Maternal Infant practice questions for ATI CMS

A nurse is caring for a client who is experiencing prolonged labor. Which of the following fetal monitoring results indicates fetal compromise? A. Baseline fetal heart rate of 110 - 130 bpm B. Moderate baseline variability C. Accelerations in response to fetal stimulation D. Late decelerations with fetal bradycardia

D. Late decelerations with fetal bradycardia Rationale: Late decels and bradycardia indicate that the fetus is not tolerating labor and might be compromised. These findings should be assessed in relation to the clinical picture of the progression of labor. Incorrect Answers: Baseline of 110 - 160 bpm is WINL, Moderate baseline variability is expected, Accelerations of at least 15 bpm are expected

A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. In what order should the nurse take the following actions when performing a fundal massage? A. Position a hand around the top of the client's fundus B. Use slight downward pressure to compress the client's fundus C. Ask the client to lie on her back w/ knees flexed D. Rotate the upper hand to massage the client's uterus E. Place a hand just above the client's symphysis pubis

1. C. Ask the client to lie on her back w/ knees flexed 2. E. Place a hand just above the client's symphysis pubis 3. A. Position a hand around the top of the client's fundus 4. D. Rotate the upper hand to massage the client's uterus 5. B. Use slight downward pressure to compress the client's fundus

A nurse is reviewing the medical record of a client at 33 weeks gestation who has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider? A. Perform a vaginal examination B. Perform continuous external fetal monitoring C. Insert a large-bore IV catheter D. Obtain a blood sample for laboratory testing

A. Perform a vaginal examination Rationale: With placenta previa, the placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina), any manipulation can cause tearing of the placenta and increased bleeding.

A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? A. Respiratory Depression B. Hypothermia C. Hypoglycemia D. Jaundice

A. Respiratory Depression Rationale: Mag sulfate can cause respiratory and neuromuscular depression in the newborn. Incorrect answers: Preterm newborn can have difficulty with thermoregulation d/t immature temp-control mechanisms, can experience hypoglycemia d/t immaturity, can experience jaundice r/t prematurity, but none of these a r/t mag sulfate

A nurse in a clinic is caring for a client who is pregnant and reports a last menstrual period (LMP) that began on December 7. Which of the following dates would be the client's estimated date of birth (EDB)? A. September 14 B. September 7 C. March 14 D. March 7

A. September 14 Rationale: Naegele's Rule: LMP - 3months + 7 days = EDB

A nurse is caring for several clients. Which of hte following clients should the nurse identify as a candidate for oral contraceptives? A. a client who smokes 2 packs of cigarettes/week B. A client who is breastfeeding a 7-month-old infant C. A client who is taking an anticonvulsant medication D. A client who is taking anti-HIV protease inhibitors

B. A client who is breastfeeding a 7-month-old infant Rationale: A client can begin using oral contraceptives 4 weeks after childbirth Incorrect Answers: Smoking is contraindicated for oral contraceptive b/c both increase risk for MI & Stroke; Many meds interact negatively with oral contraceptives, including anticonvulsants, systemic antifungals, anti-HIV protease inhibitors, & antituberculosis meds

A nurse is caring for a newborn who weighs 4 lb. How many kilograms does the newborn weigh?

1.8 Kg Rationale: 2.2 lbs / Kg (1 Kg/2.2 lbs.) (4 lbs) = 1.8

A nurse is teaching a prenatal class about pain management during labor. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I can apply a heating pad to my back to relieve back pain." B. "I can have a low spinal block to help with labor pain." C. "I can have butorphanol every 2 hrs. during labor." D. "My time limit for staying in the hydrotherapy tub is 30 minutes."

A. "I can apply a heating pad to my back to relieve back pain." Rationale: Heat applications to the lower back can help promote relaxation and relieve pain b/c they reduce ischemia in the muscles and bring more blood flow to the area. The client should have 1 or 2 layers of cloth between her skin and the heating pad. Incorrect Answer: Low spinal anesthesia is useful during a vaginal birth, but not for managing labor pain; if prescribed, can receive butorphanol q3-4 hrs.; most clients stay in hydrotherapy for 30-60 min. but there is no time limit.

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching? A. "I should feed my baby 8-12 times a day, based on cues." B. "My baby should ha 6 or 7 wet diapers a day during the first week." C. "I should switch my baby to the other breast after 15 minutes of feeding." D. "My nipple pain should go away after a few weeks of breastfeeding."

A. "I should feed my baby 8-12 times a day, based on cues." Rationale: For the first few days, parents might have to wake the newborn q2-3hrs. Once the infant is feding well and gaining weight, feedings should be based on the infant displaying hunger cues, such as sucking on the fist and rooting. Incorrect Answers: During the 1st week of life, newborns should have a minimum of 1 wet diaper for every day of their age. by end of 1st week, infants should have 6-8 wet diapers each day. The mother should switch breasts based on cues from the infant, not based on the clock. She should feed the infant on a breast until the infant takes a break and the breast softened. Offer the other breast which the infant may or may not take. This ensures an adequate intake of fatty hindmilk. Nipple pain is not an expected finding of breast feeding, mothers who experience nipple pain throughout the feeding should seek the assistance of a lactation consultant.

A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned her fetus might be at risk. Which of the following statements should the nurse provide? A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has the disorder." B. "If the genetic screening shows that your baby has this disorder, I can provide you with information about an abortion clinic." C. "Screening for trisomy 13 syndrome and other chromosomal disorders is done automatically fir clients at increased risk." D. "I can provide you information about sterilization so that the disorder is not passed to your future children."

A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has the disorder." Rationale: Genetic screening has multiple legal and ethical considerations that must be addressed prior to testing. The client will need to sign an informed consent form prior to screening.

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority? A. 480 mL urine output in 24 hr. B. Blood pressure 144/92 mmHg C. +2 edema of the feet D. 1+ protein in urine

A. 480 mL urine output in 24 hr. Rationale: Using urgent vs nonurgent, the priority finding is 480 mL of urine output in 24 hr. b/c the min acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Incorrect answers: BP 144/92 mmHg, +2 edema, & 1+ protein are expected findings w/ preeclampsia therefore nonurgent

A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect? A. Abundant lanugo B. Good flexion C. Heel creases covering the bottom of the feet D. Dry parchment-like skin

A. Abundant lanugo Rationale: Newborns who are premature have abundant lanugo (fine hair), especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinna, and forehead Incorrect Answers: Premature newborns demonstrate hypotonia and a relaxed posture, full-term newborns demonstrate moderate flexion of the arms and legs; Premature newborns have few heel creases, full-term newborns have heel creases that cover most of the bottom of the feet; Premature newborns have abundant vernix caseosa, a thick whitish substance, covering and protecting their skin in utero, post-mature newborns are likely to have dry, parchment-like skin.

A nurse is caring for a client in the 3rd trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test? A. Ask the client to drink a glass of orange juice B. Prepare the client for a vaginal examination C. Request a serum hemoglobin level D. Obtain a clean-catch urine specimen

A. Ask the client to drink a glass of orange juice Rationale: Give orange juice of glucose preparation prior to test to raise the client's blood glucose level & help promote fetal movement. Incorrect answers: A non-stress test involves the application of a fetal heart monitor and a tocodynamometer to track uterine contractions and fetal movement; there is no vaginal exam, doesn't involve client's hemoglobin level, it doesn't involve identifying indications of a UTI in the client

A nurse is caring for a client who is experiencing preterm labor. Which of the following medications should the nurse anticipate administering to enhance fetal lung maturation? A. Betamethasone B. Nifedipine C. Indomethacin D. Verapamil

A. Betamethasone Rationale: Betamethasone is administered as antenatal glucocorticoid therapy and is given to clients who are experiencing preterm labor to stimulate fetal lung maturation. Incorrect Answers: Nifedipine is administered as tocolytic for preterm labor; Indomethacin is administered as tocolytic therapy for preterm labor; Verapamil is used to treat maternal and fetal arrhythmias during pregnancy.

A nurse is caring for a client who is in labor. Which of the following assessment findings should the nurse report to the provider? A. Fetal heart rate baseline of 90 bpm B. Maternal temperature of 37.8C (100F) C. Uterine relaxation for 1 min between contractions D. Uterine contractions increasing in intensity

A. Fetal heart rate baseline of 90 bpm Rationale: Fetal heart rate of 90 bpm is considered bradycardia and should be reported to the provider. Fetal bradycardia is associated with fetal cardiac defects, maternal hypoglycemia, and fetal viral infections. Wrong answers: A temp of 38C (100.4F) or greater should be reported, is associated with chorioamnionitis, an infection caused by bacteria ascending from the vagina to the uterus; There should be at least 1 min of rest between contractions, < 1 min can lead to fetal hypoxia and should be reported to the provider; As labor progresses, UCs are expected to increase in intensity and frequency.

A nurse is caring for a client who is 8 hr. postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (SATA) A. Massage the fundus B. Give oxygen at 2 L/min via nasal cannula C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30*

A. Massage the fundus C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30* Rationale: The nurse should massage the fundus to expel clots and help the uterus contract. The nurse should ass oxytocin to the intravenous drip and insert an indwelling urinary catheter to monitor urinary output and perfusion to the kidneys. Finally, the nurse should place the client in a lateral position with her legs elevated 30* Incorrect Answer: The nurse should administer 10 L/min via nonrebreather face mask.

A nurse is caring for a client who is 38 weeks of gestation and is receiving an oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first? A. Place the client in a side-lying position B. Discontinue the oxytocin infusion C. Apply oxygen to the client via face mask D. Check for umbilical cord prolapse

A. Place the client in a side-lying position Rationale: According to evidenced-based practice, the nurse should act quickly to restore the oxygen supply to the fetus. Variable decelerations reflect an umbilical cord prolapse; therefore, the nurse should act immediately to help shift the pressure of the presenting part off the cord. Incorrect answers: The nurse should d/c the oxytocin infusion b/c fetal distress must resolve b/4 proceeding w/ the birth, the nurse should administer oxygen to help prevent or relieve fetal hypoxia, the nurse should perform or assist with a vaginal examination to check for umbilical cord prolapse b/c this can cause variable decelerations; however EBP indicates that the nurse should take a different action before all of these.

A nurse is caring for a client who recently gave birth and plans to breastfed. Which of the following actions should the nurse take? A. Place the unwrapped newborn on the mother's bare chest B. Feed the infant 5 to 15 mL of 5% glucose water to assess the suck/swallow reflex. C. Bathe the newborn under running warm water before feeding. D. Administer vitamin K and eye prophylaxis prior to feeding.

A. Place the unwrapped newborn on the mother's bare chest Rationale: Skin-to-skin contact will maintain the newborn's temp and illicit instinctive newborn feeding behaviors Wrong Answers: breastfed infants shouldn't be fed anything except breastmilk unless deemed medically necessary; Newborns should never be bathed under running water & bathing should be delayed until after 1st feeding; Routine care such as beathing, weighing, eye prophylaxis, and Vitamin K injection should all be delayed until after the infant has completed the 1st feeding.

A nurse is providing care for a client who is in the 2nd stage of labor. The fetal heart tracing indicates multiple variable decelerations. Which of the following actions should the nurse take? A. Prepare an amnioinfusion B. Place the client in a supine position C. Administer oxygen 2 L/min. via nasal cannula. D. Give a glucocorticoid

A. Prepare an amnioinfusion Rationale: The nurse should prepare an amnioinfusion to decrease cord compression Incorrect Answer: The nurse should assist the client into a side-lying or knee-to-chest position to decrease umbilical cord compression; The nurse should administer 8-10 L/min of oxygen by non-rebreather face mask to enhance O2 saturation; The nurse should administer a glucocorticoid for a client who is experiencing preterm labor to accelerate fetal lung maturity in fetuses between 24 & 34 weeks, not given to clients who are having variable decels.

A nurse is caring for a client at 34 wks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa of and abruptio placenta? A. Uterine tone B. Fetal Heart Rate C. Blood pressure D. Amount of bleeding

A. Uterine tone Rationale: Uterus will be relaxed, soft, and painless if the bleeding is caused by placenta previa. With abruptio placenta, the uterus will be firm and board-like, and the client will complain of pain. Wrong Answers: Fetal distress may be present in both, Hypotension may be present in both, amount of blood loss is not diagnostic of the cause of the bleeding.

A nurse is assessing a client who is at 20 weeks gestation and reports frequent episodes of indigestion and heartburn. Which of the following instructions should the nurse give the client? A. "Limit your intake of food to twice per day" B. "Decrease your intake of spicy foods" C. "Rest in a supine position for a few minutes after eating" D. "Increase your intake of water and carbonated beverages"

B. "Decrease your intake of spicy foods" Rationale: Spicy foods cause gastric irritation, which may increase during pregnancy as a result of various physiological changes. Incorrect answers: Ingesting large amounts of food at once can cause bloating, distention, & nausea, instead consume small frequent meals; laying in a supine position might exacerbate indigestion & is known to cause heartburn and reflux of gastric content; Increasing water can exacerbate indigestion b/c it increases feelings of fullness and carbonated beverages add gas to digestive tract.

A nurse is teaching a prenatal class about nonpharmacological comfort measures during labor. Which of the following statements should the nurse identify as an indication that the instructions have been understood? A. "I can have my partner apply counterpressure to my upper abdomen." B. "My baby will be monitored with a Doppler device during hydrotherapy." C. "I can have the nurse apply acupressure to my lower abdomen." D. "My TENS unit will not help with lower back pain during early labor."

B. "My baby will be monitored with a Doppler device during hydrotherapy." Rationale: During hydrotherapy the FHR will be monitored with a fetoscope, a doppler device' or wireless external fetal monitor. Incorrect Answers: The client's partner should apply counter pressure to her lower back; Acupressure can help relieve pain but the sites for applying pressure are the lower back, hips, neck, shoulders, wrists, ankles, soles of the feet, small toes, and just below the knee caps, not the abdomen; TENS delivers electrical impulses on either side of the spine & can help relieve back pain during the early part of the 1st stage of labor.

A nurse is providing care to a client who is 2 hours postpartum and is receiving oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. "This could indicate a possible uterine infection." B. "The bleeding is minimal until I discontinue you IV medication." C. "You might have retained some fragments of your placenta." D. "You will require additional medication to increase your bleeding."

B. "The bleeding is minimal until I discontinue you IV medication." Rationale: The flow of lochia is often often scant while receiving oxytocic medication until the effects of the med wear off. This can be observed no matter the route of administration of the oxytocic med. Incorrect answers: Increased, not decreased, bleeding can indicated infection or placental fragments, fever or foul smelling discharge can also indicate infection, postpartum days 7-14 might have sudden increase in bleeding as sloughing of eschar occurs over placental site (should subside in 1-2 hrs.); No addt'l med is warranted at this time to induce bleeding, once oxytocin wears off, lochia will return to a more normal flow

A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is common during pregnancy. Which of the following responses should the nurse make? A. "Have you discussed this with your doctor?" B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." C. "Women who are already prone to vaginal yeast infections get them during pregnancy." D. "Why are you concerned about yeast infections during pregnancy?"

B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." Rationale: This is an information seeking question; therefore, the therapeutic response is an answer that provides the client with the information she requested.

A nurse is assessing a newborn and notes an axillary temperature of 96.9 F (36 C). Which of the following actions should the nurse perform? A. Obtain a rectal temperature B. Assess the newborn's blood glucose level C. Bathe the newborn with warm water D. Position the infant's bassinet in front of a heater vent

B. Assess the newborn's blood glucose level Rationale: Infants who become cold attempt to generate heat through increased muscular and metabolic activity. This process increases glucose consumption and puts the newborn at risk for hypoglycemia. Incorrect answers: Don't get a rectal temp on newborn d/t risk of rectal perforation, Bathing will increase heat loss, Placing in front of heater vent can incur heat loss through convection

A nurse is teaching a client who is at 10 weeks gestation about self-care management for common discomforts during pregnancy. Which of the following instructions should the nurse include? A. Douche every other day to minimize leukorrhea B. Consume frequent snacks to decrease episodes of nausea C. Refrain from scheduling dental procedures until the 3rd trimester D. Decreased fluid intake to reduce urinary frequency

B. Consume frequent snacks to decrease episodes of nausea Rationale: Clients with nausea during pregnancy should ingest small snacks frequently. An empty or overloaded stomach can increase feelings of nausea Incorrect answers: Douching disrupts the normal vaginal flora & can lead to vaginal infections, Leukorrhea is normal & has a protective function during pregnancy. Pregnant clients should maintain good dental hygiene and see a dentist as needed throughout pregnancy; dental procedures such as x-rays & use of local anesthetics is safe during pregnancy; research links periodontal disease to an increase risk of preterm births and preeclampsia. At least 2 L of water should be consumed each day during pregnancy to prevent constipation caused by slowed gastrointestinal motility and oral iron supplements

A nurse is caring for a client in labor and observes a pattern of early decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Notify the provider B. Document the findings and continue to monitor. C. Administer oxygen via face mask. D. Assist with sterile speculum exam.

B. Document the findings and continue to monitor. Rationale: Early decels are a normal and benign finding by compression of the fetal head during uterine contractions.

A nurse is assessing a client who is at 36 weeks gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? A. Varicose veins B. Double vision C. Leukorrhea D. Flatulence

B. Double vision Rationale: Double vision, blurred vision, or visual disturbances are signs of potential complications associated with preeclampsia. The nurse should report this finding to the provider. Incorrect answers: Varicose veins (caused by relaxation of the smooth muscle walls of the veins and pelvic vasocongestion), Leukorrhea (a hormonal production of an abundant amount of mucus), Flatulence (progesterone causes reduced gastrointestinal motility) are all common manifestations associated with pregnancy.

A nurse is teaching a client with pre-eclampsia who is scheduled to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching? A. Elevated blood pressure B. Feeling of warmth C. Hyperactivity D. Generalized pruritus

B. Feeling of warmth Rationale: Expect a feeling of warmth all over the body while the magnesium sulfate if infusing. Incorrect answers: Expect a drop in BP; Expect feeling sedated; Generalized pruritus can be a manifestation of an allergic reaction to magnesium sulfate

A nurse in labor and delivery is teaching a newly licensed nurse about performing the McRoberts maneuver to relieve shoulder dystocia. Which of the following pieces of information should the nurse include? A. Position the client on her hands and knees while in bed. B. Flex the client's legs apart and raise her knees to her abdomen. C. Apply gentle pressure on the client's fundus while she is lying supine. D. Push the fetus's anterior shoulder under the symphysis pubis externally.

B. Flex the client's legs apart and raise her knees to her abdomen. Rationale: The McRoberts maneuver includes helping the client flex her knees apart, which rotates the pubic bone anteriorly. This movement releases the anterior shoulder, but the nurse should not apply pressure directly to the anterior shoulder during this maneuver. This maneuver can be used for clients with or without epidural anesthesia. Incorrect Answers: This positioning is the Gaskin maneuver, which includes positioning the client on her hands and knees to release the anterior shoulder of the fundus; Using fundal pressure will not release the anterior shoulder of the fetus and is associated with neonatal neurological complications, this intervention should be avoided; When the nurse applies suprapubic pressure, the anterior shoulder of the fetus is pushed underneath the symphysis pubis. This dislodges the anterior shoulder and allows the fetus to rotate, but it is not the McRoberts maneuver.

A nurse is talking with a client at 20 weeks of gestation who is scheduled for a sonogram. The client states, "I am here to have my regular prenatal checkup, but I do not want any pictures taken of my baby." Which of the following responses should the nurse make? A. "Do not worry. We can do the sonogram without showing you the sex of the baby." B. I would like to hear more about why you do not want the sonogram, including any cultural reasons." C. "I think you should reconsider b/c the sonogram is an important part of the baby's checkup." D. "You have the right to tell the doctor that you do not want the sonogram."

B. I would like to hear more about why you do not want the sonogram, including any cultural reasons."

A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first? A. Check for a full bladder B. Massage the fundus C. Measure vital signs D. Administer carboprost IM

B. Massage the fundus Rationale: The primary cause of postpartum bleeding is uterine atony, which is manifested by a relaxed, boggy uterus. the greatest risk to this client is hemorrhage. Incorrect Answers: Full bladder can cause uterine atony but in this case massaging the fundus comes first, vital signs important but will not help identify reason for bleeding, Administering carboprost is an appropriate action for managing postpartum hemorrhage but start w/ massage fundus

A nurse in a prenatal clinic is reviewing the laboratory results of a client who is 33 weeks of gestation. For which of the following results should the nurse notify the provider? A. Hgb 11.3 g/dL B. Platelet count 135,000/mm^3 C. WBC count 10,500/mm^3 D. Hct 38%

B. Platelet count 135,000/mm^3 Rationale: The low platelet count is an indication of thrombocytopenia, A low platelet count is a manifestation of preeclampsia or HELLP syndrome and requires further evaluation Incorrect Answers: Hgb <11 g/dL is ad indication of anemia & should be reported; WBC count >15,000mm^3 is an indication of infection & should be reported; Hct <33% is indication of anemia & should be reportd

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis

B. Retinopathy Rationale: O2 therapy can cause retinopathy, especially in preterm newborns. It is a disorder of retinal blood vessel development in premature newborns. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. This condition can reduce vision or result in complete blindness. Incorrect Answers: O2 therapy doesn't cause atelectasis but can be used for clients who have atelectasis; O2 therapy doesn't cause interstitial emphysema but can be used for clients who have interstitial emphysema; O2 therapy doesn't cause necrotizing enterocolitis (NEC), a severe disease of premature newborns. In NEC, the lining of the interstitial wall dies, and the tissue sloughs off. The cause is unknown, Decreased blood flow to the bowel may keep the bowel from producing the normal protective mucus. Bacteria in the intestine may also contribute.

A nurse is assessing a client who is receiving magnesium sulfate as a treatment for pre-eclampsia. Which of the following clinical findings is the nurse's priority? A. Respirations 16/min B. Urinary output 40 mL in 2 hrs. C. Reflexes +2 D. Fetal heart rate 158/min.

B. Urinary output 40 mL in 2 hrs. Rationale: Urinary output is critical to the excretion of magnesium from the body. The nurse should d/c the mag sulfated if the hourly output is <30mL/hr.

A nurse is determining an Apgar score for a newborn who was born 1 min. ago. For which of the following findings should the nurse assign a score of 1? A. Heart rate 116/min B. Weak cry C. Flaccid muscles D. No response to stimuli

B. Weak cry Rationale: Slow weak cry = score of 1 Incorrect Answers: HR >100 = Score of 2 Flaccid muscle tone = 0 No response to stimuli = 0

A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include? A. "A fetal stethoscope can first detect your baby's heart rate at 22 weeks." B. "After week 16, we can see if your baby is a boy or girl." C. "A doppler device can detect your baby's heart rate at 12 weeks." D. "You will first feel the baby move at about 8 weeks."

C. "A doppler device can detect your baby's heart rate at 12 weeks." Rationale: Fetal heart rate can be detected with a doppler device toward the end of the 1st trimester, often as early as 10 weeks Incorrect Answers: Fetal heart tones can be heard with a fetoscope by the end of the 16th week; the sex of the fetus is distinguishable on a sonogram by end of 12th week; Quickening (feeling fetal movement) is typically possible at 15-16 weeks in multiparous clients, however, it's sometimes not possible until week 18 or later in nulliparous clients.

A nurse in an outpatient setting is providing education for a client who is pregnant. Which of the following statements should the nurse include in the teaching? A. "During the last trimester, you should sleep mainly on your back." B. "During the 2nd trimester, you will notice increased urinary frequency and urgency." C. "You will probably first notice your baby moving when you are around 20 weeks gestation." D. "You should plan to gain 40 to 45 pounds during your pregnancy."

C. "You will probably first notice your baby moving when you are around 20 weeks gestation." Rationale: Fetal movement is typically noted @ 18 to 20 weeks gestation. Multiparous clients might notice movement earlier. Incorrect Answers: Avoid supine position during latter half of pregnancy d/t risk of vena cava compression; urinary frequency during 1st & 3rd trimester is expected, frequency and urgency during 2nd trimester should be reported; Recommended weight gain during pregnancy is typically 25 to 30 lbs.

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? A. "You should supplemental your baby with formula until you notice that your breasts become firm and full." B. "You should adhere to a schedule when feeding your baby to ensure she is getting enough to eat." C. "Your milk supply will noticeably increase in volume around the 3rd or 4th day after delivery." D. "It is typical for your nipples to hurt for the 1st few weeks while you are breastfeeding."

C. "Your milk supply will noticeably increase in volume around the 3rd or 4th day after delivery." Rationale: As the colostrum transitions to mature breast milk, the volume of milk produced will also increase, breasts feel fuller & firmer usually 72 - 96 hrs. after delivery & milk is leaking from the nipples. Wrong Answers: Colostrum is present b4 newborn is delivered, unless medical indication, no need to supplement; should breastfeed on demand, sticking to strict schedule can lead to failure to meet nutritional needs; painful nipples are indication that the newborn is not correctly latched onto the breast

A nurse is providing teaching about calcium intake to a client who is breastfeeding. Which of the following is the recommended daily calcium intake for a client who is breastfeeding? A. 800 mg B. 400 mg C. 1,000 mg D. 2,000 mg

C. 1,000 mg Rationale: The nurse should instruct the client that 1,000 mg of clacium is recommended for women age 19 and older, as well as those who are lactating. This amount of calcium is sufficient to meet the needs of the client and the infant b/c additional calcium is absorbed from the intestines during this time. Both A & B are incorrect b/c they are below the recommended daily allowance of calcium for women age 19 & older. D is incorrect b/c 2,00mg is above the recommended daily allowance and a high calcium intake can result in the development of kidney stones and decrease the absorption of other nutrients, such as iron and zinc.

A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine? A. Shellfish B. Gelatin C. Baker's yeast D. Eggs

C. Baker's yeast Rationale: An allergy to baker's yeast is a contraindication to receiving the hep B vaccine. The nurse should notify the client's provider. Incorrect answers: Allergy to shellfish shouldn't receive IV contrast dye which contains iodine; allergy to gelatin should not receive the MMR vaccine; allergy to eggs shouldn't receive the influenza vaccine.

A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended action of the medication in relation to the CNS? A. Accentuate the effects of narcotics on the CNS. B. Depress the activity of the CNS C. Block the effects of narcotics on the CNS D. Stimulate activity of the CNS

C. Block the effects of narcotics on the CNS Rationale: By blocking the effects of narcotics on the CNS, naloxone prevents CNS and respiratory depression in the newborn following delivery.

A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer? A. Protamine sulfate B. Naloxone C. Calcium gluconate D. Flumazenil

C. Calcium gluconate Rationale: D/C mag sulfate infusion immediately and prepare to administer calcium gluconate IV to reverse effects of mag sulfate and to prevent cardiac and respiratory arrest. Incorrect Answers: Protamine sulfate helps reverse effects of heparin, Naloxone reverses opioids, Flumazenil reverses benzos.

A nurse is providing teaching about the selection of commercial formula to the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Soy-based formula is recommended to decrease colic. B. Amino acid formula is recommended to increase the newborn's protein intake. C. Cow's milk-based formula is recommended for healthy newborns. D. Low-iron formula is recommended to prevent excess iron intake.

C. Cow's milk-based formula is recommended for healthy newborns. Rationale: Cow's milk-based formulas are similar to human breast milk and are recommended for newborns & infants unless prescribed otherwise by the provider. Certain conditions that might indicate a need to switch to an alternate formula include galactosemia, a congenital lactase deficiency, and immunoglobulin E allergies. Incorrect Answers: Soy-based formula is not known to decrease colic; Amino acid formulas are recommended for newborns & infants who have a protein intolerance; Iron-fortified formulas are recommended since they meet the newborn's daily iron requirements.

A nurse is planning care for a client who is at 35 weeks gestation. Which of the following laboratory tests should the nurse obtain? A. Rubella titer B. Blood type C. Group B streptococcus B-hemolytic D. 1-hour glucose tolerance test

C. Group B streptococcus B-hemolytic Rationale: A vaginal/anal group B streptococcus B-hemolytic (GBS) culture should be done @ 35-37 weeks gestation to screen for infections. Prophylactic antibiotics should be given during labor to clients who are + for GBS Incorrect Answers: Rubella titer is obtained at 1st prenatal visit; Maternal blood type & Rh factor should be obtained at 1st prenatal visit to determine if client will need Rho(D) immune globulin at 28 wks.; !-hr. glucose tolerance test should be obtained at 24 - 28 weeks

A nurse is caring for a client labor who has an epidural for pain relief. Which of the following is a complication of the epidural block? A. Nausea and vomiting B. Tachycardia C. Hypotension D. Respiratory depression

C. Hypotension Rationale: Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of epidural anesthesia in order to decrease the likelihood of this complication. Incorrect answers: Nausea & vomiting not adverse effect of epidural; Tachycardia is an adverse effect of opioid agonist-antagonist analgesics such as butorphanol tartrate but not epidural; Patients receiving mag sulfate for pre-eclampsia & premature labor are at risk for respiratory depression but not epidural.

A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching? A. Newborn respiratory depression at birth B. Impaired ability of the neonate to maintain body temperature. C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variability

C. Impaired placental perfusion Rationale: Maternal hypotension can occur in 10-30% of women who receive epidural of spinal anesthesia. This can result in decreased blood flow to the placenta and impair the delivery of oxygen to the fetus. Wrong Answers: Respiratory depression in newborn may occur if narcotic agonist-antagonist analgesics are administered to mother w/i 1-4 hrs. of birth; Diazepam in labor can disrupt newborn thermoregulation and result in hypothermia; minimal of absent FHR variability is a side effect of administering opioids to a laboring client.

A nurse at a prenatal clinic is assessing an adult client who had genital cutting performed as a child as part of her cultural practices. The nurse notes the client's clitoris and labia minora were removed, and she has scarring in the vaginal area. Which of the following actions should the nurse take? A. Report the findings to the local authorities. B. Ask the client who performed the cutting. C. Inform the client that giving birth vaginally might not be possible. D. Prepare the client for the increased risk of spontaneous abortion.

C. Inform the client that giving birth vaginally might not be possible. Rationale: Female genital cutting is done in early adolescence as part of some religious and cultural practices. Scarring can result and may necessitate cesarean delivery. Wrong answers: Though illegal in US, can't report maltreatment of a competent adult without consent; asking questions may offend cultural beliefs; FGM can cause difficulty conceiving or delivering but not risk for spontaneous abortion.

A nurse is caring for a client in active labor whose fetus is in a persistent occiput posterior position. Which of the following actions should the nurse take to promote rotation of the fetal head? A. Apply counterpressure to the client's back B. Place heat on the client's lower back C. Instruct the client to squat during contractions D. Encourage the client to ambulate in the hall

C. Instruct the client to squat during contractions Rationale: Measures to encourage rotation of the fetal head to a more anterior position include squatting during contractions, getting on hands & knees during contractions, and lying on the same side as the fetal spine. Incorrect Answers: Counterpressure helps relieve pain d/t pressure of the occiput on spinal nerves; Heat application to the lower back can promote relaxation & relieve pain; Ambulation is helpful when membranes are intact & when the client has not received analgesia; none of these will help rotate the fetal head.

A nurse is caring for a client who just had spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and a prolapsed umbilical cord. Which of the following actions should the nurse take first? A. Place the client in an extreme Trendelenburg position B. Increase the IV fluid infusion rate C. Manually apply upward pressure intravaginally on the presenting part. D. Administer 8 to 10 L/min of oxygen via a nonrebreather face mask

C. Manually apply upward pressure intravaginally on the presenting part. Rationale: The greatest risk here is fetal CNS injury of death from fetal hypoxia D/T cord compression. The 1st action is to insert a gloved hand into the vagina and apply upward pressure to the presenting part to move it away from the cord. Incorrect Answers: The nurse should place the client in and extreme Trendelenburg position, a knee-chest position, or a modified Sim's position to use gravity to keep the pressure of the presenting part off of the cord, nurse should increase IV infusion rate to promote hydration, Should administer O2 to help prevent fetal hypoxia: however, another action comes before these.

A nurse is assessing a postpartum client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. The nurse should plan to administer which of the following medications? A. Terbutaline B. Magnesium sulfate C. Oxytocin D. Methylergonovine

C. Oxytocin Rationale: Oxytocin is a uterotonic medication that causes the uterus to contract and reduces excessive uterine bleeding. Incorrect Answers: Terbutaline is a tocolytic med that causes uterine relaxation and is used to treat preterm labor, not uterine atony; Magnesium Sulfate is a tocolytic med used to treat preterm labor and decrease the risk of eclamptic seizures, not for uterine atony; Methylergonovine is a uterotonic med that has an adverse effect of hypertension, therefore contraindicated for patient with preeclampsia.

A nurse is providing teaching for a client about hormonal changes during pregnancy. The nurse identifies that which of the following hormones plays a key role in preventing miscarriage? A. Oxytocin B. Prolactin C. Progesterone D. Estrogen

C. Progesterone Rationale: Progesterone maintains the endometrium and has a relaxant effect on the uterus so that the fetus is not expelled. Wrong Answers: Oxytocin stimulates uterine contractions and is responsible for the excretion of milk during lactation, Prolactin prepares the breasts to synthesize and secrete milk, Estrogen stimulates uterine contractility and growth of the uterus and breast glandular tissue, estrogen levels rise near the end of pregnancy to prepare for the onset of labor.

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? A. Uterine rupture B. Placental abruption C. Prolapsed umbilical cord D. Amniotic fluid embolus

C. Prolapsed umbilical cord Rationale: Prolonged deceleration during uterine contraction is a sign of cord prolapse, an emergent condition that should be reported immediately Incorrect Answers: Signs of uterine rupture include constant abdominal pain, loss of fetal station, abnormal fetal heart rate tracing, and cessation of contractions, not related to rupture of membranes; Manifestations of placenta abruption include abdominal pain, vaginal bleeding, uterine tenderness, & contractions, rupture of membranes not contributing factor; Signs of amniotic fluid embolus include maternal respiratory distress, and hemodynamic instability, spontaneous rupture of membranes not a contributing factor.

A nurse is teaching a client who is at 30 weeks gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching? A. Mild constipation B. Nasal congestion C. Vaginal bleeding D. 10 fetal movements / hour

C. Vaginal bleeding Rationale: Vaginal bleeding can be an abnormal finding during pregnancy indicating a complication such as placental abruption, placenta previa, or preterm labor Incorrect Answers: Mild constipation is an expected finding d/t slowing of intestinal motility secondary to the increase in circulating progesterone and compression of the intestines by the enlarged uterus; Nasal congestion is an expected finding during pregnancy d/t the swelling of mucous membranes secondary to increased circulating estrogen; Client should feel fetus move at least 3Xs / hour

A nurse is teaching a client who is postpartum and breastfeeding. Which of the following statements should the nurse include? A. "You will need to wait 3 months before resuming sexual intercourse." B. "You don't need to use contraception until you are 4 months postpartum." C. As long as you breastfeed, you will experience an overproduction of vaginal lubrication." D. "A reduction in sexual interest could indicate postpartum depression."

D. "A reduction in sexualr interest could indicate postpartum depression." Rationale: Manifestations of postpartum depression include decreased libido, feelings of sadness or anxiety, difficulty sleeping, or loss of appetite. Incorrect answers: A. Sexual intercourse can be resumed once the bleeding has stopped, which occurs approximately 2-4 weeks postpartum. B. Clients who breastfeed can still ovulate and will need a reliable method of birth control if they want to prevent pregnancy. C. Lactation can cause vaginal dryness, and breastfeeding mothers often benefit from the use of a water-soluble gel during intercourse.

A nurse in a prenatal clinic is caring for a client who is within the recommended guideline for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse offer? A. "Your provider can discuss ab appropriate amount of weight gain with you." B. "A weight gain of about 14 lb. each trimester is suggested." C. "If you eat nutritious foods when you feel hungry, the amount of weight gain is insignificant." D. "A weight gain of about 25 to 35 lb. is good."

D. "A weight gain of about 25 to 35 lb. is good." Rationale: Weight gain of 25 to 35 lb. is associated with good fetal outcome (4 lb. 1st trimester & 12 lb. each 2nd & 3rd trimesters is recommended)

A nurse is caring for a client who is in labor. The client asks the nurse, "Why are you pressing on my abdomen?" Which of the following responses should the nurse make? A. "I can determine your baby's heart rate." B. "I can confirm that you have sufficient fluid around your baby." C. "I can confirm that your baby moves with stimulation." D. "I can determine the position of your baby."

D. "I can determine the position of your baby." Rationale: Palpating the abdomen can determine which fetal part is in the uterus fundus and where the back of the fetus is. Palpating the lower abdomen will help determine whether the fetus's head is down or if another extremity is the presenting part. Wrong Answer: FHR can't be palpated, Ultrasound is used to determine presence and amount of amniotic fluid, pressing on abdomen is unlikely to elicit fetal movement, top elicit movement try vibroacoustic stimulation & fetal scalp stimulation.

A nurse is explaining lactation suppression to a client whose newborn will be bottle-fed. Which of the following client statements indicates an understanding of the teaching? A. "I should lightly massage my breasts when I feel discomfort." B. "I should express a small amount of milk if my breasts feel tight." C. "I should take a warm shower twice a day." D. "I should wear a support bra for a few days."

D. "I should wear a support bra for a few days." Rationale: Patient should wear a support bra that fits securely continuously for first 3 days postpartum to help suppress lactation. Incorrect Answers: Avoid stimulation of the breasts which promotes lactation; expression of milk promotes lactation; warm water promotes lactation.

A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today." D. "I will avoid any of my family members who are ill."

D. "I will avoid any of my family members who are ill." Rationale: While the causative organisms of mastitis tend to be bacterial, exposure to viral illness can compromise the immune system and leave the client vulnerable to mastitis. Incorrect Answers: Adequate emptying of breasts reduces the risk. Flu-like symptoms could indicate maternal illness of early mastitis but client should continue to breastfeed in order to promote adequate breast emptying, Underwire nursing bras can prevent adequate breast emptying and can predispose the client to mastitis.

A nurse is teaching a client who is postpartum about keeping the newborn safe. Which of the following statements should the nurse identify as and indication that the client understands the instructions? A. "I will put bumper pads in the crib." B. "I will warm mu baby's formula in the microwave on a low setting." C. :I will place my baby on his stomach to sleep." D. "I will purchase a firm mattress for the crib."

D. "I will purchase a firm mattress for the crib." Rationale: A firm mattress that leaves no gaps between it and th crib rails helps prevent suffocation and entrapment.

A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements? A. "Prolactin is increasing the blood supply to your uterus, and you are feeling the blood vessel engorgement." B. "You probably have a small blood clot in your uterus, which is causing the uterus to contract in order to expel it." C. "Your breasts are secreting a hormone that enters the bloodstream and causes your abdominal muscles to contract." D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract."

D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract." Rationale: Oxytocin is released in response to breastfeeding. This hormone also causes the uterus to contract, which decreases the risk for postpartum hemorrhage and increases involution. Incorrect answers: Prolactin is responsible for milk production, not uterine contractions. Uterine contractions with breastfeeding do not indicate the the uterus is trying to expel clotted blood. Small clots are typically expressed in the lochia rubra. Breast tissue doesn't secrete hormones. the hormones that affect breast functions, such as milk production, are produced by the anterior pituitary gland and the posterior pituitary gland.

A nurse is teaching a client who is at 12 weeks gestation and has HIV. Which of the following statements should the nurse include in the teaching? A. "Breastfeed your newborn to provide passive immunity" B. "Abstain from sexual intercourse throughout pregnancy" C. "You will be in isolation after delivery" D. "You should continue to take zidovudine throughout the pregnancy"

D. "You should continue to take zidovudine throughout the pregnancy" Rationale: The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmitting HIV to her newborn. Incorrect answers: The client can transmit HIV through the breast milk and should bottle feed; Can continue tho have sexual intercourse during pregnancy as long as condom is used; will only require standard precautions after delivery.

While caring for a client who is in active labor, a nurse notes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Administer methyl-prostaglandin IM B. Encourage the client to use the shower C. Place the client in a supine position D. Apply oxygen at 10 L/min via nonrebreather face mask

D. Apply oxygen at 10 L/min via nonrebreather face mask rationale: Late decels are caused by uteroplacental insufficiency and require intervention to increase oxygen flow to the fetus. Administering O2 to the client will increase the amount of oxygen available to the fetus. Incorrect Answers: Methyl-prostaglandin is a uterotonic, will increase contractility of the uterus. Should never be administered to a pregnant client. Shower decreases discomfort for patient but doesn't increase oxygen to fetus. Supine position can decrease uteroplacental blood flow d/t compression of the vena cava. Client should be placed in lateral position to optimize cardiac output.

A nurse is providing teaching to the parents of a newborn about bottle-feeding. Which of the following instructions should the nurse include in the teaching? A. Dilute ready-to-feed formula it the newborn is gaining weight too quickly B. Prop the bottle with a blanket for the last feeding of the day C. Discard unused refrigerated formula after 72 hr. D. Boil water for powdered formula for 1-2 min.

D. Boil water for powdered formula for 1-2 min. Rationale: Run tap water for 2 minutes then boil for 1-2 min. before mixing it w/ formula to decrease risk of contamination Incorrect Answers: Don't dilute ready-to-feed formula b/c newborn will get full b/4 consuming the appropriate amount of calories or nutrients; always hold bottle when feeding to prevent aspiration; unused prepared formula is only good for 48 hrs.

A charge nurse is teaching newly licensed nurses about teratogens that affect fetal development. The nurses should recognize that which of the following is an example of a teratogen? A. Consuming caffeine during pregnancy B. A family history of a genetic disorder C. Gum disease in a pregnant client D. Drinking alcohol during pregnancy

D. Drinking alcohol during pregnancy Rationale: Alcohol is an outside substance, that is ingested during pregnancy, can cause abnormal fetal development. Alcohol consumption during pregnancy can cause CNS disorders, abnormal craniofacial features, and cognitive impairment

A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? A. Bacterial Vaginosis B. Trichomoniasis C. Candidiasis D. Gonorrhea

D. Gonorrhea Rationale: Gonorrhea is often asymptomatic. The client may have purulent endocervical discharge. Gonorrhea is one of the infectious conditions on the Nationally Notifiable Infections list and should be reported by the nurse to the community health department, which will report the infection to the CDC. Incorrect Answers: A. Bacterial vaginosis, also known as vaginitis, is the most common vaginal infection. Manifestations include client report of "fishy odor" and vaginal discharge that appears thin, watery, gray, white, or milky. The client may also report pruritus. This vaginal infection doesn't require reporting: however, it should be treated with metronidazole or clindamycin cream. B. Trichomoniasis can be asymptomatic. Manifestations include greenish to yellowish mucopurulent, frothy, malodorous discharge. This vaginal infection does not require reporting. C. Candidiasis, also known as a yeast infection, is the 2nd most common vaginal infection. Manifestations include a client report of thick, cottage cheese-like discharge and vaginal itching. This vaginal infection does not require reporting.

A nurse is assisting with monitoring the fetal heart rate tracings of a client who is in labor. Which of the following findings should the nurse report to the provider? A. Baseline fetal heart rate of 110 to 130 bpm B. Moderate baseline variability C. Accelerations in response to fetal stimulation D. Late decelerations with fetal bradycardia

D. Late decelerations with fetal bradycardia Rationale: Fetal monitoring showing recurrent late decelerations and bradycardia indicates that the fetus is not tolerating labor and may be compromised. these findings should be assessed in relation to the clinical picture of the progression of labor of labor. The nurse should notify the provider to update the plan of care for the client and her baby. Incorrect Answers: Fetal Heart Rate 110-160bpm WNL Moderate baseline variability WNL Accelerations of at least 15bpm WNL

A nurse is caring for a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder. B. Place the client in a knee-chest position. C. Plan to administer calcium gluconate D. Prepare the client for an emergency cesarean delivery.

D. Prepare the client for an emergency cesarean delivery. Rationale: A sudden onset of abdominal pain in a laboring client who previously delivered by cesarean section, accompanied by a prolonged fetal deceleration, is a manifestation of a uterine rupture, which requires an emergency cesarean delivery.

A nurse is caring for a preterm infant in the NICU. Which of the following actions by the nurse will promote the infant's optimal development? A. Avoiding swaddling B. Placing the infant in the supine position C. Providing physical care at short, frequent intervals D. Reducing ambient noise and lighting

D. Reducing ambient noise and lighting Rationale: Minimizing light and noise stimuli in the nursery is an important aspect of promoting optimal development. Lighting should be dimmed at night, and blankets should be place over the incubators during the daylight hours. Noise levels should always be kept to a minimum. Incorrect answers: Body containment w/i blankets promotes self-regulation and decreases stimuli, the flexed position promotes proper body alignment, which is necessary for optimal development; the preferred positions are prone and side-lying, these positions promote flexion of the arms and legs' which is essential for development care of pre-term infants; physical care should be clustered to allow longer intervals of sleep.

A nurse is planning care for a newborn who is receiving phototherapy. Which of the following interventions should the nurse include in the plan of care? A. Apply lotion to the skin during phototherapy B. Supplement feedings with oral glucose water C. Cover the nares with an opaque mask D. Turn and reposition the newborn q2hrs during phototherapy

D. Turn and reposition the newborn q2hrs during phototherapy Rationale: Turn & reposition q2-3hrs to allow maximum exposure of skin surfaces to phototherapy light. Incorrect Answers: Creams & lotions can absorb heat and cause burns; Hydrate w/breast milk or formula, glucose water and plain water do not promote the excretion of bilirubin in the stools which facilitates the resolution of jaundice; Applying opaque eye masks prevents damage to the newborn's retinas and corneas from the phototherapy light. Covering the nares is unnecessary and might interfere with respiration.