Maternity
A young couple are very excited to discover they are pregnant and ask the nurse when to expect the baby. Based on a July 20 LMP, which day will the nurse predict for delivery? Select one: a. April 27 b. March 13 c. April 13 d. May 20
a. April 27 Naegele rule is to subtract 3 months and add 7 days from the first day of the last menstrual period to determine an expected due date, making the client's due date April 27.
An infant born via a cesarean delivery appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant? Select one: a. Tachypnea b. Cardiac murmur c. Hypoglycemia d. Hyperthermia
a. Tachypnea The infant born from a cesarean birth has not had the opportunity to exit the birth canal and experience the squeezing of fluid from the lungs. The lungs have more amniotic fluid than the lungs of a baby from a vaginal birth and are at greater risk for respiratory complications, such as tachypnea. An infant born by cesarean birth is not at increased risk for hyperthermia, hypoglycemia, or a cardiac murmur.
The nurse is assessing a client at her first prenatal visit and notes that she is exposed to various chemicals at her place of employment. Which statement by the client would indicate she needs additional health education to protect her and her fetus? Select one: a. "I only work four hours a day so I don't exposed to much." b. "The gloves they provide irritate my hands, so I don't use them." c. "There hasn't been a chemical spill in three years." d. "I have an assistant helping me now to handle the chemicals."
b. "The gloves they provide irritate my hands, so I don't use them." There are various chemicals which are recognized for their teratogenic effects and must be avoided during pregnancy. The nurse should find out which chemicals the client is exposed to and determine the risk factor. The greatest danger is the client handling chemicals without a barrier protection such as gloves. The other issues may also be dangers depending on the chemicals and the environment in which the client is working and should also be evaluated.
The newborn weighing 6 lb 6 oz (2856 g), now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss? Select one: a. "We need to do a more in-depth assessment." b. "This is a normal response." c. "How often are you feeding your baby?" d. "You may need to supplement breast-feedings for a while."
b. "This is a normal response." The infant has a 5% to 10% loss of birth weight during the first few days of life as the body loses excess fluid and has limited food intake. This physiologic weight loss amounts to a total loss of 6 to 10 oz. There would be no need to assess for other problems. It is also not related to feeding, nor would a breast-feeding mother need to offer supplementary formula feedings. These responses would be inappropriate.
The mother calls the nurse to check her baby after noting the right side of the body is dark red while the left side of the baby is pale. Which question to the mother should the nurse prioritize when assessing the situation? Select one: a. "How long has it been since you last breast-fed?" b. "Was the baby recently crying?" c. "Was the baby sleeping on their back?" d. "Did you hold the baby while they were sleeping?"
b. "Was the baby recently crying?" This is termed Harlequin sign and is related to dilatation of blood vessels often following vigorous crying. This can also happen if the baby is sleeping on its side instead of its back. The condition will resolve without intervention. This is not caused by breast-feeding or holding the baby while the infant is sleeping.
A client at 19 weeks' gestation reports continued alcohol use 1 to 2 times each week to the nurse at her prenatal visit. Which suggestion should the nurse prioritize for this client? Select one: a. She should avoid alcohol in the first trimester. b. Alcohol should not be consumed during pregnancy. c. The effects of alcohol on the fetus are not fully understood. d. She may have an occasional drink after the first trimester.
b. Alcohol should not be consumed during pregnancy. There is no safe amount of alcohol to consume during pregnancy. If the client refuses or has a problem, alert the health care provider for the appropriate referral.
The nurse discovers a new prescription for RhoGAM for a client who is about to undergo a diagnostic procedure. The nurse will administer the RhoGAM after which procedure? Select one: a. Contraction stress test b. Amniocentesis c. Nonstress test d. Biophysical profile
b. Amniocentesis Amniocentesis is an invasive procedure whereby a needle is inserted into amniotic sac to obtain a small amount of fluid. This places the pregnancy at risk for a woman with Rh(D)-negative blood, since the puncture can allow the seepage of blood and amniotic fluid into the woman's system. She should receive RhoGAM after the procedure to protect her and future babies. The CST, NST, and a biophysical profile are noninvasive tests.
The nurse is assessing a client at 12 weeks' gestation who reports enjoying her usual slow, long daily walk. The nurse should point out which recommendation to this client? Select one: a. Reduce walking to half a block daily. b. Continue this as long as she enjoys it. c. Stop and rest every block. d. Engage in aerobics for greater benefits.
b. Continue this as long as she enjoys it. Walking is an excellent exercise during pregnancy because it is low impact and increases venous circulation. Exercise should be maintained as long as it is comfortable, but intensity should not increase over what is normally performed.
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? Select one: a. Conduction b. Convection c. Radiation d. Evaporation
b. Convection There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. The cold air blowing on the infant's skin will cause heat loss.
The nurse is meeting with a client at 28 weeks' gestation. To prepare her for the final trimester, which factor should the nurse prioritize in the teaching session? Select one: a. Preventing anemia b. Decreasing shortness of breath c. Decreasing bleeding gums d. Preventing varicosities
b. Decreasing shortness of breath As the fetus grows inside the mother, there is more pressure on the diaphragm and more difficulty breathing, and episodes of dyspnea may occur. This tends to decrease with lightening, when the fetus drops. Preventing anemia, decreasing bleeding gums, and preventing varicosities are situations which should be addressed throughout the entire pregnancy.
The nurse is monitoring an infant who was born at 0515 hrs. At 1315 hrs, the same day, the nurse determines the infant is starting to show yellowish staining on the head and face. Which action should the LPN prioritize? Select one: a. Start phototherapy. b. Document and report to RN. c. Continue monitoring, report if spreads. d. Repeat bilirubin levels.
b. Document and report to RN. Jaundice which appears in the first 24 hours may be a sign of excessive bilirubin in the blood and is now seeping into the tissues. This needs to be further evaluated and should be reported to the RN immediately so further assessments, including lab work, can be ordered. Jaundice in the first 24 hours is considered pathologic and needs to be evaluated immediately. Physiologic jaundice usually occurs on the second or third day after birth and is considered a normal event as the bilirubin levels rise. It should clear up with the use of phototherapy.
A 25-year-old client at 27 weeks' gestation reports waking up with leg cramps. Which suggestion should the nurse point out to the client to help relieve this discomfort? Select one: a. Use plantar flexion exercises three times every day. b. Dorsiflex the foot while extending her leg during the cramp. c. Encourage her to drink more fluids, 10 glasses a day. d. Avoid any supplementation of vitamins or minerals.
b. Dorsiflex the foot while extending her leg during the cramp. Plantar flexion can make cramps worse, so dorsiflexion while extending the leg can relieve the cramp; excess fluid and lack of supplementation with vitamins or minerals may worsen cramps. Performing plantar flexion exercise does not prevent the cramp. Increasing fluids may help, but has never proven to eliminate cramping.
The nurse is teaching a pregnant client some nonpharmacologic ways to handle common situations encountered during pregnancy. The nurse determines the session is successful when the client correctly chooses which condition that can be minimized if she avoids drinking fluids with her meals? Select one: a. Nosebleeds b. Heartburn c. Blood clots d. Constipation
b. Heartburn Filling the stomach with heavy food and fluid can cause overfill and place pressure on the stomach, increasing gastric reflux. Avoid excess fluids with meals and eat small frequent meals to avoid heartburn. Nosebleeds result from increased estrogen. Blood clots can result from sitting still for too long. Constipation can result from increased progesterone.
The nurse is conducting an assessment on a newborn male and the parents' question why the nurse is using a penlight to examine the scrotal sac. The nurse should point out this helps to eliminate which potential disorder? Select one: a. Cryptorchidism b. Hydrocele c. Epispadias d. Phimosis
b. Hydrocele Hydrocele occurs when there is a buildup of fluid in the scrotal sac and should be noted on assessment. If there is fluid in the scrotal sac, it will be translucent when the penlight is placed against it. If there isn't fluid, the sac will remain dark. Cryptorchidism results when the testes do not descend into the scrotal sac during fetal life. These are checked by putting slight pressure on the scrotal sac to feel the testes. The urinary meatus should be positioned at the tip of the penis. If the opening is located abnormally on the dorsal (upper) surface of the glans penis, the condition is called epispadias. Phimosis, or tightly adherent foreskin, is a normal condition in the term newborn.
The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which suggestion should the nurse prioritize for this client? Select one: a. Taking mineral oil b. Increasing fluid intake c. Reducing iron supplement d. Increasing intake of meat
b. Increasing fluid intake Increasing fluid content by drinking at least 8 glasses of noncaffeinated beverages helps relieve constipation in both pregnant and nonpregnant women. Reducing an iron supplement could lead to anemia; mineral oil can reduce absorption of fat-soluble vitamins. The client should add foods rich in fiber which would include grains, vegetables, and fruits (instead of meat) to the diet.
The nursing instructor is teaching a class on the physiologic properities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function? Select one: a. It expands the lungs with breaths. b. It keeps alveoli from collapsing with breaths. c. It removes fluid from the lungs. d. It allows oxygen to move in the lungs.
b. It keeps alveoli from collapsing with breaths. The role of surfactant is to act on surface tension and assist in keeping the alveoli open in the lungs so the lungs do not collapse with the respiratory effort of the newborn. Surfactant does not expand the lungs, remove fluid from the lungs, or allow oxygen to move in the lungs.
A client who is uncertain when her LMP occurred is given an EDD of April 23 after the first ultrasound. Based on this information, the nurse determines the client's LMP was probably which day? Select one: a. July 13 b. July 16 c. July 19 d. July 21
b. July 16 According to Naegele rule, the last menstrual period was July 16th. Take the LMP and add 7 days and subtract 3 months; if finding the LMP from the EDD, subtract 7 days and add 3 months.
The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response? Select one: a. Fencing b. Moro c. Tonic neck d. Rooting
b. Moro The Moro reflex is also known as the startle reflex. When the infant is startled, they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.
A pregnant client reports difficulty sleeping well. Which suggestion for sleeping should the nurse prioritize to assist this client? Select one: a. On her stomach with a pillow under her breasts b. On her side with the weight of the uterus on the bed c. On her back with a pillow under her knees and hips d. On her back with a pillow under her head
b. On her side with the weight of the uterus on the bed Resting on the side prevents pressure from the uterus against the vena cava and therefore allows blood to return to the uterus. Other positions may be more uncomfortable or may exacerbate the problems associated with pressure on the vena cava.
The nurse notes a newborn has a temperature of 97.4oF (36.3oC) on assessment. The nurse takes action to prevent which complication first? Select one: a. Seizure b. Respiratory distress c. Cardiovascular distress d. Hypoglycemia
b. Respiratory distress It takes oxygen to produce heat and an infant who has an episode of cold stress is at risk for respiratory distress. The infant needs to be warmed. The temperature should be in the range of 97.7°F to 98.6°F (36.5°C to 37°C). After respiratory distress sets in, it can be followed by seizures, cardiovascular distress or hypoglycemia.
The nurse is assisting a pregnant client who has just underwent a nonstress test that was ruled reactive. Which factor will the nurse point out when questioned by the client about the results? Select one: a. There is no evidence of congenital anomalies or deformities. b. The fetal heart rate increases with activity and indicates fetal well-being. c. The fetus is developing at a fast rate but doing fine. d. The results indicate a stress test is needed for further evaluation.
b. The fetal heart rate increases with activity and indicates fetal well-being. A nonstress test is a noninvasive way to monitor fetal well-being. A reactive NST is a positive sign the fetus is tolerating pregnancy well by demonstrating heart rate increase with activity and indicates fetal well-being. This test is not used to determine congenital anomalies or deformities. It does not determine the speed that the fetus is developing. Further evaluation would be necessary if the results were nonreactive.
A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse? Select one: a. "The baby may have a problem; let's schedule an appointment." b. "This can be related to cleaning her perineal area; be more careful." c. "This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." d. "If this continues, call us back; for now, just watch her."
c. "This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." The mother is describing pseudomenstruation and is usually the result of the infant no longer having the mother's hormones in the body. This is not a cause for alarm. It is always appropriate to offer to schedule an appointment if the mother continues to be upset. The nurse should know that the infant's "bleeding" is not indicative of a pathologic process and should be careful to not upset the mother further. The statement of it being related to the way the mother is cleaning the perineum is incorrect for it places the blame on the mother for the infant's problem. The instruction to call back if it continues does not meet the mother's need to know why this is happening to her baby, and it negates her concern for her infant.
A young mother is concerned for her baby and asks the nurse if her baby is okay. What is the best response if the nurse notes: RR 66, nostrils flaring, and grunting sounds during respiration? Select one: a. "Your baby is fine, just learning how to breathe." b. "Let's put a blanket around the baby; the baby is cold." c. "Your baby is having a little trouble breathing. I'll let the RN know." d. "Your baby is too warm. Let's take the blanket off."
c. "Your baby is having a little trouble breathing. I'll let the RN know." The assessment findings discussed are signs of respiratory distress. An infant with a respiratory rate of greater than 60 with noise requires further assessment. This does not indicate the infant is either too cold or too warm, so using or not using a blanket would not be a factor in this scenario.
The LPN is preparing to assist the RN with the initial admissions assessment of the newborn. The nurse should explain to the new mother that this will be completed in what time frame after birth? Select one: a. 30 minutes b. 1 hour c. 2 hours d. 4 hours
c. 2 hours The infant and mother need time for bonding after delivery. While the nurse is monitoring and may take vital signs, the initial full exam must be completed within 2 hours of birth. The options of 30 minutes or 1 hour are options which would be based on the individual situation. Waiting for 4 hours is too long and may result in danger signs of potential complications being missed.
The nurse notes the following on a newborn's assessment: poor muscle tone, jitteriness, and temperature 97.0oF (36.1oC), HR 120 bpm, RR 26 breathes per minute, and blood pressure 60/40 mm Hg. Which nursing action should the nurse prioritize? Select one: a. Check the infant's temperature again. b. Complete an entire set of vital signs. c. Assess the infant's blood sugar. d. Check oxygen saturation of the blood.
c. Assess the infant's blood sugar. The poor muscle tone, low temperature, and jitteriness are signs and symptoms indicative of hypoglycemia. The nurse should assess the blood glucose first. Assessing the vital signs and oxygen saturation would be assessed again at the appropriate time. The main concern at the moment is assessing for hypoglycemia to prevent further complications.
The parents are concerned their newborn appears to be cold all the time. The nurse should point out the infant is best helped by which primary method in the first few days? Select one: a. External with blankets by the nursing staff b. Skin to skin contact with mother c. Brown fat store usage d. Shivering and increased metabolic rate
c. Brown fat store usage Brown fat stores are used by the newborn infant to maintain warmth until feeding begins and the infant is able to maintain temperature without assistance. The infant's thermoregulatory system is not fully functional at birth. Infants cannot shiver to warm themselves. The use of external blankets as well as skin to skin contact with the mother assists in keeping the baby's temperature within the normal range, but they are not the primary mechanism for temperature regulation in the newborn infant.
A pregnant client arrives for her first prenatal appointment. She reports her previous pregnancy ended at 19 weeks, and she has 3-year-old twins born at 30 weeks' gestation. How will the nurse document this in her records? Select one: a. G2 T2 P1 A0 L2 b. G2 T1 P1 A1 L1 c. G3 T0 P2 A1 L2 d. G3 T2 P2 A0 L1
c. G3 T0 P2 A1 L2 G indicates the total number of pregnancies (2 prior, now pregnant = 3); T indicates term deliveries at or beyond 38 weeks' gestation (none = 0); P is for preterm deliveries (at 20 to 37 weeks = 2); A is for abortions or pregnancies ending before 20 week's gestation (1); and L refers to living children which is 2. Thus, G3 T0 P2 A1 L2 is what the nurse should note in the client's record.
Which result should the nurse prioritize for further action? Select one: a. Infant A - 52 mg/dL b. Infant B - 56 mg/dL c. Infant C - 48 mg/dL d. Infant D - 60 mg/dL
c. Infant C - 48 mg/dL Blood glucose levels between 50 and 60 mg/dL during the 24 hours of life are considered normal. Levels less than 50 are indicative of hypoglycemia in the newborn. Infant C is showing potential hypoglycemia. Infants A, B, and D have values within the normal range.
The nurse is responding to an infant crying and notes it is very high pitched and shrill. The nurse predicts this is most likely related to which situation? Select one: a. Normal cry from pain b. Tired and stress from delivery c. Neurologic dysfunction d. Cold stress cry
c. Neurologic dysfunction A high-pitched cry which is shrill is associated with a neurologic disorder. The nurse will need to inform the RN and provider to assess the infant further. A high-pitched, shrill cry in a newborn is not a normal cry from pain; it does not indicate the infant is tired and stressed from delivery, and it is not a cry indicating cold stress.
The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? Select one: a. Oxygen is exchanged in the lungs. b. Fluid is removed from the alveoli and replaced with air. c. Pressure changes occur and result in closure of the ductus arteriosus. d. The oxygen in the blood decreases.
c. Pressure changes occur and result in closure of the ductus arteriosus. The ductus arteriosus is one of the openings through which there was fetal circulation. At birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. The exchange of oxygen in the lungs and increasing oxygen content in the blood are respiratory functions. The removal of the fluid from the alveoli occurs mainly during the birthing process and is completed by the lungs after birth.
The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex? Select one: a. Moro b. Tonic neck c. Rooting d. Sucking
c. Rooting This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle) reflex are total body reflexes and assess neurologic function in the newborn.
A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile? Select one: a. Travel no more than 120 miles daily. b. Sit in the back seat with feet elevated. c. Stop and walk every two hours. d. Limit trips away from home, greater than 200 miles.
c. Stop and walk every two hours. Walking increases venous return and reduces the possibility of thrombophlebitis, a risk for pregnant women who sit for extended periods of time. Limiting mileage, sitting in the back with the feet elevated, and limiting trips may help, but they are not enough to prevent phlebitis.
The health care provider has prescribed an over-the-counter antacid for a pregnant client in her first trimester who is having ongoing nausea, vomiting, and heartburn. Which instruction concerning the antacid should the nurse prioritize after noting the client is also prescribed a multivitamin supplement? Select one: a. Avoid caffeinated beverages. b. Take only at bedtime. c. Take antacid 1 hour after the multivitamin. d. Take with dairy products.
c. Take antacid 1 hour after the multivitamin. Antacids interfere with the uptake of the vitamin contents so the client should take the antacid 1 hour after taking the multivitamin. Caffeine should be avoided due to increases in blood pressure and diuretic effects. Antacids can be taken more often than solely at bedtime and some clients need them after each meal. Antacids do not have to be taken with dairy products. The priority is to avoid allowing the antacid to cancel out the multivitamin
The nurse is assessing a 24-year-old pregnant client who reports excessive vaginal discharge that is messy and unpleasant but without a strong odor, itching, or irritation present. Which response should the nurse prioritize? Select one: a. Douche frequently with mild soap and water. b. See her primary care provider. c. Use sanitary pads. d. Decrease her fluid intake.
c. Use sanitary pads. Vaginal discharge increases during pregnancy and is a concern for many women. Encourage the client to keep clean and wear sanitary pads as needed. Douching may be dangerous for the mother. STIs are not indicated simply by discharge. Pregnant women should not decrease fluid intake.
The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance? Select one: a. Lanugo b. Milia c. Vernix d. Amniotic fluid
c. Vernix Vernix is the coating on the infant that was covering fetal skin to prevent the skin from the drying effects of amniotic fluid. Lanugo is fine, downy hair that is present in abundance on the preterm infant but is found in thinning patches on the shoulders, arms, and back of the term newborn. Milia are frequently found on the infant's face. These tiny white papules resemble pimples in appearance. Normal amniotic fluid is not thick and white; it should be clear and give the baby a wet appearance.
The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature? Select one: a. Bathe the infant immediately after birth. b. Place the infant on the mother's abdomen after birth. c. Wrap the infant in a warm, dry blanket. d. Turn the temperature up in the birth room.
c. Wrap the infant in a warm, dry blanket. Evaporation is one of the four ways a newborn can lose heat. As moisture evaporates from the body surface of the infant, the newborn loses heat. Wrapping the infant in a warm, dry blanket will allow the moisture to be absorbed, limiting heat loss from evaporation. Bathing the infant will only add to the evaporative heat loss. The newborn's skin is wet, so placing him on the mother' abdomen will not prevent evaporation and heat loss. Increasing the ambient temperature in the birth room does not address the evaporation problem.
The nurse receives a report from labor and delivery on an infant and mother couplet. Which reported Apgar score will the nurse prioritize for close observation for the entire transition period? Select one: a. 8 at 1 minute; 9 at 5 minutes b. 7 at 1minute; 8 at 5 minutes c. 6 at 1 minute; 7 at 5 minutes d. 5 at 1 minute; 6 at 5 minutes
d. 5 at 1 minute; 6 at 5 minutes APGAR scores between 4 and 6 at 5 minutes of life indicate a newborn is having difficulty in adjusting to life outside the womb and needs close observation. The infant would transition in the nursery under close observation. The other choices would indicate that the newborn is transitioning with minimal difficulty and will not need close monitoring for the entire transition period.
The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 97.7oF (36.5oC), and blood pressure 78/40 mm Hg. Which action should the nurse prioritize? Select one: a. Report tachypnea. b. Recheck blood pressure in 15 minutes. c. Put warming blanket over infant. d. Document normal findings.
d. Document normal findings. These vital signs are within normal limits and should be documented. The heart rate should be 110 to 160 bpm; RR should be 30 to 60 breaths per minute. The axillary temperature can range from 97.7°F to 98.6°F (36.5°C to 37°C). Blood pressure should be 60 to 80/40 to 45 mm Hg. There is no need to contact the health care provider, recheck the blood pressure in 15 minutes, or place a blanket on the infant.
A client at 27 weeks' gestation still walks daily but reports 'terrible' heartburn at night. Which action should the nurse point out will best address this situation? Select one: a. Stop or severely curtail her exercise. b. Take sodium bicarbonate. c. Seek emergency medical care. d. Elevate the head of the bed.
d. Elevate the head of the bed. Heartburn is a common problem worsening as the pregnancy progresses. The pregnancy hormones relax the lower esophageal sphincter, resulting in increased heartburn. Elevation of the head of the bed will help prevent the acid from refluxing. Exercise does not negatively impact heartburn and should be continued. The pregnant mother should not take any medication that is not prescribed by her primary care provider. Heartburn is not a medical emergency.
The nurse is assisting new parents adjust to the birth of their first child. The parents appear hesitant to pick up the baby, stating they are afraid they will make the baby cry. What is the best response if the nurse discovers the infant is lying relatively still with eyes wide open, looking at the parents? Select one: a. Suggest they rock the baby to sleep b. Encourage the mother to breastfeed c. Commend the parents for making the right choice d. Encourage the parents to pick up the baby
d. Encourage the parents to pick up the baby Dr. T. Berry Brazelton's Neonatal Behavioral Scale is often used to note the state of reactivity in newborns. This infant is in the quiet alert state with the eyes open and attentive to people. There is movement, but limited. This is a good time for the parents to interact with the infant, such as picking up the infant, touching, talking, and bonding with the infant. Other states of reactivity include: Active alert: eyes are open and active body movements are present, newborn responds to stimuli with activity; Deep sleep: quiet, nonrestless sleep state, newborn is hard to awaken; Light sleep: eyes are closed but more activity is noted, newborn moves actively and may show sucking behavior; Drowsy: eyes open and close and the eyelids look heavy, body activity is present with intermittent periods of fussiness; and Crying: eyes may be tightly closed, thrashing movements are made in conjunction with active crying. This would not be the time for the parents to avoid interacting with the infant. There is also no indication the infant is hungry or tired, so feeding or trying to get the infant to go to sleep would also be inappropriate at this time.
A new mother is learning how to change the diaper on her newborn and becomes concerned after observing a rash on the trunk of the infant. Which response should the nurse prioritize? Select one: a. Immediately call the RN or health care provider. b. Change and bathe the infant. c. Check all of the baby's vital signs before calling the doctor. d. Explain this is normal.
d. Explain this is normal. Erythema toxicum is otherwise known as normal newborn rash. The rash will resolve without intervention. There is no need to call the RN or health care provider, change and bathe the infant, or check the vital signs.
A pregnant vegan reports eating lots of dark green leafy vegetables, legumes, citrus fruits, and berries. To ensure that her infant's nervous system will develop properly, what foods should the nurse recommend that she add to her diet? Select one: a. Milk and cheese b. Carrots, sweet potatoes, and mangoes c. Nuts, seeds, and chocolate d. Fortified cereals
d. Fortified cereals The best source to recommend are the fortified cereals to meet the amino acid needs necessary for the development of her infant's nervous system during pregnancy. She should be encouraged to include fortified cereals to meet these needs. The carrots, sweet potatoes, mangoes, nuts, and seeds will add other nutrients to her diet. A vegan will not eat milk and cheese, as they are animal products.
The nurse has just received the results of a pregnant client's MSAFP screening and notes the levels are elevated. The nurse should prioritize which discussion with the client? Select one: a. Risk for Down syndrome b. Risk for neural tube defects c. Test needs to be repeated d. Further testing is required
d. Further testing is required The maternal serum alpha-fetoprotein (MSAFP) measures the levels of alpha-fetoprotein, which is a protein manufactured by the fetus. The woman's blood contains small amounts of this protein during pregnancy. The blood test is run between 16 and 20 weeks' gestation; an abnormal level indicates a need for further testing to determine the risks her fetus may face. Higher levels can indicate multiple fetuses, death of the fetus, the presence of neural tube defects, and possibly Down syndrome; however, further testing such as ultrasound or amniocentesis is required to determine the exact cause of the elevation.
The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse? Select one: a. Spinal column movement b. Shoulder movement c. Clavicles for dislocation d. Hip for dislocation
d. Hip for dislocation Ortolani maneuver is used to assess the possibility of a dislocated hip in an infant. Ortolani maneuver does not assess for spinal column movement, shoulder movement, nor does it assess the clavicles for dislocation. There is no specific movement to assess for spinal column movement, shoulder movement, or clavicle dislocation.
A 31-year-old client at 28 weeks' gestation reports frequent low back pain and ankle edema by the end of the day. Which suggestion should the nurse prioritize for this client? Select one: a. Soak feet every night and perform pelvic rocks. b. Lie on right side with feet elevated and a heating pad on the back. c. Sit semi-Fowler's with feet below for breaks at work. d. Rest when possible with feet elevated at or above the heart.
d. Rest when possible with feet elevated at or above the heart. Resting in the recumbent position helps alleviate stress on the back, and elevating the legs will help relieve the edema. Soaking the feet or lying on the right side will not alleviate the edema. Sitting semi-Fowler's is not enough to alleviate the edema.