22. A nurse is caring for a 10-day-old neonate who was born at 33 weeks' gestation. Which of the following actions assist the nurse in assessing for signs of feeding tolerance? (Select all that apply.) a. Check for presence of bowel sounds b. Assess temperature c. Check gastric residual by aspirating stomach contents d. Assess stools

ANS: a, c, d a. Feedings should be held and physician notified if bowel sounds are absent. b. The neonate's temperature has no direct effect on feeding tolerance. c. Aspirated stomach contents are assessed for amount, color, and consistency. This assists in the evaluation of the degree of digestion and absorption. d. Stools are assessed for consistency, amount, and frequency. This assists in the evaluation of the degree of digestion and absorption.

General skin care for full-term infants includes which of the following? (Select all that apply.) a. Avoid daily bathing with soap. b. Use a cleanser with an alkaline pH. c. Avoid fragrant soaps. d. Apply petrolatum-based ointments sparingly to dry skin, but avoid head and face.

ANS: a, c, d It is not necessary to bathe an infant daily. Daily bathing with soap can cause dry skin in the infant. The cleanser should be of neutral pH and free of additives such as fragrances that could be irritants.

The nurse is caring for a postpartum woman who gave birth to a healthy, full-term baby girl. She has a 2-year-old son. She voices concern about her older child's adjustment to the new baby. Nursing actions that will facilitate the older son's adjustment to having a new baby in the house would include which of the following? (Select all that apply.) a. Explain to the mother that she can have her son lie in bed with her when he is visiting her in the hospital. b. Teach her son how to change the baby's diapers. c. Assist her son in holding his new baby sister. d. Recommend that she spend time reading to her older son while he sits in her lap.

ANS: a, c, d Two-year-olds enjoy being close to their mothers, including lying next to their mothers or being held. Changing diapers is not viewed as a pleasurable experience and is not developmentally appropriate for a 2-year-old. Children enjoy being able to hold their sibling and feeling "grown up."

19. Which of the following factors increases the risk of necrotizing enterocolitis (NEC) in very premature neonates? (Select all that apply.) a. Early oral feedings with formula b. Prolonged use of mechanical ventilation c. Hyperbilirubinemia d. Nasogastic feedings

ANS: a, d a. Preterm neonates have a decreased ability to digest and absorb formula. Undigested formula can cause a blockage in the intestines leading to necrosis of the bowel. b. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. c. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. d. Bacterial colonization in the intestines can occur from contaminated feeding tubes causing an inflammatory response in the bowel.

29. The perinatal nurse observed the pediatrician completing the Ballard Gestational Age by Maturity Rating tool. The maturity components used with this assessment tool are (select all that apply): a. Physical b. Behavioral c. Reflexive d. Neuromuscular

ANS: a, d With the Ballard assessment system, the infant examination yields a score of neuromuscular and physical maturity that can be extrapolated onto a corresponding age scale to reveal the infant's gestational age in weeks.

35. The nurse explains to a pregnant patient that the mother's prior exposure to illness and immunizations prompts the development of antibodies in the newborn in a process termed __________ immunity.

ANS: active acquired The pregnant woman's exposure to illness and immunizations prompts the development of antibodies in a process termed active acquired immunity. The infant receives passive acquired immunity through antibodies that have been passed through the placenta by way of the IgG immunoglobulins.

7. Karen, a G2, P1, experienced a precipitous birth 90 minutes ago. Her infant is 4200 grams and a repair of a second-degree laceration was needed following the birth. As part of the nursing assessment, the nurse discovers that Karen's uterus is boggy. Furthermore, it is noted that Karen's vaginal bleeding has increased. The nurse's most appropriate first action is to: a. Assess vital signs including blood pressure and pulse. b. Massage the uterine fundus with continual lower segment support. c. Measure and document each perineal pad changed in order to assess blood loss. d. Ensure appropriate lighting for a perineal repair if it is needed.

ANS: b As the primary caregiver, the registered nurse may be the first person to identify excessive blood loss and initiate immediate actions. The nurse should first locate the uterine fundus and initiate fundal massage. Nursing actions performed after the massage are frequent vital sign measurements with an automatic device, measuring the length of time it takes for blood loss to saturate a pad, and assessing for bladder distention.

5. The perinatal nurse teaches the postpartum woman about warning signs regarding development of postpartum infection. Signs and symptoms that merit assessment by the health-care provider include the development of a fever and: a. Breast engorgement b. Uterine tenderness c. Diarrhea d. Emotional lability

ANS: b During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F, often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.

14. Which of the following neonatal signs or symptoms would the nurse expect to see in a neonate with an elevated bilirubin level? a. Low glucose b. Poor feeding c. Hyperactivity d. Hyperthermia

ANS: b a. Hypoglycemia is not a sign that is related to an elevated bilirubin level. b. The baby is likely to feed poorly. An elevated bilirubin level adversely affects the central nervous system. Babies are often sleepy and feed poorly when the bilirubin level is elevated. c. Hyperactivity is the opposite of the behavior one would expect the baby to exhibit. d. Hyperthermia is not directly related to an elevated bilirubin level.

6. The nurse assesses that a full-term neonate's temperature is 36.2°C. The first nursing action is to: a. Turn up the heat in the room. b. Place the neonate on the mother's chest with a warm blanket over the mother and baby. c. Take the neonate to the nursery and place in a radiant warmer. d. Notify the neonate's primary provider.

ANS: b a. Increasing the heat in the room will take a long period of time before it has an effect on the neonate. b. Skin-to-skin contact along with use of a warm blanket is the best intervention with mild temperature decrease in the neonate. c. If the temperature remains low, then the neonate needs to be placed under a radiant warmer. d. The primary health provider is notified if the temperature remains low after interventions.

3. A full-term neonate who is 30 hours old has a bilirubin level of 10 mg/dL. The neonate has a yellowish tint to the skin of the face. The mother is breastfeeding her newborn. The nurse caring for this neonate would anticipate which of the following interventions? a. Phototherapy b. Feeding neonate every 2 to 3 hours c. Switch from breastfeeding to bottle feeding d. Assess red blood cell count

ANS: b a. Phototherapy is considered when the levels are 12 mg/dL or higher when the neonate is 25 to 48 hours old. Neonates re-absorb increased amounts of unconjugated bilirubin in the intestines due to lack of intestinal bacteria and decreased gastrointestinal motility. b. Adequate hydration promotes excretion of bilirubin in the urine. c. Colostrum acts as a laxative and assists in the passage of meconium. d. Assessing RBC is not a treatment for hyperbilirubinemia.

16. A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions would be appropriate for the nurse to delegate to the CNA? a. Admit a newly delivered baby to the nursery. b. Bathe and weigh a 3-hour-old baby. c. Provide discharge teaching to the mother of a 4-day-old baby. d. Interpret a bilirubin level reported by the laboratory.

ANS: b a. The RN should admit a new baby to the nursery. b. The CNA could bathe and weigh a 3-hour-old baby. c. The RN should provide clients with needed teaching. d. The RN should interpret a bilirubin level.

15. A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip? a. Grasp the inner aspects of the baby's calves with thumbs and forefingers. b. Gently abduct the baby's thighs. c. Palpate the baby's patellae to assess for subluxation of the bones. d. Dorsiflex the baby's feet.

ANS: b a. The nurse would grasp the baby's thighs with thumbs and forefingers. b. The nurse would gently abduct the baby's legs. c. The nurse would palpate the trochanter to assess for changes. d. The nurse would not dorsiflex the feet to assess for developmental dysplasia of the hip (DDH).

he perinatal nurse observes the new mother watching her baby daughter closely, touching her face, and asking many questions about infant feeding. This stage of mothering is best described as: a. Taking in b. Taking hold c. Taking charge d. Taking time

ANS: b As the mother's physical condition improves, she begins to take charge and enters the taking-hold phase where she assumes care for herself and her infant. At this time, the mother eagerly wants information about infant care and shows signs of bonding with her infant. During this phase, the nurse should closely observe mother-infant interactions for signs of poor bonding, and if present, implement actions to facilitate attachment.

The nurse is developing a discharge teaching plan for a 21-year-old first-time mom. This was an unplanned pregnancy. She had a prolonged labor and an early postpartum hemorrhage. The woman plans to breastfeed her baby. She plans to return to work when her baby is 3 months old. Based on this information, the three primary learning needs of this woman are: a. Breastfeeding, bathing of the newborn, and infant safety b. Breastfeeding, storage of milk, and nutrition c. Breastfeeding, contraception, infant safety d. Breastfeeding, storage of milk, and rest

ANS: b Feedback a. These are important learning needs but do not reflect an understanding of learning needs based on early postpartum hemorrhage and returning to work in 3 months. b. Because this is the woman's first time breastfeeding and she plans to return to work, it is important that she feels comfortable with her understanding of breastfeeding and knows how to store her milk when she returns to work. Because she had a postpartum hemorrhage, she needs to learn what foods are high in iron. c. These are important learning needs but do not reflect an understanding of learning needs based on early postpartum hemorrhage and returning to work in 3 months. d. These are important learning needs but do not reflect an understanding of learning needs based on early postpartum hemorrhage.

The perinatal nurse is teaching her new mother about breastfeeding and explains that the most appropriate time to breastfeed is: a. 3 to 4 hours after the last feeding b. When her infant is in a quiet alert state c. When her infant is in an active alert state d. When her infant exhibits hunger-related crying

ANS: b The optimal time to breastfeed is when the baby is in a quiet alert state. Crying is usually a late sign of hunger, and achieving satisfactory latch-on at this time is difficult. Latch-on is proper attachment of the infant to the breast for feeding. The neonate is most alert during the first 1 to 2 hours after an unmedicated birth, and this is the ideal time to put the infant to the breast.

The nurse notes that a new father gazes at his baby for prolonged periods of time and comments that his baby is beautiful and he is very happy having a baby. These behaviors are commonly associated with: a. Bonding b. Engrossment c. Couvade syndrome d. Attachment

ANS: b b. Correct. Characteristics of engrossment are visual awareness of baby, tactile awareness of baby, perception that baby is perfect, strong attraction to baby, feeling of strong elation, and increased self-esteem.

28. A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal problems could have resulted in this complication? (Select all that apply.) a. Cholecystitis b. Hypertension c. Cigarette smoker d. Candidiasis e. Cerebral palsy

ANS: b, c Babies born to women with cholecystitis are not especially high risk for IUGR. Babies born to women with PIH or who smoke are high risk for IUGR. Babies born to women with candidiasis or cerebral palsy are not especially high risk for IUGR.

27. The perinatal nurse caring for Emily, a 24-year-old mother of an infant born at 26 weeks' gestation, is providing discharge teaching. Emily is going to travel to the specialty center approximately 200 miles away where her daughter is receiving care. The nurse tells Emily that it is normal for Emily to feel (select all that apply): a. In control b. Anxious c. Guilty d. Overwhelmed

ANS: b, c, d a. Parents usually feel out of control. b. Correct answer. c. Correct answer. d. Correct answer.

Which of the following are disadvantages of bottle feeding? (Select all that apply.) a. Hampers mother-infant attachment b. Increases cost c. Increases risk of infection d. Increases risk of childhood obesity

ANS: b, c, d Feedback a. Bottle feeding does not interfere with mother-infant attachment. b. The cost of formula is greater than the cost of eating a well-balanced diet. c. Bottle-fed babies are at higher risk for infection because formulas lack the antibiotics that are found in colostrum and human milk. d. There is a relationship between childhood obesity and bottle feeding.

A nurse is going to teach her postpartum patient about newborn bathing, diapering, and swaddling. Which of the following indicates that the nurse incorporated teaching/learning principles in her teaching plans? (Select all that apply.) a. Asked family members to leave b. Turned off TV c. Closed the door of the room d. Administered analgesics a few hours before teaching session

ANS: b, c, d Feedback a. It is often helpful to have family members present, with the woman's permission, so they can also learn about caring for the newborn. b. Turning off the TV decreases the amount of distractions and allows the woman to focus on learning about infant care. c. Closing the door decreases the amount of distractions and allows the woman to focus on learning about infant care. d. Administering analgesia prior to the teaching session will enhance the woman's comfort and facilitate her ability to focus on the teaching session.

The let-down reflex occurs in response to the release of oxytocin. Which of the following can stimulate the release of oxytocin? (Select all that apply.) a. Prolactin release b. Infant suckling c. Infant crying d. Sexual activity

ANS: b, c, d Feedback a. Prolactin stimulates milk production but does not have a direct effect on the release of oxytocin. b. Infant suckling can cause the release of oxytocin. c. Hearing an infant cry can cause the release of oxytocin. d. An orgasm triggers the release of oxytocin.

The nurse is caring for a recently immigrated Chinese woman in the postpartum unit. Based on cultural beliefs and practices of the woman, the nurse would anticipate which of the following? (Select all that apply.) a. The woman prefers cold water for drinking. b. The woman prefers not to shower. c. The woman prefers to have her female relatives care for her baby. d. The woman prefers to have her family bring her food to eat.

ANS: b, c, d In traditional Chinese beliefs and practices, the woman is to rest and female family members take care of the woman and her infant. During the first month, the woman is to avoid yin energy by eating specific foods and avoiding drinking or touching cold water.

The perinatal nurse is teaching the new mother who has chosen to formula feed her infant. Appropriate instructions to be given to this mother include (select all that apply): a. Mix the formula with hot water only. b. Periodically check the nipple for slow flow. c. Prepare only enough formula to last for 24 hours. d. Discard any unused formula that remains in a bottle following use.

ANS: b, c, d Parents should be advised to read and follow the manufacturer's instructions explicitly when preparing the formula, because some require no water and some need to be diluted with water. Cold water should be used to mix the powder, only the amount to be used for each feeding should be prepared, and any unused formula should be discarded. The nipples should be checked periodically during feedings for correct flow and should be replaced regularly.

Typical signs of abusive head trauma (Shaken Baby Syndrome) include which of the following? (Select all that apply.) a. Broken clavicle b. Poor feeding c. Vomiting d. Breathing problems

ANS: b, c, d Symptoms of abusive head trauma are extreme irritability, breathing problems, convulsions, vomiting, and pale or bluish skin.

Which of the following nursing actions are important in the care of a postpartum woman who is at risk for orthostatic hypotension? (Select all that apply.) a. Have patient remain in bed for the first 4 hours postbirth. b. Instruct patient to slowly rise to a standing position. c. Open an ammonia ampule and have the patient smell the ammonia prior to getting out of bed. d. Explain to the patient the cause and incidence of orthostatic hypotension.

ANS: b, d Postpartum women are at risk for orthostatic hypotension during the first few hours postdelivery. Orthostatic hypotension is a sudden drop in the blood pressure when the woman stands up due to decreased vascular resistance in the pelvis. The woman should be instructed to sit on the edge of her bed for a few minutes and then slowly stand up. The nurse or aide should be with the woman the first few times she ambulates. Ammonia ampules are used when the woman faints and is not given prior to fainting.

28. A perinatal nurse assesses a term newborn for respiratory functioning. The nurse knows that which of the following conditions is normal for newborns? (Select all that apply.) a. A respiratory rate of 60 to 80 breaths per minute b. A breathing pattern that is often shallow, diaphragmatic, and irregular c. Periodic episodes of apnea d. The neonate's lung sounds may sound moist during early auscultation

ANS: b, d a. The normal respiratory rate for a healthy term newborn is 40 to 60 breaths per minute. b. The breathing pattern is often shallow, diaphragmatic, and irregular. c. Apnea is cessation of breathing that lasts more than 20 seconds; it is abnormal in the term neonate. d. Most fetal fluid is reabsorbed within the first few hours, but in some infants this process may take up to 24 hours and the lungs may sound moist for the first 24 hours.

4. The perinatal nurse accurately defines postpartum hemorrhage by including a decrease in hematocrit levels from pre- to postbirth by: a. 5% b. 8% c. 10% d. 15%

ANS: c Historically, practitioners have defined postpartum hemorrhage as a blood loss greater than 500 mL following a vaginal birth and 1000 mL or more following a cesarean birth. Hematocrit levels that decrease 10% from pre- to postbirth measurements are also included in the definition.

10. The perinatal nurse notifies the physician of the findings related to Juanita's assessment. The first step in care will most likely be to: a. Prepare Juanita for surgery b. Administer intravenous fluids c. Apply ice to the perineum d. Insert a urinary catheter

ANS: c If the hematoma is less than 3 to 5 centimeters in diameter, the physician usually orders palliative treatments such as ice to the area for the first 12 hours along with pain medication. After 12 hours, sitz baths are prescribed to replace the application of ice. However, a hematoma larger than 5 centimeters may require incision and drainage with the possible placement of a drain.

11. A 1-day-old neonate in the well-baby nursery is suspected of suffering from drug withdrawal because he is markedly hyperreflexic and is exhibiting which of the following additional sign or symptom? a. Prolonged periods of sleep b. Hypovolemic anemia c. Repeated bouts of diarrhea d. Pronounced pustular rash

ANS: c a. Babies who are withdrawing from drugs have disorganized behavioral states and sleep very poorly. b. There is nothing in the scenario that indicates that this child is hypovolemic or anemic. c. Babies who are experiencing withdrawal often experience bouts of diarrhea. d. A pustular rash is characteristic of an infectious problem, not of neonatal abstinence syndrome.

4. A NICU nurse is caring for a full-term neonate being treated for group B streptococcus. The mother of the neonate is crying and shares that she cannot understand how her baby became infected. The best response by the nurse is: a. "Newborns are more susceptible to infections due to an immature immune system. Would you like additional information on the newborn immune system?" b. "The infection was transmitted to your baby during the birthing process. Do you have a history of sexual transmitted infections?" c. "Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the vaginal area. What other questions do you have regarding your baby's health?" d. "I see that this is very upsetting for you. I will come back later and answer your questions."

ANS: c a. Correct information, but does not fully address the woman's concern. b. Correct, but GBS is not a sexually transmitted disease. c. Correct. This response answers her questions and allows her to ask additional questions about her baby's health. d. Acknowledges that she is upset but does not provide immediate information.

7. A multipara, 26 weeks' gestation and accompanied by her husband, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? a. Encourage the parents to pray for the baby's soul. b. Advise the parents that it is better for the baby to have died than to have had to live with a defect. c. Encourage the parents to hold the baby. d. Advise the parents to refrain from discussing the baby's death with their other children.

ANS: c a. It is inappropriate for the nurse to advise prayer. The parents must decide for themselves how they wish to express their spirituality. b. This is an inappropriate suggestion. c. This is an appropriate suggestion. Encouraging parents to spend time with their baby and hold their baby is an action that supports the parents during the grieving process. d. This is an inappropriate suggestion. It is very important for the parents to clearly communicate the baby's death with their other children.

20. The nurse is assessing the neonate's skin and notes the presence of small, irregular, red patches on the cheeks that will develop into single, yellow pimples on the chest or abdomen. The name for this common neonatal skin condition is: a. Milia b. Neonatal acne c. Erythema toxicum d. Pustular melanosis

ANS: c a. Milia presents as small, white papules or sebaceous cysts on the infant's face that resemble pimples. b. Acne, a skin condition common in adolescents, may also be present in newborns and is related to excessive amounts of maternal hormones. Over time, neonatal acne disappears spontaneously from the infant's cheeks and chest. c. Erythema toxicum is a newborn rash that consists of small, irregular, flat, red patches on the checks that develop into singular, small, yellow pimples appearing on the chest, abdomen, and extremities. d. Pustular melanosis is a condition in which small pustules are formed prior to birth. As the pustule disintegrates, a small residue or "scale" in the shape of the pustule is formed, and this lesion later develops into a small (1 to 2 millimeter) macule, or flat spot. Macules, which are brown in color, appear similar to freckles and are frequently located on the chest and extremities. Pustular melanosis occurs more commonly on African American infants than on Caucasian infants.

8. The nurse is assessing a baby girl on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? a. Intermittent strabismus b. Startling c. Grunting d. Vaginal bleeding

ANS: c a. Pseudostrabismus is a normal finding. b. Startling is a normal finding. c. Grunting is a sign of respiratory distress. The neonatologist should be notified. d. Vaginal bleeding is a normal finding.

9. Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? a. The baby with respirations 52, oxygen saturation 98% b. The baby with Apgar 9/9, weight 2960 grams c. The baby with temperature 96.3°F, length 17 inches d. The baby with glucose 60 mg/dL, heart rate 132

ANS: c a. The baby's findings are within normal limits. Another baby should be seen first. b. The baby's findings are within normal limits. Another baby should be seen first. c. This baby should be assessed first. The baby's temperature is low; therefore, the baby could develop cold stress syndrome. In addition, the baby is short and, therefore, could be preterm. d. The baby's findings are within normal limits. Another baby should be seen first.

16. The NICU nurse recognizes that respiratory distress syndrome results from a developmental lack of: a. Lecithin b. Calcium c. Surfactant d. Magnesium

ANS: c a. The ratio of lecithin to sphingomyelin in the amniotic fluid is used to assess maturity of fetal lungs. b. Calcium is needed to prevent undermineralization of bones. c. Respiratory distress syndrome (RDS) is a developmental respiratory disorder that affects preterm newborns due to lack of lung surfactant. The pathology of RDS is that there is diffuse atelectasis with congestion and edema in the lung spaces. On deflation, the alveoli collapse, and there is decreased lung compliance. d. Magnesium is needed to prevent undermineralization of bones.

21. The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks' gestation with no birth trauma. The nurse's findings include the following parameters: heart rate, 136 beats per minute; respiratory rate, 64 breaths per minute; temperature, 98.2°F (36.8°C); length, 49.5 cm; and weight, 3500 g. The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate consultation with the baby's health-care provider? a. Respiratory rate b. Presence of a heart murmur c. Absent bowel sounds d. Weight

ANS: c a. The respiratory rate and weight are normal findings. It is not uncommon to hear murmurs in infants less than 24 hours old. b. It is not uncommon to hear murmurs in infants less than 24 hours old. c. Bowel obstruction in the neonate is often first identified by an absence of bowel sounds in a small, distinct section of the intestines; therefore, this finding should be reported. d. The weight is within normal limits.

9. It is noted that the amniotic fluid of a 42-week gestation baby, born 30 seconds ago, is thick and green. Which of the following actions by the nurse is critical at this time? a. Perform a gavage feeding immediately. b. Assess the brachial pulse. c. Assist a physician with intubation. d. Stimulate the baby to cry.

ANS: c a. This action is not appropriate. The baby needs tracheal suctioning. b. The baby needs to have tracheal suctioning. The most important action to promote health for the baby is for the health-care team to establish an airway that is free of meconium. c. This action is appropriate. The baby needs to be intubated in order for deep suctioning to be performed by the physician. A nurse would not intubate and suction but rather would assist with the procedures. d. It is strictly contraindicated to stimulate the baby to cry until the trachea has been suctioned. The baby would aspirate the meconium-stained fluid, which could result in meconium-aspiration syndrome.

14. The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

ANS: c a. This is a description of the rooting reflex. b. This is a description of the Babinski reflex. c. This is a description of the Moro reflex. d. This is a description of the tonic neck reflex.

4. When assessing the apical pulse of the neonate, the stethoscope should be placed at the: a. First or second intercostal space b. Second or third intercostal space c. Third or fourth intercostal space d. Fourth or fifth intercostal space

ANS: c a. This is not the point of maximal impulse (PMI). b. This is not the point of maximal impulse (PMI). c. This is the point of maximal impulse (PMI). d. This is not the point of maximal impulse (PMI).

3. Which of the following neonates is at highest risk for cold stress? a. A 36 gestational week LGA neonate b. A 32 gestational week AGA neonate c. A 33 gestational week SGA neonate d. A 38 gestational week AGA neonate

ANS: c a. This neonate should have adequate stores of brown fat. b. This neonate is at risk for cold stress due to gestational age that results in less brown fat. c. This neonate is at risk for cold stress due to gestational age that results in less brown fat. This neonate is at higher risk because this neonate is SGA and has a higher probability of less brown fat than the 32-week AGA. d. This neonate should have adequate stores of brown fat.

7. A nurse is assessing for the tonic neck reflex. This is elicited by: a. Making a load sound near the neonate. b. Placing the neonate in a sitting position. c. Turning the neonate's head to the side so that the chin is over the shoulder while the neonate is in a supine position. d. Holding the neonate in a semi-sitting position and letting the head slightly drop back.

ANS: c a. This will elicit a startle reflex. b. This is not used for eliciting a reflex. c. This is correct. d. This tests for head lag.

A woman on the day of discharge from the postpartum unit requests clean towels so she can take a shower, asks a number of questions regarding breastfeeding, and shares that she is nervous about taking her baby home and not being able to remember everything she has been taught. These are behaviors associated with: a. Bonding b. Taking in c. Taking hold d. Attachment

ANS: c Correct. These are common behaviors of women in the taking-hold phase. Women during this phase have moved to being more independent and able to initiate self-care. They are highly interested in learning about the care of their baby but can easily become frustrated and discouraged when they do not immediately master a new skill.

A postpartum woman, who gave birth 12 hours ago, is breastfeeding her baby. She tells her nurse that she is concerned that her baby is not getting enough food since her milk has not come in. The best response for this patient is: a. "I understand your concern, but your baby will be okay until your milk comes in." b. "Your baby seems content, so you should not worry about him getting enough to eat." c. "Milk normally comes in around the third day. Prior to that, he is getting colostrum which is high in protein and immunoglobulins which are important for your baby's health." d. "You can bottle feed until your milk comes in."

ANS: c Feedback a. Incorrect because it does not inform the woman of what to expect with the stages of milk. b. This conveys a message that the woman's concern is not important. c. This response provides information on the stages of milk production to help the woman understand her newborn's nutritional needs. d. Incorrect response. It is important to avoid bottles until breastfeeding has been well established.

Which of the following statements indicates that a new mother needs additional teaching? a. "I need to supervise my cat when she is in the same room as my baby." b. "I will place my baby on her back when she is sleeping." c. "I will not leave my baby on an elevated flat surface after she is able to turn over on her own." d. "I have asked my husband to install safety latches on the lower cabinets."

ANS: c Feedback a. Pets should always be supervised when in the same room as the infant, because they can intentionally and unintentionally harm the infant. b. True statement. c. Newborns/infants should never be left on an elevated flat surface because they may roll or wiggle and fall off. d. True statement.

A nurse is providing discharge teaching to the parents of a 2-day-old neonate. Which of the following information should be included in the discharge teaching on umbilical cord care? a. Cleanse the cord twice a day with hydrogen peroxide. b. Remove the cord with sterile tweezers if the cord does not fall off by 10 days of age. c. Call the doctor if greenish discharge appears. d. Cover the cord with sterile dressing until it falls off.

ANS: c Feedback a. There is a controversy in the literature regarding what should be used to clean the cord, but hydrogen peroxide is not one of the recommended agents. b. The cord should be allowed to fall off on its own. c. The green drainage may be a sign of infection. d. There is no need to cover the cord.

The nurse is teaching the parents of a 1-day-old baby how to give their baby a bath. Which of the following actions should be included? a. Clean the eye from the outer canthus to the inner canthus. b. Keep the door of the room open to allow for ventilation. c. Gather all supplies before beginning the bath. d. Check the temperature of the water with your fingertip.

ANS: c Feedback a. To decrease the risk of infection, the eyes should be cleaned from the inner to the outer canthus. b. Keeping doors open can cause a drop in baby's temperature by convection. c. If items must be obtained while the bath is being given, the baby may become hypothermic from evaporation resulting from exposure to the air when wet. d. The safest way to check the temperature is with a thermometer or, if none, with the elbow or forearm.

A woman is 3 hours post-early-postpartum hemorrhage of 800 mL at delivery. Select the nursing actions for care of this patient. (Select all that apply.) a. Limit fluid intake to prevent nausea and vomiting. b. Assess fundus every 4 hours during the first 8 hours. c. Explain the importance of preventing an overdistended bladder. d. Provide assistance with ambulation.

ANS: c, d Fluid intake should be increased following a postpartum hemorrhage to decrease the risk of hypovolemia. The fundus should be assessed a minimum of every hour for the first 4 hours following a PPH. The woman needs to know the importance of preventing an overdistended bladder to decrease the risk of further hemorrhage. After postpartum hemorrhage, a woman is at risk for orthostatic hypotension.

21. Nursing actions that minimize oxygen demands in the neonate include which of the following? (Select all that apply.) a. Providing frequent rest breaks when feeding b. Placing neonate on back for sleeping c. Maintaining a neutral thermal environment (NTE) d. Clustering nursing care

ANS: c, d a. A prolonged feeding session increases energy consumption that increases oxygen consumption. b. Placing the neonate on the back for sleeping has no effect on oxygen consumption. c. A decrease in environmental temperature leads to a decrease in the neonate's body temperature which leads to an increase in respiratory and heart rate that leads to an increase in oxygen consumption. d. Clustering of nursing care decreases stress which decreases oxygen requirements.

27. The clinical nurse recalls that the newborn has four mechanisms by which heat is lost following birth: evaporation, conduction, convection, and radiation. Which of the following are examples of heat lost via convection? (Select all that apply.) a. An infant loses heat when not dried adequately after birth b. An infant is placed on a cold scale c. An infant is placed under a ceiling fan d. An infant is placed near an open window

ANS: c, d a. Evaporation is the loss of heat that occurs when water is converted into a vapor, such as inadequately dried skin. b. Conduction is the loss of heat to a cooler surface by direct skin contact, such as occurs when the infant is placed on a cold surface. c. Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as when being placed near an open window or fan. d. Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as when being placed near an open window or fan.

Which of the following nursing actions are directed at assisting men in their transition to fatherhood? (Select all that apply.) a. Encourage the woman to take on the major responsibility for infant care. b. Talk to the man, away from his partner, about his expectations of the fathering role. c. Praise the father for his interactions with his infant. d. Provide information on infant care and behavior to both parents.

ANS: c, d It is important to first have the couple discuss with each other their expectations of the fathering role. Once this has occurred, then the woman and nurse need to support the man in his role of infant care. Both parents need to receive information about infant care and infant behaviors, and both parents need to be praised for their interactions with their baby.

26. A baby was born 4 days ago at 34 weeks' gestation. She is receiving phototherapy as ordered by the physician for physiological jaundice. She has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability. The nurse's priority nursing action(s) is (are) to (select all that apply): a. Verify laboratory results to check for hypomagnesia. b. Verify laboratory results to check for hypoglycemia. c. Monitor the baby's temperature to check for hypothermia. d. Calculate 24-hour intake and output to check for dehydration

ANS: c, d There are two priority nursing interventions for hyperbilirubinemia. Hydration status is important if the newborn shows signs of dehydration such as dry skin and mucus membranes, poor intake, concentrated urine or limited urine output, and irritability. The newborn should also be kept warm while receiving phototherapy. When an infant is under phototherapy, the temperature needs to be monitored closely because the lights give off extra heat, but if the newborn is in an open crib and undressed, hypothermia may occur. Hypomagnesia and hypoglycemia are not related to phototherapy.

39. As the perinatal nurse performs an assessment of the infant's head, ears, eyes, nose, and throat, the ears are noted to be low set. This clinical finding would require follow-up due to the potential for __________.

ANS: chromosomal abnormalities Special attention is paid to the shape, size, and placement of the ears. Low-set ears may signal the need for further assessment and evaluation for chromosomal abnormalities. Placement of one ear slightly lower than the other is a common finding that generally has no clinical significance

29. The perinatal nurse assessing a newborn for jaundice recalls that __________ is a process that converts the yellow lipid-soluble (nonexcretable) bilirubin pigment (present in bile) into a water-soluble (excretable) pigment.

ANS: conjugation Conjugation of bilirubin constitutes a major function of the newborn's liver. Conjugation is a process that converts the yellow lipid-soluble (nonexcretable) bilirubin pigment (present in bile) into a water-soluble (excretable) pigment.

8. The nurse is massaging a boggy uterus. The uterus does not respond to the massage. Which medication would the nurse expect would be given first: a. Methergine b. Ergotrate c. Carboprost d. Oxytocin or pitocin

ANS: d If the cause of the hemorrhage is uterine atony, continual fundal massage with lower uterine segment support is mandatory. While one member of the team massages the fundus, another nurse establishes intravenous access with a large bore needle and administers oxytocic drugs in the following order: oxytocin (Pitocin), followed by methylergonovine (Methergine) or ergonovine (Ergotrate), and carboprost (Hemabate).

11. The clinic nurse sees Xiao and her infant in the clinic for their 2-week follow-up visit. Xiao appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. She is carrying her son in the infant carrier and when asked to put him on the examining table, she holds him away from her body. The clinic nurse's most appropriate question to ask would be: a. "What has happened to you?" b. "Do you have help at home?" c. "Is there anything wrong with your son?" d. "Would you tell me about the first few days at home?"

ANS: d The well-baby checkup that generally takes place 1 to 2 weeks following the hospital discharge may offer the first opportunity to assess the mother-baby dyad. In this setting, the nurse needs to be alert for subtle cues from the new mother, such as making negative comments about the baby or herself, ignoring the baby's or other children's needs, as well as the mother's physical appearance. In a private area, the nurse should take time to explore the new mother's feelings. A nonthreatening way to open the dialogue might be to say: "Tell me how the first few days at home have gone." This statement provides the new mother with an opportunity to share both positive and negative impressions.

6. The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist as soon as possible? a. 1-day-old, HR 170 bpm, crying b. 2-day-old, T 98.9°F, slightly jaundice c. 3-day-old, breastfeeding q 2 h, rooting d. 4-day-old, RR 70 rpm, dusky coloring

ANS: d a. A slight tachycardia—170 bpm—is normal when a baby is crying. b. Slight jaundice on day 2 is within normal limits. c. It is normal for a breastfed baby to feed every 2 hours. d. A dusky skin color is abnormal in any neonate, whether or not the respiration rate is normal, although this baby is also slightly tachypneic.

18. The perinatal nurse explains to a student nurse the cardiopulmonary adaptations that occur in the neonate. Which one of the following statements accurately describes the sequence of these changes? a. As air enters the lungs, the PO2 rises in the alveoli, which causes pulmonary artery relaxation and results in an increase in pulmonary vascular resistance. b. As the pulmonary vascular resistance increases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. c. Decreased pulmonary blood volume contributes to the conversion from fetal to newborn circulation. d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.

ANS: d a. As air enters the lungs, the PO2 rises in the alveoli. This normal physiologic response causes pulmonary artery relaxation and results in a decrease in pulmonary vascular resistance. b. As the pulmonary vascular resistance decreases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. c. The increased pulmonary blood volume contributes to the conversion from fetal to newborn circulation. d. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.

17. A pregnant patient at 35 weeks' gestation gives birth to a healthy baby boy. What factors regarding the development of the normal respiratory system should the nurse consider when performing an assessment of the neonate? a. As the fetus approaches term, there is an increase in the secretion of intrapulmonary fluid. b. Lung expansion after birth suppresses the release of surfactant. c. Surfactant causes an increased surface tension within the alveoli, which allows for alveolar reexpansion following each exhalation. d. Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.

ANS: d a. As the fetus approaches term, there is a decrease in the secretion of intrapulmonary fluid, which assists in reducing the pulmonary resistance to blood flow and facilitates the initiation of air breathing. b. Lung expansion after birth stimulates the release of surfactant, a slippery, detergent-like lipoprotein. c. Surfactant causes a decreased surface tension within the alveoli, which allows for alveolar reexpansion following each exhalation. d. Under normal circumstances, by the 34th to 36th weeks of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.

2. A nurse assesses that a 3-day-old neonate who was born at 34 weeks' gestation has abdominal distention and vomiting. These assessment findings are most likely related to: a. Respiratory Distress Syndrome (RDS) b. Bronchopulmonary Dysplasia (BPD) c. Periventricular Hemorrhage (PVH) d. Necrotizing Enterocolitis (NEC)

ANS: d a. Assessment findings for RDS include tachypnea, intercostal retractions, respiratory grunting, and nasal flaring. b. Assessment findings for BPD include chest retractions; audible wheezing, rales, and rhonchi; hypoxia; and bronchospasm. c. Assessment findings for PVH include bradycardia, hypotonia, full and/or tense anterior fontanel, and hyperglycemia. d. Assessment findings related to NEC include abdominal distention, bloody stools, abdominal distention, vomiting, and increased gastric residual. These signs and symptoms are related to the premature neonate's inability to fully digest stomach contents and limitation in absorptive function.

11. A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in the baby as a result? a. Skin color is dusky. b. Vital signs are labile. c. Glucose levels are subnormal. d. Circumcision site oozes blood.

ANS: d a. Dusky coloring is due to poor oxygenation. b. Labile vital signs can be caused by a number of things, including cold stress syndrome, sepsis, and poor oxygenation. c. Subnormal glucose levels can be caused by a number of things, including prenatal diabetes mellitus, cold stress syndrome, and sepsis. d. The circumcision may ooze blood due to the lack of vitamin K, which is required for the hepatic synthesis of blood coagulation factors II, VII, and X.

5. A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia, and tremors and is extremely irritable. Based on these observations, the nurse suspects which of the following? a. Hypoglycemia b. Hypercalcemia c. Cold stress d. Neonatal withdrawal

ANS: d a. Signs and symptoms of hypoglycemia are jitteriness, hypotonia, irritability, apnea, lethargy, and temperature instability, but not nasal congestion. b. Signs and symptoms of hypercalcemia are vomiting, constipation, and cardiac arrhythmias. c. Signs and symptoms of cold stress are decreased temperature, cool skin, lethargy, pallor, tachypnea, hypotonia, jitteriness, weak cry, and grunting. d. These are common signs and symptoms of neonatal withdrawal.

19. A perinatal nurse assesses the skin condition of a newborn, which is characterized by a yellow coloration of the skin, sclera, and oral mucous membranes. What condition is most likely the cause of this symptom? a. Hypoglycemia b. Physiologic anemia of infancy c. Low glomerular filtration rate d. Jaundice

ANS: d a. Signs and symptoms of hypoglycemia include jitteriness, diaphoresis, poor muscle tone, poor sucking reflex, temperature instability, respiratory distress, tachycardia, dyspnea, apnea, high-pitched cry, irritability, lethargy, and seizures or coma. b. A low red blood cell (RBC) count signals physiologic anemia of infancy. c. The neonate's elevated hematocrit (related to the high concentration of RBCs) and low blood pressure may lead to a decreased glomerular filtration rate. d. Jaundice is a condition characterized by a yellow (icteric) coloration of the skin, sclera, and oral mucous membranes and results from the accumulation of bile pigments associated with an excessive amount of bilirubin in the blood.

13. A neonate is admitted to the nursery. The nurse makes the following assessments: weight 2845 grams, overriding sagittal suture, closed posterior fontanel, and point of maximum intensity at the xiphoid process. Which of the assessments should be reported to the health-care practitioner? a. Birth weight b. Sagittal suture line c. Closed posterior fontanel d. Point of maximum intensity

ANS: d a. The birth weight is normally between 2500 and 4000 grams. b. With molding, there may be an overlapping sagittal suture at birth. c. With molding, the posterior fontanel may be closed at birth. d. The point of maximum intensity should be felt lateral to the left nipple at about the third or fourth intracostal space.

24. Heat loss through radiation can be reduced by: a. Closing door to room b. Warming equipment used on the neonate c. Drying the neonate d. Placing crib near a warm wall

ANS: d a. This is an example of preventing heat loss due to convection. b. This is an example of reducing heat loss due to conduction. c. This is an example of reducing heat loss due to evaporation. d. Placing the crib near a warm wall is an example of heat loss due to radiation.

17. The NICU nurse is providing care to a 35-week-old infant who has been in the neonatal intensive care unit for the past 3 weeks. His mother wants to breastfeed her son naturally but is currently pumping her breasts to obtain milk. His mother is concerned that she is only producing about 1 ounce of milk every 3 hours. The nurse's best response to the patient's mother would be: a. "Pumping is hard work and you are doing very well. It is good to get about 1 ounce of milk every 3 hours." b. "Natural breastfeeding will be a challenging goal for your baby. Beginning today, you will need to begin to pump your breasts more often." c. "Your baby will not be ready to go home for at least another week. You can begin to pump more often in the next few days in preparation for taking your child home." d. "You have been working hard to give your son your breast milk. We can map out a schedule to help you begin today to pump more

ANS: d a. This is correct information but does not assist the women in producing more milk. b. This does not provide her with a plan to increase her milk. c. This does not provide her with a plan. d. The mother should be praised for her efforts to breastfeed and encouraged to continue to pump her milk. A determined schedule for pumping the milk will help the mother keep her milk flow steady and provide enough nutrients for the infant after discharge.

A nurse is making a home visit on the seventh postpartum day to assess a 23-year-old primipara woman and her full-term, healthy baby. Breastfeeding is the method of infant nutrition. The woman tells the nurse that she does not think her milk is good because it looks very watery when she expresses a little before each feeding. The nurse's best response is: a. "This is normal. You only have to be concerned when your baby does not gain weight." b. "What types of foods are you eating? A lack of protein in the diet can cause watery looking breast milk." c. "How much fluid are you drinking while you are nursing your baby? Too much fluid during the feeding session can dilute the breast milk." d. "This is normal and is referred to as foremilk which is higher in water content. Later in the feeding the fat content increases and the milk becomes richer in appearance."

ANS: d Feedback a. Correct information but does not provide information for the woman to understand the different types of milk. b. Incorrect information. c. Incorrect information. d. Correct. This provides an explanation for the consistency of the milk and reassures the woman that the appearance of the milk is normal.

Instructions to a mother of an uncircumcised male infant should include which of the following? a. Instruct her to use a cotton swab to clean under the foreskin. b. Instruct her to clean the penis by retracting the foreskin. c. Instruct her to clean the penis with alcohol. d. Instruct her not to retract the foreskin.

ANS: d Feedback a. Use of cotton swabs or retracting the foreskin can damage the inner layer of the foreskin and cause adhesions. b. Retracting the foreskin can damage the inner layer of the foreskin and cause adhesions. c. Use of alcohol is irritating and painful. d. Parents should not retract the foreskin. The foreskin will fully retract on its own around 5 years of age.

The nurse is teaching the parents of a healthy newborn about infant safety. Which of the following should be included in the teaching plan? a. Water temperature for the infant's bath should be 39°C. b. Crib slates should be a maximum of 3 inches apart. c. Cover electrical outlets once the infant is crawling. d. Remove strings from infant sleepwear.

ANS: d Feedback a. Water temperature should be 38°C. b. Crib slates should be no wider than 2 3/8 inches. c. Electrical covers should be covered before the infant begins to crawl, because infants can roll around to move and reach outlets before they crawl. d. Strings should be removed from bedding, sleepwear, pacifiers, and other objects that come in contact with the infant to decrease the risk of strangulation.

Felicity Chan, a new mother, is accompanied by her mother during her hospital stay on the postpartum unit. Felicity's mother makes specific, various requests of the nurses including bringing warm tea, a cot to sleep on, and that the baby not be bathed at this time. Felicity's mother is also concerned about the amount of work that Felicity may be doing in the provision of infant care. Felicity asks for help with breastfeeding. After Felicity has finished breastfeeding, her mother asks for a bottle so they can warm it and "feed" the baby. How would the perinatal nurse best respond to Felicity's mother in a culturally sensitive way? a. Ask Felicity's mother to leave for 30 minutes to allow for some private time with Felicity to explore her learning needs privately. b. Ask both Felicity and her mother about the preferred infant feeding method, and assess what they already know. c. Convey to Felicity and her mother an un

ANS: d In certain multicultural populations such as India, Thailand, and China, the woman's postpartum confinement lasts for 40 days. During this time, prolonged rest with restricted activity is believed to be essential. The postpartum period is an important time for ensuring future good health, and great emphasis is placed on allowing the mother's body to regain balance after the birth of a child. To provide sensitive, appropriate care, nurses need to adopt a flexible approach when caring for women who embrace non-Western health beliefs and practices. The nurse should advocate for the patient by inquiring about her feeding preferences and by providing information to the mother and her family to support her in her decision.

23. The perinatal nurse contacts the pediatrician about a heart murmur that was auscultated during a routine newborn assessment. This finding would be abnormal at: a. 8 to 12 hours b. 12 to 24 hours c. 24 to 48 hours d. 48 to 72 hours

ANS: d It is not uncommon to hear murmurs in infants less than 24 hours old. The murmurs are characterized by a sound (best heard near the sternal border at the second or third intercostal space on the left side) that grows louder during systole. Although a heart sound arising from a patent ductus arteriosus may be heard initially, the sound disappears within 2 to 3 days when the ductus closes. If a murmur remains audible after the second day of life and intensifies to a "whoosh" sound, further investigation is warranted because this finding is not characteristic of a patent ductus and may indicate the presence of another type of heart lesion.

40. Assessment of the infant's anterior fontanel is an important part of the physical examination. The nurse knows that dehydration can cause a __________ in the fontanel and __________ might increase the pressure in the fontanel.

ANS: depression; crying Fontanels should be assessed at least once per shift to make sure that they are open and flat with no bulging or depression

32. The perinatal nurse explains to the student nurse that successful cardiopulmonary adaptation in the neonate involves five major changes: an increased aortic pressure and decreased venous pressure; an increased systemic pressure and decreased pulmonary pressure; and closure of the __________, the __________, and the __________.

ANS: foramen ovale; ductus arteriosus; ductus venosus Following placental separation at birth, the umbilical arteries and vein constrict as the fetal circulatory system is interrupted. Successful cardiopulmonary adaptation in the neonate involves five major changes: an increased aortic pressure and decreased venous pressure; an increased systemic pressure and decreased pulmonary pressure; and closure of the foramen ovale, the ductus arteriosus, and the ductus venosus

The perinatal nurse provides information about postpartum depression to all families members because of the potential danger not only to the mother but also to the __________.

ANS: infant The earlier that postpartum depression is recognized and treatment begun, the better is the prognosis for a full recovery. The nurse should involve the family in helping the patient cope with her feelings and assisting with infant care.

30. Providing information to parents about jaundice constitutes an important component of the nurse's discharge teaching. Ensuring that parents know when and who to call if their infant develops signs of jaundice will help decrease the risk of __________, or permanent brain damage.

ANS: kernicterus All newborns are screened before discharge for physiological jaundice. The central nervous system can be damaged from unconjugated bilirubin. If bilirubin crosses the blood-brain barrier, it can damage the cerebrum, causing a condition called kernicterus. Kernicterus occurs from brain cell necrosis and can permanently damage a newborn, depending on the amount of time the neurons are exposed to bilirubin, the susceptibility of the nervous system, and the function of the surviving neurons.

A nurse assesses a G2 P1 woman who gave birth to a 4500 gram baby boy 2 hours ago. The nurse notes that the woman's labor was only 2 hours and that the infant was delivered by the labor nurse. The nurse's assessment findings are: Fundus firm and midline at umbilicus Lochia heavy—saturates pad within 15 minutes and bleeding is a steady stream without clots Perineum intact, slight bruising Ice pack on perineum Vital signs are B/P 105/65, P 98, R 20, T 38° Based on this information, the nurse is concerned that the woman has a __________ of the __________ or __________.

ANS: laceration; cervix; vagina Based on the assessment data, the woman is experiencing an early postpartum hemorrhage (PPH). The hemorrhage is most likely not due to uterine atony because the fundus is firm and midline. Laceration of the cervix or vagina is the second most common cause of early PPH. This woman is displaying typical signs and symptoms of laceration of cervix or vagina—firm, midline fundus with steady stream of blood without clots.

The clinic nurse discusses gradual warming of expressed breast milk or formula and cautions against use of the __________ for heating breast milk or formula.

ANS: microwave oven With regard to infant feeding and safety, parents should be taught to warm bottles slowly, never to use a microwave oven to heat breast milk or formula, and never to prop a bottle in the infant's mouth, as this practice creates a choking hazard.

33. Part of the assessment of a preterm infant includes obtaining an abdominal girth measurement. The NICU nurse performs this assessment because the patient is at risk for __________.

ANS: necrotizing enterocolitis (NEC) When caring for a child with necrotizing enterocolitis, the nurse must measure and record frequent abdominal circumferences, auscultate bowel sounds before every feeding, and observe the abdomen for distention (observable loops or shiny skin indicating distention).

33. Upon assessment of the temperature of a newborn, the nurse recalls that the __________ is the range of temperature in which the newborn's body temperature can be maintained with minimal metabolic demands and oxygen consumption.

ANS: neutral thermal environment (NTE) After ensuring effective respirations, facilitating a neutral thermal environment is an essential nursing action. Ideally, a supply of warm, dry linens should be available to prevent neonatal cold stress.

When reviewing potential causes for postpartum hemorrhage with the student nurse, the nurse is sure to include the finding of a(n) __________ bladder.

ANS: overdistended An overdistended bladder, which displaces the uterus above and to the right of the umbilicus, can cause uterine atony and lead to hemorrhage

Postpartum woman are at an increased risk of thrombus formation immediately following birth due to an increased __________ level

ANS: plasma fibrinogen Levels of plasma fibrinogen tend to remain elevated during the first few postpartal weeks. Although this alteration exerts a protective effect against hemorrhage, it increases the patient's risk of thrombus formation

31. The NICU nurse recognizes that the infant who requires ventilation for meconium aspiration syndrome is most often __________.

ANS: post-term Meconium aspiration pneumonia occurs in 10% to 26% of all deliveries, and the incidence increases directly with gestational age. (Before 37 weeks' gestation there is a 2% incidence, and at 42 weeks' gestation there is a 44% incidence.)

The perinatal nurse understands that the hormonal processes involved in breastfeeding include decreased serum __________ and __________ levels immediately following birth which lead to an increased serum __________ level that causes milk production by the fourth to fifth postpartal days.

ANS: progesterone; estrogen; prolactin Circulating levels of estrogen and progesterone decrease dramatically following delivery of the placenta. The decline in these two hormones signals the anterior pituitary gland to produce prolactin in readiness for lactation.

A postpartum woman who describes symptoms of hallucinations and suicidal thoughts is most likely experiencing postpartum __________.

ANS: psychosis Postpartum psychosis is a rare but severe form of mental illness that severely affects not only the new mother, but the entire family. Postpartum psychosis may present with symptoms of postpartum depression. However, the distinguishing signs of psychosis are hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, suicidal and homicidal thoughts, and a loss of touch with reality.

36. The nurse is aware that the __________ state, which generally occurs during the first 30 minutes to 1 hour after birth, characterizes the first period of reactivity and provides an excellent time for parents to bond with their infant.

ANS: quiet alert The quiet alert state generally occurs during the first 30 minutes to 1 hour after birth and characterizes the first period of reactivity. This period is an excellent time for parents to bond with their infant. After that time, the infant's alert states result from choice or necessity. Stimuli that may prompt wakefulness include hunger, cold, and heat—once the triggering stimuli are removed, the infant tends to fall back to sleep

The development of a large hematoma can place the postpartum woman at risk for __________.

ANS: shock Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as "full." If the hematoma is large, signs of shock may be evident, and the patient may exhibit an absence of lochia and an inability to void.

The perinatal nurse encourages all mothers to place their infants under 12 months of age in the supine position for sleeping, because a leading cause of death for this age group is __________.

ANS: sudden infant death syndrome Sudden infant death syndrome (SIDS) is a leading cause of death among infants between the ages of 1 and 12 months. Having infants sleep on their backs has decreased the risk of SIDS.

The perinatal nurse explains to a new mother that the first sign of a postpartum infection will most likely be an increased __________.

ANS: temperature During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F (38.4°C), often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.

Primary breast engorgement is an increase in the __________ and __________ systems that precedes the initiation of milk production.

ANS: vascular; lymphatic Primary breast engorgement is an increase in the vascular and lymphatic systems that precedes the initiation of milk production. Subsequent breast engorgement is related to distention of milk glands.

32. The NICU nurse's patient assignment includes an infant who is 25 weeks' gestation. The nurse knows that according to the gestational age, this infant would be described as __________.

ANS: very premature The definition of very premature is a neonate born at less than 32 weeks' gestation. The definition of premature is a neonate born between 32 and 34 weeks' gestation. The definition of late premature is a neonate born between 34 and 37 weeks' gestation.

34. When assessing a newborn for coagulation factors, the perinatal nurse recalls that coagulation factors to enable the newborn to effectively clot blood after childbirth are activated by __________.

ANS: vitamin K Due to the absence of vitamin K at birth, the neonate is at risk for developing a blood clotting deficiency during the first few days of life. The infant is given an intramuscular injection of vitamin K, phytonadione (AquaMEPHYTON), during the initial care and assessment to prevent hemorrhagic disease of the newborn.

A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? (SATA)

Apnea for 10-second periods Obligatory nose breathing

A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. Which of the following actions should the nurse implement?

Apply petroleum gauze to the site

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

Attempts to place his hand in his mouth

A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given 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. "I need a second vaccination at my postpartum visit." A second varicella immunization is needed at 4 to 8 weeks following delivery by clients who had no history of immunity.

A nurse is reviewing discharge teaching with a client who has a urinary tract infection. Which of the following statements by the client indicates understanding of the teaching? (Select all that apply.) A. "I will perform peri care and apply a perineal pad in a back‑to‑front direction." B. "I will drink cranberry and prune juices to make my 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."

B. "I will drink cranberry and prune juices to make my urine more acidic." C. "I will drink large amounts of fluids to flush the bacteria from my urinary tract." E. "I will take Tylenol for any discomfort." Acidification of urine inhibits bacterial multiplication. Increased fluid intake can help to flush the bacteria from the urinary tract. Acetaminophen is taken to reduce discomfort and pain associated with a urinary tract infection.

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. "Your son is showing an adverse sibling response." Adverse responses by a sibling to a new infant can include regression in toileting habits.

Which of the following women are at risk for osteoporosis? Select all that apply A. 45 year old woman with DXA of -0.5 B. A 25 year old woman with anorexia C. A 35 year old non smoking woman D. A 30 year old woman who had weight loss surgery

B. A 25 year old woman with anorexia D. A 30 year old woman who had weight loss surgery

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 episiotomy that is erythematous and has extended into a third‑degree laceration B. A client who does not wash her 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 client who does not wash her hands between perineal care and breastfeeding The client who does not wash her hands between perineal care and breastfeeding is at an increased risk for developing mastitis. Therefore, she is most at risk for developing a postpartum infection.

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 hr in duration B. A client who had 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 client who had premature rupture of membranes and prolonged labor Premature rupture of membranes with prolonged labor poses the greatest risk for developing a postpartum infection because the birth canal was open, allowing pathogens to enter.

A nurse is caring for a newborn who was born at 38 weeks gestation, weighs 3200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neotate 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. Appropriate for gestational age

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 antipsychotics as prescribed. B. Ask the client if she has thoughts of harming herself or her 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. Ask the client if she has thoughts of harming herself or her infant. The nurse should identify that the greatest risk to the client and her infant is self‑harm or harm directed toward the infant. Therefore, the priority action the nurse should take is to directly ask the client if she has thoughts of self‑harm, suicide, or harming the infant.

Obesity places women at risk for a variety of health problems. These risk include: select all that apply A. Stroke B. Breast cancer C. Colon cancer D. Menstrual disorders

B. Breast cancer D. Menstrual disorders

A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following findings? (Select all that apply.) A. Paranoia that her infant will be harmed B. Concerns about lack of income to pay bills C. Anxiety about assuming a new role as a mother D. Rapid decline in estrogen and progesterone E. Feeling of inadequacy with the new role as a mother

B. Concerns about lack of income to pay bills C. Anxiety about assuming a new role as a mother D. Rapid decline in estrogen and progesterone E. Feeling of inadequacy with the new role as a mother Feelings of financial inadequacy to provide for family is a finding associated with postpartum depression. Anxiety about assuming a new role as a mother is a finding associated with postpartum depression. The rapid decline in estrogen and progesterone is a finding associated with postpartum depression. Feeling of inadequacies with the new role as a mother is a finding associated with postpartum depression.

A teaching plan for a 40 year old woman having her first mammogram should include: Select all that apply A. Informing her that she should have a mammogram every 5 years B. Explaining that she might experience a sensation that her breast is being squeezed or pinched C. Instructing her to avoid use of deodorant under her arms on the day of her appointment. D. Explaining that this is a screening test versus a diagnostic test.

B. Explaining that she might experience a sensation that her breast is being squeezed or pinched C. Instructing her to avoid use of deodorant under her arms on the day of her appointment. D. Explaining that this is a screening test versus a diagnostic test.

A client in the early postpartum period is very excited and talkative. She is repeatedly telling the nurse every detail of her labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take? A. Come back later when the client is more cooperative. B. Give the client time to express her feelings. C. Tell the client she needs to be quiet so the assessment can be completed. D. Redirect the client's focus so that she will become quiet.

B. 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.

The ambulatory care nurse is instructing a woman regarding oral biphosphonates in the treatment of osteoporosis. The teaching plan should include which of the following? A. Take the medication on a full stomach B. Remain upright for 30 minutes after taking the medication C. Take the medication with the evening meal D. Take the medication with her calcium supplement

B. Remain upright for 30 minutes after taking the medication

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. Urinary retention Urinary retention can result in a distention of the bladder. A distended bladder can cause uterine atony and lateral displacement from the midline, usually to the right.

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?

Back seat, rear-facing

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. "Completely empty each breast at each feeding or use a pump." Instruct the client to completely empty each breast at each feeding to prevent milk stasis, which provides a medium for bacterial growth.

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 normal postural discharge of lochia Lochia typically trickles from the vaginal opening but flows more steadily during uterine contractions. Massaging the uterus or ambulation can result in a gush of lochia with the expression of clots and dark blood that has been pooled in the vagina, but it should soon decrease back to a trickle of bright red lochia in the early puerperium.

In addition to being the most common sexually transmitted virus in the US, _______is also the main cause of cervical cancer. A. HIV B. Chlamydia C. Human papillomavirus D. Gonorrhea

C. Human papillomavirus

A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time she sneezes or coughs. Which of the following interventions should the nurse suggest? A. Sit‑ups B. Pelvic tilt exercises C. Kegel exercises D. Abdominal crunches

C. Kegel exercises Kegel exercises consist of the voluntary contraction and relaxation of the pubococcygeus muscle to strengthen the pelvic muscles, which will assist the client in decreasing urinary stress incontinence that occurs with sneezing and coughing.

A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact her 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

C. Sore nipple with cracks and fissures A sore nipple that has cracks and fissures is an indication of mastitis.

Based on her knowledge of the number one leading cause of death for girls/women 15-24 years of age, the clinic nurse stresses the importance of ______with her 19 year old client A. Eating foods high in calcium and vitamin D B. Avoiding second hand smoke C. Wearing seatbelts when traveling in an automobile D. Exercising daily to improve muscle strength and balance

C. Wearing seat belts when traveling in an automobile

A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority?

Covering the newborn's head with a cap

A nurse is reviewing breastfeeding positions with the mother of a newborn. Which of the following positions should the nurse discuss?

Cradle

A nurse is completing a newborn assessment and observes small 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. Epstein's pearls

A nurse on the postpartum unit is planning care for a client who 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. Measure leg circumferences. The nurse should plan to measure the circumference of the leg to assess for changes in the client's condition.

A _______is a screening test that involves a microscopic examination of cells taken from the cervix for early detection of cancerous or precancerous cells. A. cervical biopsy B. Colposcopy C. Cervical conization D. Papanicolaou test

D. Papanicolaou test

A nurse in the delivery room is planning to promote maternal‑infant bonding for 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. Position the neonate skin‑to‑skin on the client's chest. Placing the neonate in the en face position on the client's chest immediately after birth is the priority nursing intervention to promote maternal‑infant bonding.

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 clinical findings? A. Postpartum fatigue B. Postpartum psychosis C. Letting‑go phase D. Postpartum blues

D. Postpartum blues Postpartum blues are characterized by tearfulness, insomnia, lack of appetite, and feeling let‑down.

A nurse concludes that the father of an infant is not showing positive signs of parent‑infant bonding. He appears very anxious and nervous when the infant's mother asks him to bring her the infant. Which of the following actions should the nurse use to promote father‑infant bonding? A. Hand the father the infant, and suggest that he change the diaper. B. Ask the father why he is so anxious and nervous. C. Tell the father that he will grow accustomed to the infant. D. Provide education about infant care when the father is present.

D. Provide education about infant care when the father is present. Nursing interventions to promote paternal bonding include providing education about infant care and encouraging the father to take a hands‑on approach.

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

Erythromycin

A newborn was not dried completely after birth. Which of the following mechanisms should the nurse understand causes heat loss? A) Conduction B) Convection C) Evaporation D) Radiation

Evaporation

Lesbians are at _________ risk for breast, cervical, endometrial, and ovarian cancer than heterosexual women A. higher B. lower C. the same

Higher

A nurse is assessing the reflexes of a newborn.In checking for the moro reflex, the nurse should perform which of the following?

Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backwards

A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? (SATA)

Hypospadias Family Hx of hemophilia Epispadias

A nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by the parent indicates an understanding of the teaching?

I will clean his penis with each diaper change

A nurse is preparing to administer a vitamin K injection to a newborn. Which of the following responses should the nurse make to the newborn's mother regarding why this medication is given?

It assists with blood clotting

A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse in the teaching?

Keep the diaper folded below the cord

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

Keep the nipple full of formula throughout the feeding

A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1100 g. Which of the following are expected findings in this newborn? (SATA)

Lanugo Weak grasp reflex Translucent skin

A nurse is taking a newborn to a mother following a circumcision. Which of the following actions should the nurse take for security purposes?

Match the mother's id band with the newborns id band

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?

Oxygen saturation

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)

Place used bottles in the dishwasher Check the nipple for appropriate flow of formula Use tap water to dilute concentrated formula

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

A nurse is giving instructions to a mother about how to breastfeed her newborn. Which of the following actions by the mother indicates understanding of the teaching?

When latched on, the infant's nose, cheek, and chin are touching the breast