Exam 3 Quizlet

A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform? 1. Cover the baby's eyes with eye pads. 2. Turn the lights on for ten minutes every hour. 3. Clothe the baby in a shirt and diaper only. 4. Tightly swaddle the baby in a baby blanket.

1. Cover the baby's eyes with eye pads.

A full-term infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. Which of the following actions should the nurse perform at this time? 1. Feed the baby formula or breast milk. 2. Assess the baby's blood pressure. 3. Tightly swaddle the baby. 4. Monitor the baby's urinary output.

1. Feed the baby formula or breast milk.

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O negative. 2. Type A negative. 3. Type B positive. 4. Type AB positive.

1. Type O negative.

Which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 96.5°F? 1. Blood glucose of 50 mg/dL. 2. Acrocyanosis. 3. Tachypnea. 4. Oxygen saturation of 96%

3. Tachypnea.

A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? A. Switch to bottle feeding the baby for 2 weeks B. Stop the breast feedings and switch to bottle-feeding permanently C. Feed the newborn infant less frequently D. Continue to breastfeed every 2-4 hours

D. Continue to breastfeed every 2-4 hours Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.

A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client? A. Assess vital signs every 4 hours B. Inform health care provider of assessment findings C. Measure fundal height every 4 hours D. Prepare an ice pack for application to the area.

D. Prepare an ice pack for application to the area. Application of ice will reduce swelling caused by hematoma formation in the vulvar area. The other options are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a) Assess the woman's fundus. b) Begin an IV infusion of Ringer's lactate solution. c) Call the woman's health care provider. d) Assess the woman's vital signs.

a) Assess the woman's fundus. Explanation: In order to have a suggested idea of the location of the bleeding the nurse would need to assess the funds of the patient first. Although all actions may be appropriate, they would not have the priority of fundal assessment.

Which neonate is at highest risk for developing cold stress? A.A neonate that delivered at 42 weeks 6 days B.A neonate diagnosed with down syndrome C.A neonate that is Appropriate for Gestational Age (AGA) D.A neonate that has a blood sugar of 50

A.A neonate that delivered at 42 weeks 6 days

The nurse is assisting a multiparous woman to the bathroom for the first time since she delivered 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. What is the priority action of the nurse? A.Assist the client to empty her bladder B.Help the client back to bed to check the fundus C.Assess her blood pressure and pulse D.Begin an IV of lactated Ringer's solution

B Help the client back to bed to check the fundus. Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is not firm, gentle fundal massage is performed until the uterus contracts.

A neonate needs to be gavage-fed. What is the nurses action prior to each feeding? A.Inject 10-15cc of air, listening with a stethoscope over epigastrium for sudden rush of air movement into the stomach. B.Aspirate stomach contents with a syringe and note amount, color and consistency. C.Place the end of the gavage tube in a glass of water and watch for air bubbles. D.Obtain x-ray verification of correct placement of the tube.

B.Aspirate stomach contents with a syringe and note amount, color and consistency.

The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43 week gestation newborn with Apgar scores of 1 and 4. In planning care for the admission of the newborn, what is the nurse's highest priority? A.Turn on the apnea and cardiorespiratory monitors. B.Connect the resuscitation bag to the oxygen outlet. C.Set up the intravenous line with 5% dextrose in water. D.Set the radiant warmer control temperature at 97.6 degrees F.

B.Connect the resuscitation bag to the oxygen outlet.

An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: a. Birth injury. b. Hypocalcemia. c. Hypoglycemia d. Seizures.

C (Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.)

While completing a newborn assessment, the nurse should be aware that the most common birth injury for a LGA newborn is: a. To the soft tissues. b. Caused by forceps gripping the head on delivery. c. Fracture of the humerus and femur. d. Fracture of the clavicle.

D (The most common birth injury is fracture of the clavicle (collarbone). It usually heals without treatment, although the arm and shoulder may be immobilized for comfort.)

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage?a) Uterine atony b) Uterine contraction c) Uterine prolapse d) Uterine subinvolution

a)Uterine atony Explanation: Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally the nurse assists the woman with perineal care and applying a new perineal pad.

A newborn nursery nurse notes that a 36-hour-old baby's body is jaundiced. Which of the following nursing interventions will be most therapeutic? 1. Maintain a warm ambient environment. 2. Have the mother feed the baby frequently. 3. Have the mother hold the baby skin to skin. 4. Place the baby naked by a closed sunlit window.

2. Have the mother feed the baby frequently.

A neonate has intrauterine growth restriction secondary to placental insufficiency. Which of the following signs/symptoms should the nurse expect to observe at delivery? (Select all that apply) 1. Thrombocytopenia. 2. Neutropenia. 3. Polycythemia. 4. Hypoglycemia. 5. Hyperlipidemia

3. Polycythemia. 4. Hypoglycemia.

A baby is born with esophageal atresia and tracheoesophageal fistula. Which of the following complications of pregnancy would the nurse expect to note in the mother's history? 1. Preeclampsia. 2. Idiopathic thrombocytopenia. 3. Polyhydramnios. 4. Severe iron deficiency anemia.

3. Polyhydramnios.

Which of the following neonates is at highest risk for cold stress syndrome? 1. Infant of diabetic mother. 2. Infant with Rh incompatibility. 3. Postdates neonate. 4. Down syndrome neonate.

3. Postdates neonate.

A baby is born with a diaphragmatic hernia. Which of the following signs/symptoms would the nurse observe in the delivery room? 1. Projectile vomiting. 2. High-pitched crying. 3. Respiratory distress. 4. Fecal incontinence

3. Respiratory distress.

A nurse suspects that a postpartum patient has mastitis. The following assessment provides what data to support this assessment? (Select all that apply) A) Shooting pain in her nipple during breastfeeding. B) Late onset of nipple pain C) Pink, flaking, pruritic skin of the affected nipple. D) Nipple soreness when the infant latches on.

A) Shooting pain in her nipple during breastfeeding. B) Late onset of nipple pain C) Pink, flaking, pruritic skin of the affected nipple. Mastitis is characterized by late-onset nipple pain, followed by shooting pain during and between feedings. The skin of the affected breast becomes pink, flaking, and pruritic. Nipple soreness, engorgement, and the letdown reflex are not symptoms of Mastitis.

A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz, 21 inches long, TPR: 96.6°F, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following actions is of highest probability? 1. Swaddle the baby to provide warmth. 2. Assess the glucose level of the baby. 3. Take the baby to the mother for feeding. 4. Administer the neonatal medications.

2. Assess the glucose level of the baby.

The nurse is calling clients at 4 weeks postpartum. Which client should be seen immediately? A.The client who describes feeling sad all the time B.The client who reports hearing voices talking about the baby C.The client who states she has no appetite and wants to sleep all day D.The client who says she needs a refill on her sertraline (Zoloft) next week

B The client who reports hearing voices talking about the baby. Hearing voices is an indication the client is experiencing postpartum psychosis, and is the highest priority because the voices might tell her to harm her baby.

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A. Hypotension and Bradycardia B. Tachypnea, retractions, and grunting C. Acrocyanosis and grunting D. The presence of a barrel chest with grunting

B. Tachypnea, retractions, and grunting The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery, the priority of care is to A. clean the umbilical cord with Betadine to prevent infection B. give the baby a bath C. call the laboratory to collect a PKU screening test D. check the baby's serum glucose level and initiate feedings if < 40 mg/dL

D. check the baby's serum glucose level and initiate feedings if < 40 mg/dL

A 7 pound 14 ounce infant was born 2 hours ago to an insulin-dependent diabetic mother. The infant's blood sugar is 47 mg/dL. What is the priority nursing action? A.Recheck the blood sugar in 6 hours B.Begin an IV of 10% dextrose C.Feed the baby 1 ounce of formula D.Document the findings in the chart

D.Document the findings in the chart

A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: A.Warming the crib pad B.Turning on the overhead radiant warmer C.Closing the doors to the room D.Drying the infant in a warm blanket

D.Drying the infant in a warm blanket Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.

A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F. She complains of abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition? a) Endometritis b) Episiotomy infection c) Mastitis d) Subinvolution

a)Endometritis Explanation: The woman with endometritis typically looks ill and commonly develops a fever of 100.4°F (38°C) or higher (more commonly 101°F [38.4°C], possibly as high as 104°F [40°C]) on the third to fourth postpartum day. The rise in temperature at this specific time is the most significant finding. The woman exhibits tachycardia, typically a rise in pulse rate of 10 beats per minute for each rise in temperature of one degree. In addition, the woman may report chills, anorexia, and general malaise. She also may report abdominal cramping and pain, including strong afterpains. Fundal assessment reveals uterine subinvolution and tenderness. Lochia typically increases in amount and is dark, purulent, and foul-smelling. However, with certain microorganisms, her lochia may be scant or absent.

You receive orders to administer methylergonovine (Methergine) 0.2 mg to a postpartum woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication? a) She can walk without experiencing dizziness. b) Her blood pressure is below 140/90. c) Her urine output is over 50 mL/h. d) Her hematocrit level is over 45%.

b)Her blood pressure is below 140/90. Explanation: Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

A postpartal woman calls you into her room because she is having a very heavy lochia flow containing large clots. Your first action would be to a) Assess her blood pressure. b) Palpate her fundus. c) Have her turn to her left side. d) Assess her perineum.

b)Palpate her fundus. Explanation: Palpating the fundus will cause it to contract and reduce bleeding. This makes options A, C, and D incorrect.

A Hispanic woman who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which of the following causes of the hemorrhage is most likely in this client?a) Cervical laceration b) Uterine atony c) Retained placental fragment d) Disseminated intravascular coagulation

b)Uterine atony Explanation: Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage. A cervical laceration is less likely because the blood is dark, not bright red, and bleeding from such a laceration usually occurs immediately after detachment of the placenta. Disseminated intravascular coagulation is typically associated with premature separation of the placenta, a missed early miscarriage, or fetal death, none of which is evident in this scenario. A retained placental fragment is possible, and could contribute to the atony, but there is no evidence for this in the scenario.

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? a) Moderate amount of lochia rubra b) Uterine atony c) Thrombophlebitis d) Hemoglobin level of 12 g/dl

b)Uterine atony Explanation: Multiparous women typically experience a loss of uterine tone due to frequent distention of the uterus from previous pregnancies. As a result, this client is also at higher risk for hemorrhage. Thrombophlebitis doesn't increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright-red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which of the following would the nurse suspect? a) Uterine inversion b) Uterine atony c) Hematoma d) Laceration

d)Laceration Explanation: Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright-red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.