Maternal exam 2

Hypoglycemia in a mature newborn is denied as a blood glucose level below which amount? a. 100 mg/100 mL whole blood b. 80 c. 40 d. 30

40

The nurse is teaching new parents how to calculate the amount of formula to feed their newborn each day. The baby weighs 8 lbs. How Much formula should the nurse teach the parents to provide a. 20-24 oz b. 30 - 36 c. 42 - 54 d. 60 - 72

20-24 oz

While assessing the newborn's 5 minute apgar score, the nurse notes the following: heart rate 154, respiratory effort lusty cry, muscle tone well flexed with active movement, reflex irritability crying vigorously with stimulation, color hands and feet are blue. What score would she assign to this newborn

9

A newborn goes through many changes at the time of delivery when transitioning to extrauterine life. What changes.. a. Acrocyanosis b. Apnea c. Atonia d. Asymmetry

Acrocyanosis

The nurse is providing discharge teaching to the postpartum client regarding mood changes to report. In differentiating between the baby blues and postpartum depression, which of the following statements should be included.. a. Baby blues are the result of hormonal shifts and should resolve by the end of the sixth postpartum week b.Baby blues may present in the first few days after birth and resolve prior to the second postpartum week c. Postpartum depression may occur on the 5th postpartum day but will resolve spontaneously by the end of the 6th week. d. Postpartum depression is the result of hormonal changes related to the end of pregnancy and will not require intervention or medication management

Baby blues may present in the first few days after birth and resolve prior to the second postpartum week

While inspecting a newborn's head, the nurse identifies a swelling of the scalp on the right posterior side of the head Do not cross suture line a. Caput succedaneum b. Cephalohematoma c. Enlarged fontanelle d. Moldin

Cephalohematoma

A woman who delivered a term neonate 3 days ago is complaining of fever, fatigue, and heavy vaginal discharge. On assessment, the nurse... a. Mastitis b. Urinary tract infection c. Postpartum hemorrhage d. Endometritis

Endometritis

A nurse at a well-baby clinic is collecting data about a nine-month-old infant. The nurse understands that what occurs at this Stage of development a. Builds a tower of 2 cubes b. Walking with one handheld c. Use of one to three word sentence d. Fears strangers

Fears strangers

By the time children reach their twelfth birthday, they should have learned to trust others and should have developed a sense of what a. Integrity b. Intimacy c. Identity d. Industry

Industry

According to erickson, which stage of development has the developmental task, trust vs mistrust a. Infancy b. Toddler c. Early Childhood d. Adolescence

Infancy

The nurse is assessing a child who has been diagnosed with mononucleosis for splenomegaly. Which area of the abdomen would be palpated to identify this abnormality

LUQ

A nurse is caring for a 9-month-old with influenza. Which of the following might be a toy that could be used to interact, play, or distract them from the discomfort. a. Legos b. Teddy bear with button eyes c. Large plastic blocks d. Doll

Large plastic blocks

The nurse is caring to a postpartum woman 18 hours after the primary cesarean section for preeclampsia. The client is noted to have a boggy uterus and a moderate to large amount of vaginal bleeding. The nurse notifies the physician of these findings and expects an order for what a. Terbutaline b. Methergine c. Misoprostol d. Magnesium sulfate

Misoprostol

During the assessment of a 7-year-old male the nurse notes an abnormal depression of the lower portion of the sternum. The child is alert and orientated and in no apparent distress. a. Anterior chest wall trauma b. Pectus carinatum c. Pneumothorax d. Pectus excavatum

Pectus excavatum

The nurse is assisting a new mother to begin breastfeeding. Which action is the most appropriate for the nurse to take a. Positioning the newborn near her breast and stroking his cheek to encourage him to latch. b. Stressing that breastfeeding is a normal process and will need minimal help learning it c. Cautioning her not to allow the newborn to grasp the areola of her breast to prevent soreness d. Encouraging her to lie on her side and help the baby become wide awake by talking to him

Positioning the newborn near her breast and stroking his cheek to encourage him to latch

At birth the newborn has dry, cracked skin, absence of vernix, lack of subcutaneous fat, and fingernails extending beyond the fingertips. Based on these findings a. Postterm b. Preterm c. SGA d. LGA

Postterm

A newborn with has just returned from surgery to place a gastrostomy tube.Which nursing diagnosis will the nurse use a. Risk for imbalanced nutrition b. Risk for deficient fluid volume c. Risk for impaired skin integrity d. Risk for ineffective gas exchange

Risk for skin integrity

Which of the following actions should the nurse take to prepare the preschool aged child for a physical examination a. Allow the child to role play b. Use medical terminology to describe what will happen c. Separate the child form the caregiver during the exam d. Keep medical equipment visible to the child

a. Allow the child to role play

A postpartum woman has a fourth-degree perineal laceration. Which of the following physician orders would the nurse anticipate a. An order for PRN docusate sodium b. Administer of acetaminophen/oxycodone for pain c. Administer of a sitz bath d. Administration of an enema

a. An order for PRN docusate sodium

When assessing a newborn, the apgar score determines the ability of the newborn to transition to extrauterine life. Which of the following does the Apgar score assess a. Color b. Heart rate c. Respiration d. Gender e. Birthtime

a. Color b. Heart rate c. Respiration

The nurse is assessing a term newborn. Which finding should the nurse expect when assessing the pattern of sole creases a. Creases on two thirds of the foot b. Heel creases but no anterior creases c. Longitudinal but no horizontal creases d. Creases covering one fourth of the foot

a. Creases on two thirds of the foot

A nurse is providing teaching about expected changes during puberty to a group of parents of adolescent girls. Which of the following statements by one ... a. Girls usually stop growing about 2 years after menarche b. Girls are expected to gain about 45 lbs during puberty c. Girls experience menstruation prior to breast development d. Girls typically grow more than 10 inches during puberty

a. Girls usually stop growing about 2 years after menarche

According to piaget, which basic concept will the child learn during the first year of life? a. He is not an extension of their parents b. He cannot be fooled by changing shapes c. His parents are not perfect d. Most procedures can be reverse

a. He is not an extension of their parents

A preterm newborn is placed in a radiant heat warmer immediately after birth. Which of the following nursing diagnoses is this .... a. Ineffective thermoregulation related to immaturity b. Risk for imbalanced nutrition, less than body requirements c. Risk for deficient fluid volume related to insensible water loss d. Impaired gas exchange related to immune pulmonary functioning

a. Ineffective thermoregulation related to immaturity

In caring for the postpartum client, the nurse will include assessment and observation for signs of postpartum hemorrhage. Which of the following would a. Macrosomic infant b. dysfunctional or prolonged labor c. Multiparity d. Maternal blood type ae. History of iron deficiency anemia

a. Macrosomic infant b. dysfunctional or prolonged labor c. Multiparity

After delivery, a client is diagnosed with postpartum preeclampsia. What care will the nurse provide to this client (Select all) a. Maintain on bed rest with bathroom privileges b. Monitor urine output and daily weight c. Instruct on the need for a fluid bolus d. Administer magnesium sulfate as prescribed e. Administer antihypertensive medication as prescribed

a. Maintain on bed rest with bathroom privileges b. Monitor urine output and daily weight d. Administer magnesium sulfate as prescribed e. Administer antihypertensive medication as prescribed

The nurse is called to the room of a client who had a term delivery of a 9 lb, 8 oz newborn 24 hours ago. The client is noted to have lost consciousness on her way to the bathroom. Upon assessment the fundus is noted to be boggy and deviated to the left with a moderate amount of vaginal bleeding. What is the priority nursing action? a. Massage the fundus b. Empty the bladder c. Administer methergine d. Initiate IV access

a. Massage the fundus

The nurse instructs the parents of a newborn on actions to prevent sudden infant death syndrome. Which observation indicates that teaching has been effective a. Newborn is placed on the back to sleep b. Mother removes a pacifier from the baby's mouth c. The baby is on an every 2 hour formula feeding schedule d. Parents signed a waiver refusing routing immunizations after birth

a. Newborn is placed on the back to sleep

The nurse is evaluating a new mother's ability to effectively breastfeed her newborn. Which criteria indicates that the mother should be ...(select all that apply) Asked differently a. Nipples are everted b. Breast are soft and nontender c. Mother holds the newborn close to her breast Phrased "Mother holds newborn in a football hold" d. Newborn swallows spontaneously and frequently e. Nurse places pillows under the baby for support

a. Nipples are everted b. Breast are soft and nontender c. Mother holds the newborn close to her breast Phrased "Mother holds newborn in a football hold" d. Newborn swallows spontaneously and frequently

Which technique is used to palpate the fundal height on a postpartum client? a. Placing one hand at the base of the uterus and one on the fundus b. Placing one hand on the fundus, one on the perineum c. Resting both hands on the fundus d. Palpating the fundus with only fingertip pressure

a. Placing one hand at the base of the uterus and one on the fundus

Which action by the mother relates to the nurse that she is accepting her child a. She turns her face to meet the newborn's eyes when she holds her b. She fills out the birth certificate while in the hospital c. She has many visitors in the room d. Her husband spends time holding the baby

a. She turns her face to meet the newborn's eyes when she holds her

The nurse in the pediatric clinic is providing education to the parents of a child newly diagnosed with autism. Which of the following would be included in the ... a. Social skills training b. Speech and language therapy c. Structured and predictable environment d. Delayed vaccination schedule e. Daily medication to improve attentiveness

a. Social skills training b. Speech and language therapy c. Structured and predictable environment

The nurse in the pediatric clinic is recording anthropometric data in the 12-month-old child's chart. The father asks, is my son growing the way that he should?" Which of the following nurses response a. The child's weight will be triple the birth weight by one year of age b. The child's height should increase by 2 inches per month c. The child's weight at 12 months should be double the birth weight. d. Increases in height/length are most rapid from 9-12 months

a. The child's weight will be triple the birth weight by one year of age

During a home visit, a new mother is concerned that after three meconium stools her newborn is now starting to have yellow seedy stools. What should the nurse explain a. This is a normal finding b. This is most likely a symptom of diarrhea c. The baby may be developing an allergy to breast milk d. The child will need to be isolated until the stool can be cultured

a. This is a normal finding

The nurse observes a mother telling a toddler that pasta and potatoes will make the child fat. What should the nurse instruct the mother about these food items a. Toddlers need carbohydrates for brain function b. It is more important to restrict protein than carbohydrates c. No more than 30% of all food should be from carbohydrate sources d. The child should be instructed to restrict carbohydrates after the age of 5 years

a. Toddlers need carbohydrates for brain function

During a home visit, the nurse determines that a toddler has a difficult temperament. What did the nurse observe in this visit? (select all that apply) a. Withdrawing b. Rhythmic c. Intense mood d. Menial adaptability

a. Withdrawing c. Intense mood d. Menial adaptability

A newborn is prescribed to receive vitamin k 0.5 mg intramuscularly. What should the nurse do to administer this medication to the newborn? a. Administer the medication in the deltoid muscle b. Administer the medication into the vastus lateralis c. Provide the medication immediately before breastfeeding d. Notify the physician for swelling and irritation at the injection site.

b. Administer the medication into the vastus lateralis

The nurse had instructed a mother on the importance of providing a toddler with a balanced diet. What observation during a home visit indicates that a. The child is eating a piece of cake and ice cream for lunch b. A mother prepares a scrambled egg for the toddlers breakfast c. The mother places a serving of fried finger foods on a plate for the child d. The child takes candy from a dish that is placed on the coffee table in the living room

b. A mother prepares a scrambled egg for the toddlers breakfast

A nurse is caring for a 4-year-old female. Which of the following is expected of a preschool aged child a. Describing manifestations of illness b. Understanding causes of illness c. Relating fears to magical thinking d. Awareness of body function

c. Relating fears to magical thinking

The nurse is called to the room of a client who had a term delivery of a 9 lb, 8 oz. newborn 24 hours ago. The client is noted to have lost consciousness on her way to the bathroom a. Assess ability to void b. Assess the fundus c. Assess blood pressure and heart rate d. Administer oxytocin

b. Assess the fundus

A nurse is caring for a client who has delivered her first newborn less than 24 hours ago. The newborn has been diagnosed with hyperbilirubinemia.While providing education to the client on this condition, the nurse should include which of the following has potential causes of this condition? (select all that apply) a. Allergy to breast milk b. Biliary atresia c. Prenatal alcohol consumption d. Abo incompatibility e. Rh isoimmunization (blood group incompatibility)

b. Biliary atresia d. Abo incompatibility e. Rh isoimmunization (blood group incompatibility)

Which of the following is an advantage of breastfeeding for the newborn a. Breast milk is more difficult to digest, so it makes the newborn feel fuller longer b. Breast milk contains antibodies and thus decreases the possibility.... c. It takes less effort for a newborn to suck at a breast than from a bottle d. Breast milk leads to firmer stools, increasing bowel tone.

b. Breast milk contains antibodies and thus decreases the possibility....

A newborn has loose, yellow stools. The newborn appears healthy, but his mother is concerned that this means he is allergic to breast milk. Which of the following is the.. a. Try burping the newborn more frequently b. Breastfeed newborns stools are normally loose c. Consider changing to a soybean formula d. You may need to have the newborn investigated for bile duct disease

b. Breastfeed newborns stools are normally loose

The nurse is preparing a seminar on breastfeeding for a group of pregnant clients. Which information should the nurse include during the seminar? a. Uterine involution is slowed by breastfeeding. b. Breastfeeding enhances bonding with the newborn c. Breastfeeding might increase the risk of breast cancer d. Breastfeeding mothers have a decreased risk of developing thrombophlebitis

b. Breastfeeding enhances bonding with the newborn

A newborn was delivered 2 hours ago is being assessed in the nursery. Upon exam, the nurse notes a flattened nasal bridge, wide cat eyes a. Hemoglobin electrophoresis b. Chromosomal blood testing c. CT of the brain d. Meconium toxicology testing

b. Chromosomal blood testing

Why are postpartum women prone to urinary retention? a. Catheterization at the time of delivery reduces bladder toxicity. b. Decreased bladder sensation results from edema because of pressure of birth. c. Frequent partial voiding never relieves the bladder pressure d. Mild dehydration causes a concentrated urine volume in the bladder

b. Decreased bladder sensation results from edema because of pressure of birth.

The parents of a newborn are concerned that something is wrong with their newborn eyesight. What should the nurse reassure the parents as being an expected finding in the newborn? a. Produces tears when he cries b. Follows a light to the midline c. Has a white rather than a red reflex d. Follows the finger a full 180 degrees

b. Follows a light to the midline

The nurse on the postpartum unit is reviewing uterotonic (oxytocic) medications with a group of nursing students. Which of the following would be ... a. Terbutaline b. Hemabate c. Magnesium sulfate d. Phytonadione

b. Hemabate

Which assessment finding indicates to the nurse that a newborn has hip sublimation a. Inward rotation of the right foot b. Inability for the right hip to abduct c. Crying on straightened of the right leg d. Drawing of the legs underneath while prone

b. Inability for the right hip to abduct

The nurse assesses a postpartum client's discharge as being moderate in amount and red in color. How should the nurse document the appearance of the lochia? a. Lochia alba b. Lochia rubra c. Lochia serosa d. Lochia normalia

b. Lochia rubra

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful, inflamed area on one breast. Upon assessment, the nurse notes a wedged-shaped area on one breast to be red and warm to touch. Clients temperature is 101.8. What should the nurse consider is the potential diagnosis? a. Breast yeast infection b. Mastitis c. Plugged milk duct d. Engorgement

b. Mastitis

A nurse is assessing a newborn for congenital hip dysplasia. Which signs or symptoms should be brought to the attention of the health care provider for further assessment? (select all that apply) a. Newborn who is actively moving all extremities b. Newborn has one leg that appears longer than the other c. Newborn whos bilateral leg length is symmetric d. Newborn who has extra skin folds on the inner thigh of one leg e. Newborn who has a click in the hip joint when one hip is maneuvered

b. Newborn has one leg that appears longer than the other d. Newborn who has extra skin folds on the inner thigh of one leg e. Newborn who has a click in the hip joint when one hip is maneuvered

In providing care to the postpartum client, the nurse recognizes that women are hypercoagulable during the third trimester of pregnancy and that assessment of this client should include evaluation for the development of venous thromboembolism. Which of the following should be included in this evaluation? (select all that apply) a. Observe the distal upper extremities for swelling and edema b. Observe the lower extremities for symmetry c. Auscultation of lung sounds d. Observation of respiratory rate and effort e. Assessment of uterine cramping

b. Observe the lower extremities for symmetry c. Auscultation of lung sounds d. Observation of respiratory rate and effort

A client recently delivered a newborn and her legs are still numb from the epidural . The nurse assessed the fundus and found it to be at 1 fingerbreadth above the umbilicus and deviated to the right. What is the priority nursing .... a. Administer and IV fluid bolus b. Perform a straight catheterization to relieve bladder distention c. Administer pain medication d. Perform fundal massage and assess lochia color and amount

b. Perform a straight catheterization to relieve bladder distention

The nurse is concerned that a new mother is not showing interest in the newborn and does not participate in newborn care. What action should the nurse take to help both the mother and newborn at ... a. Notify social services department due to neglect to remove the the newborn from the home b. Schedule home visit for the mother, newborn, and support person c. Assess who is going to take care of the baby at home d. Ask the client if it would be better for the baby to put up for adoption

b. Schedule home visit for the mother, newborn, and support person

An infant develops hydrocephalus at 2 weeks of age. Which finding would the nurse expect to assess? a. A soft, fretful cry b. Hypothermia in the late afternoon c. Bulging fontanels d. Excessive thirst

c. Bulging fontanels

The nurse provides discharge instructions to a postpartum client who had a vaginal birth. Which client statement indicates that teaching has been effective? a. I should limit stair climbing to four times a day b. I can begin having intercourse when I get home c. I can return to my full-time job after 6 weeks d. I should notify the physician if my discharge decreases in amount

c. I can return to my full-time job after 6 weeks

A nurse is assessing a newborn that was admitted to the newborn nursery 28 hours ago. Mother's history includes addiction to recreational drugs. Which finding would the nurse expect a. Sleepiness b. Flaccid extremities c. Incessant crying d. Quiets with swaddling

c. Incessant crying

During a home visit, a postpartum client reports fullness and tenderness on the outer side of her right breast. With light palpation, the nurse feels a small lump with engorgement. a. Mastitis b. Breast cancer c. Plugged milk duct d. Engorgement

c. Plugged milk duct

The nurse is assessing a client at her 6-week postpartum appointment. The client states that she feels tired all the time, has trouble falling and staying asleep... a. Normal postpartum feelings b. Baby blues c. Postpartum depression d. Postpartum psychosis

c. Postpartum depression

When assessing a newborn, which of the following techniques should the nurse use to elicit the sleeping reflex- She said it was stepping reflex a. Strike a flat surface on which the newborn is lying b. Place an object in the newborns palm c. Stroke the outer edge of the sole of the newborns feet up toward the toes. d. Hold the newborn upright with his feet touching a flat surface

hold the newborn upright with his feet touching a flat surface

The nurse is preparing formula for a preterm newborn. Which type of formula will most likely be prescribed for this client a. Glucose water b. 20 calories per ounce c. Iron supplemented d. 24 calorie per ounce

d. 24 calorie per ounce

When caring for a newborn several hours after birth, what would the nurse assess as a normal newborns respiratory rate? a. 12 to 16 breaths/min b. 16 to 20 breaths/min c. 20 to 30 breaths/min d. 30 to 60 breaths per minute

d. 30 to 60 breaths per minute

A nurse is caring for a newborn with myelomeningocele. Which of the following actions should the nurse include in... a. Assist the caregiver with cuddling the newborn b. Assess the newborn's temperature rectally c. Place the newborn in a supine position d. Apply a sterile, moist dressing on the sac

d. Apply a sterile, moist dressing on the sac

The nurse is assessing the fundus on a client on postpartum day 2. What should the nurse expect when palpating the fundus? a. Fundus 4 cm above the symphysis pubis and firm b. Fundus 4 cm below the umbilicus and midline c. Funs two fingerbreadths above symphysis pubis and firm d. Fundus two fingerbreadths below the umbilicus and firm

d. Fundus two fingerbreadths below the umbilicus and firm

A newborn is jaundiced and receiving phototherapy. Which of the following is an appropriate intervention when caring for a newborn with hyperbilirubinemia and a. Apply an oil based lotion to the newborns skin to prevent drying and cracking b. Change the newborns position every 4 hours c. Limit the newborns intake of milk to prevent nausea, vomiting, and diarrhea d. Place eye shields over the newborns closed eyes.

d. Place eye shields over the newborns closed eyes

When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection a. Milk ducts b. Urinary bladder c. Blood stream d. Reproductive tract

d. Reproductive tract

The nurse is inspecting a male newborn genitalia. Which action should the nurse avoid a. Inspecting the gential area for irritated skin b. Inspecting if the urethral opening appears circular c. Palpating if testes are descended into the scrotal sac d. Retracting the foreskin over the glans to assess for secretions

d. Retracting the foreskin over the glans to assess for secretions.

A postpartum woman (gravida 1, para 1) asks the nurse immediately after delivery if she should request rooming-in with her newborn. Which of the following a. This puts too much responsibility on the first time mother b. It depends on whether you will breastfeed or not. c. Resting for the first 3 day postpartum will be better for you d. Rooming-in allows increased maternal-newborn contact

d. Rooming-in allows increased maternal-newborn contact

A postpartum woman is prescribed an antibiotic because of endometritis. Her breast-fed newborn should be observed particularly to which of the following a. Decreased sleep levels and increased appetite b. Jaundice that does not respond to phototherapy c. Irritability and loss of appetite d. Signs of thrush and easy bruising

d. Signs of thrush and easy bruising

A nurse is helping her postpartum client up to the bathroom for the first time after delivery. Which finding indicates her lochia is normal or expected? a. Locia contains large clots b. The flow is over 500 mL c. Her uterus is boggy and soft d. The color of the flow is red

d. The color of the flow is red

A new mother asks the nurse how soon she can try to breastfeed after delivery. Which of the following would be the nurse's best response? a. Immediately after birth b. After the newborn is allowed to rest c. Once the newborn has a first feeding of formula d. In 24 hours after her newborn is given water

immediately after birth

A nurse is caring for an adolescent whose mother expresses concern about the child sleeping such long hours. Which of the following a. Sleep terrors b. rapid growth c. Elevated magnesium level d. Slowed metabolism

rapid growth

A new mother asks the nurse how to determine if the baby is receiving enough breast milk. How should the nurse respond to the mother a. The newborn should not become constipated b. The newborn should sleep at least 3 hours between feedings c. You need to weigh the newborn before and after each feeding d. the newborn should gain weight and have six wet diapers daily

the newborn should gain weight and have six wet diapers daily