Maternity Ch 20 & 21
Normal HR
110 - 160
Normal Respirations
30 - 60
Normal Infant Blood Pressure
60/40 mmHg
A nurse is caring for a newborn who is determined to be small-for-gestational age with intrauterine growth restriction. Which finding would lead the nurse to also question if this infant has asymmetric growth restriction? A. The head is large in comparison with the body. B. The head and body parts are in proportion. C. The length falls below the 10th percentile. D. The length is above the 10th percentile.
A
A nursing instructor is preparing a discussion which will illustrate the different forms of spina bifida. The instructor determines the session is successful after the students correctly choose which form as being spina bifida with myelomeningocele? A. The spinal cord, meninges, and nerve roots protrude out the lower back. B. There's a cystic sac containing the spinal meninges protruding out the back. C. There is only soft-tissue inflammation without protrusion. D. There is a bony defect that occurs without soft-tissue involvement
A
During a clinical conference, a group of nursing students are discussing a newborn that is large-for-gestational-age. The instructor determines the students have successfully differentiated the potential cause after choosing which contributing maternal factor? A. being 30 pounds overweight before getting pregnant B. mother is 5 feet 3 inches (1.6 m) tall and the father is 5 feet 10 inches (1.78 m) tall C. a blood glucose of 100 several times during the pregnancy D. being a 19-year-old G2P2
A
The nurse is assessing a toddler at a well-child visit and notes the following: small in stature, appears mildly developmentally delayed; short eyelid folds; and the nose is flat. Which advice should the nurse prioritize to the mother in response to her questions about having another baby? A. "It's a good idea to stop drinking alcohol 3 months before trying to get pregnant." B. "It's important to add iron and vitamin B supplements to your diet." C. "It would be good to stop smoking before getting pregnant." D. "It's important to keep insulin levels controlled during pregnancy."
A
The nurse is caring for a newborn diagnosed with a diaphragmatic hernia. The nurse will prepare to teach the parents concerning which potential treatment modality? A. immediate surgery to correct B. will likely not need surgery C. will likely have surgery by age 1 D. will require several surgeries during the first 2 years of life
A
The nurse is examining the morning laboratory results of the newborns of mothers with diabetes. Which report finding should the nurse prioritize? A. hypocalcemia B. hypermagnesemia C. hypobilirubinemia D. hyperkalemia
A
The nurse is working with a group of parents of children who have congenital heart disorders. Which statement made by the parents should the nurse prioritize for further assessment? A. "She gets so tired when she is eating." B. "They say he has a heart murmur but it may go away." C. "His chest measurement is the same as his head." D. "When I move her legs up toward her chest I hear a click."
A
The parents of an infant diagnosed with phenylketonuria are not sure they agree with the diagnosis and proposed treatment. The nurse should point out that this condition can result in which additional condition if left untreated? A. intellectual disability B. congenital heart defects C. increased intracranial pressure D. strangulated intestine
A
The nurse is preparing a nursing care plan for a preterm infant in the newborn nursery. Which nursing diagnoses could the nurse determine to be appropriate for this infant? Select all that apply. A, B, E A. Ineffective breathing pattern B. Ineffective thermoregulation C. Risk for fluid volume excess D. Risk for imbalanced nutrition: more than body requirements E. Risk for impaired skin integrity
A, B, E
The nurse has completed an assessment on a newborn and documents a score of 17 for the physical maturity in the records. Which elements has the nurse prioritized for this assessment? Select all that apply. A, C, E, F A. skin B. posture C. breast buds D. square window E. plantar creases F. lanugo
A, C, E, F
Normal Glucose
Above 50
A caregiver brings a 13-year-old male for a pre-high school checkup and reports he has spent lots of time in the principal's office or serving detention during junior high, and questions if he is too immature to be in high school. The nurse's assessment reveals evident breasts, little underarm or chest hair, and a high pitched voice. Which condition should the nurse suspect and discuss with the primary care provider? A. Turner syndrome B. Klinefelter syndrome C. ambiguous genitalia D. hypothyroidism
B
A nursing instructor is leading a group discussion on congenital hydrocephalus. The instructor determines the session is successful after the students correctly choose which factor that determines the noncommunicating type? A. Decreased production of cerebrospinal fluid B. Obstruction that keeps CSF from passing between the ventricles and the spinal cord C. Opening between the ventricles and the spinal cord that usually closes at birth D. Defective absorption of cerebrospinal fluid
B
The community health nurse is preparing a presentation which will illustrate the various forms of spina bifida for a health fair. Which explanation should the nurse use to explain spina bifida with meningocele? A. There is protrusion of the spinal cord and meninges, with nerve roots embedded. B. The spinal meninges protrude through the bony defect and form a cystic sac. C. There is no protrusion of the spinal cord, only soft-tissue inflammation occurs. D. There is a bony defect that occurs without soft-tissue involvement
B
The nurse cares for preterm infants and assesses them for potential complications to provide adequate countermeasures to prevent father complications. Which complication should the nurse prioritize and initiate proper measures to protect the newborn? A. decreased muscle tone B. loss of body heat C. excess antibodies acquired from the mother D. increased caloric intake
B
The nurse caring for a newborn notes a distended abdomen approximately 24 hours after birth. Which action should the nurse take after review of the medical record reveals an apparent healthy newborn at birth but no documentation of a bowel movement? A. Attempt to take a rectal temperature. B. Inform the health care provider immediately. C. Schedule radiography to diagnose the problem. D. Inform the parents that the newborn might need surgery.
B
The nurse is accepting a new mother and her term infant into the unit after delivery and notes the newborn is documented as low-birth-weight. How much does the nurse expect the newborn to weigh? A. 1450 grams B. 2000 grams C. 2550 grams D. 2950 grams
B
The nurse is assessing a 4-year-old male born with a heart condition who is brought in for a routine well-child visit by his parents. The parents report he is very curious, active, and very social; however, they often see him take breaks in his playby squatting for a few minutes or sitting on the sidelines at which time they insist he take a nap. Assessment reveals a child small for his age, mildly cyanotic, and tires easily. What is the best response to the parents when they ask the nurse for suggestions on how to encourage their son to take the naps they insist on but he doesn't want to take? A. "It's important to limit Stevie's physical exertion, so it is good to bring him inside when you think he needs to rest." B. "Children are often aware of their limitations, and because he has shown that he knows when he needs to take a break he should be encouraged to control his own activity level."
B
The nurse is assessing a group of infants and notes one of the infants has chronic constipation and an enlarged abdomen. The nurse would determine this infant is showing indications of which condition? A. galactosemia B. congenital hypothyroidism C. phenylketonuria D. Turner syndrome
B
The nurse is assessing a newborn and suspects developmental dysplasia of the hip (DDH). For which sign is the nurse prioritizing in this potential diagnosis? A. Symmetry of the gluteal skin folds B. Limited abduction of the affected hip C. Lengthening of the femur D. Bilateral adduction of the legs
B
The nurse is assessing the newborn male of a teen mother who was afraid to seek appropriate prenatal care. Which assessment finding should lead the nurse to question if this infant is preterm? A. smooth skin B. lanugo on the back and shoulders C. descended testicles D. subcutaneous fat on the extremities
B
The nurse is caring for a new infant and notes on assessment the newborn is small for gestational age and also has indications of intrauterine growth restriction. Which assessments should the nurse prioritize about the mother as a potential cause for the infant's condition? A. previous smoking history B. blood glucose levels C. number of normal pregnancies D. use of food stamp program during pregnancy
B
The nurse is monitoring a newborn who exhibited a large head at birth and is exhibiting an increasing head growth on continued assessment. Which additional findings on assessment should lead the nurse to suspect hydrocephalus in this infant? A. The scalp is dull and becoming dark red. B. Eyes appear to be pushed downward. C. Hands short with curved fingers. D. Neck area is thickened and strong.
B
The nurse is preparing a nursing care plan for an infant who was born with spina bifida with myelomeningocele. Which nursing goal should the nurse prioritize for this child? A. Reducing family anxiety B. Preventing infection C. Providing caregiver teaching D. Promoting comfort measures
B
The nurse is providing care for a child following a cardiac catheterization. Which nursing action should the nurse prioritize during the first 12 hours after the procedure? A. keeping the head of the bed elevated 45 degrees B. observing the site and extremity C. changing the dressing at least every 3 hours D. monitor vital signs every 4 hours
B
The nurse is teaching the caregivers of an infant diagnosed with hypospadias how to properly care for the infant. The nurse determines the session is successful when the caregivers make which statement? A. "At least he won't have to have surgery until he is almost ready to start school." B. "Being able to most likely correct this in one stage rather than several is reassuring." C. "It is upsetting to me that he is in pain when he urinates." D. "We hadn't decided about circumcision, but he will have to be circumcised before they do the surgery."
B
The nurse is weighing and measuring a term newborn. Which assessment findings would indicate that this newborn is suffering from asymmetrical growth restriction? A. looks wasted and has poor skin turgor B. is pale with loose, dry skin C. has cracked and leathery skin D. has very thin skin and has multiple visible veins
B
The nurse is working with an adult female who has PKU and desires to become pregnant. The nurse notes on her assessment her current serum phenylalanine level is 10 mg/dl. Which instruction should the nurse prioritize for this client? A. "Think carefully about the decision. The child might be intellectually disabled since your PKU is inherited, especially if your levels stay high. B. "It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg." C. "It will be best if you cut back on vegetables and fruit before you become pregnant to get your serum phenylalanine level down under 8 mg." D. "The baby won't be able to breastfeed. You know breastfeeding is really the best way to care for a newborn."
B
The nursing instructor is conducting a discussion centered on the various methods used to describe an infant. The instructor determines the session is successful when the students correctly choose which as an indication of gestational age? A. the weight, height, and length of the newborn at birth B. the length of time between fertilization of the egg and birth C. the age of the newborn who is born before 40 weeks D. the newborn according to their birth assessment
B
The nurse is assessing a newborn to establish a gestational age. Which factors will the nurse prioritize when assessing the newborn's neuromuscular maturity? Select all that apply. B, C, D, F A. skin B. posture C. arm recoil D. heel to ear E. plantar creases F. scarf sign
B, C, D, F
The nurse is caring for a newborn who is receiving phototherapy for hemolytic disease. As the nurse explains the procedure to the mother, which instruction should the nurse prioritize? A. Leave the light off for 1 hour six times a day. B. Dress the newborn in a lightweight gown at night. C. Turn the newborn every 3 to 4 hours. D. Remove and change the eye patches every hour.
C
The nurse is caring for an infant in a hip spica cast. Which nursing intervention would the nurse prioritize to promote skin integrity? A. Place the child on a soft mattress following surgery. B. Use powder on the perineal area to avoid irritation. C. Give daily sponge baths and clean around the edges of the cast. D. Offer pacifiers to encourage the infant to suck.
C
The nurse is monitoring a new mother changing her newborn's diaper and notices a musty smell to the infant's urine. Which condition should the nurse prioritize in further assessments to rule out? A. Galactosemia B. Congenital hypothyroidism C. Phenylketonuria D. Turner syndrome
C
The nurse is preparing a presentation for a health fair that will illustrate various factors that contribute to preterm births. Which contributing factor should the nurse prioritize? A. tocolytics used to relax the uterus B. corticosteroids that are used to enhance lung maturity C. fertility treatments that are resulting in multiple births D. Antibiotics used to treat prenatal infections
C
The nurse is preparing to assess an infant who is diagnosed with a ventricular septal defect. Which assessment finding should the nurse be prepared to document? A. fatigue and dyspnea B. delayed growth and development C. loud, harsh murmur D. bounding pulse
C
The nurse is teaching new parents about their premature newborn who was born with respiratory distress syndrome (RDS). The nurse determines the teaching session is successful when the parents correctly choose which explanation as being the cause of their newborn's condition? A. The lungs are hyperextended due to increased load of work. B. The infant has inherited allergies from the mother. C. The lungs are immature and deficient in surfactant. D. The mother has a history of asthma which interfered in lung development.
C
The parents of a newborn are struggling with the news that their infant has spina bifida. Which technique should the nurse prioritize teaching to the parents that will help increase the infant's comfort and development? A. Diaper the baby safely. B. Hold the baby during feeding. C. Cuddle the baby in a chest-to-chest position. D. Clean and moisturize the myelomeningocele sac.
C
A 2-year old child has gone home following successful hip dysplasia surgery in a spica cast. Her caregiver calls 2 days later to report the child has been vomiting after eating, but has no fever. Which response should the nurse prioritize in response to this caregiver? A. "If the child develops a fever or isn't able to hold anything down over the next 24 hours she should come back to the hospital." B. "The vomiting is a possible sign of infection, and the child should be brought back in." C. "The child may be reacting to the analgesics. Observe the child for the next 8 hours and see what happens." D. If there is no fever and the child wants to eat, the cast may be too tight; she should be brought back in for recasting.
D
A newborn is diagnosed with the communicating type of congenital hydrocephalus. Which explanation should the nurse prioritize when preparing a teaching session for the parents? A. There is a decreased production of cerebrospinal fluid. B. There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord. C. There is an opening between the ventricles and the spinal cord that usually closes at birth. D. There is defective absorption of cerebrospinal fluid.
D
A nurse is providing postoperative care to an infant who had a ventriculoarterial shunt placed. Approximately 8 hours after surgery, the nurse notes on assessment shrill crying and projective vomiting. Which response should the nurse prioritize at this time? A. Assess surgical site for signs of infection. B. Increase the flow of IV fluids and maintain NPO status. C. Assess and administer pain medication. D. Notify the primary care provider immediately.
D
The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth? A. cataracts B. amblyopia C. nystagmus D. retinopathy
D
The nurse is answering questions from the parents of a newborn diagnosed with clubfoot (congenital talipes equinovarus). When asked by the parents which treatment will be used, what would the nurse predict? A. Putting the child in Bryant's traction B. Doing passive range of motion C. Placing the child in special shoes D. Application of a splint or cast
D
The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition? A. heroin withdrawal B. hypoglycemia C. hypoxia D. hemolytic disease
D
The nurse is caring for a preterm infant and notes frothing and excessive drooling. Which additional assessment finding should the nurse prioritize and report immediately? A. Bright red blood from the mouth B. Bradycardia C. Vomiting D. Severe cyanosis
D
The nurse is preparing to teach the young parents of a newborn who is diagnosed with spinal bifida occulta how to care for their newborn. Which information should the nurse prioritize when explaining this defect? A. There is protrusion of the spinal cord and meninges, with nerve roots embedded. B. The spinal meninges protrude through the bony defect and form a cystic sac. C. There is no protrusion of the spinal cord, only soft-tissue inflammation occurs. D. There is a bony defect that occurs without soft-tissue involvement
D
The nursing instructor is conducting a session with a group of nursing students researching potential respiratory difficulties in newborns. The instructor determines the session is successful after the students correctly choose which contributing factor for transient tachypnea of the newborn? A. usually occurs with maternal history of hypertension B. associated with fetal distress during labor C. often seen with advanced gestational age D. often seen with cesarean births
D
The nursing instructor is leading a discussion with a group of nursing students who are analyzing the preterm infant's physiologic immaturity and the associated difficulties the newborn and family must deal with. The instructor determines the session is successful when the students correctly choose which body system that presents with the most critical concerns related to this immaturity? A. the genitourinary system B. the musculoskeletal system C. the endocrine system D. the respiratory system
D
The nursing instructor is teaching a session on techniques that the nursing students can use to properly address concerns of parents with children who are born with a cleft lip and palate. The instructor determines the session is successful when the students correctly choose which nursing intervention as being the mosteffective in these situations? A. Help the child to understand his or her limitations. B. Keep the family informed about new and effective treatments. C. Model good medical practices for the child's family. D. Use reflective listening with nonjudgmental support.
D
The nurse is caring for a newborn with congenital hip dysplasia. Which nursing diagnoses would the nurse prioritize for this infant after the application of a hip spica cast? Select all that apply. D, E A. Risk for aspiration B. Risk for imbalanced nutrition C. Risk for fluid volume excess D. Risk for delayed growth and development E. Risk for impaired skin integrity
D, E
Intraventricular hemorrhage
Hemorrhage located within the ventricles of the brain. Palpate the soft spt
What is one of the characteristics of the preterm newborn
High caloric needs
Gavage Feeding
Nasogastric tube for infants - Every 2 hours
The nurse is monitoring a new mother changing her newborn's diaper and notices a musty smell to the infant's urine. Which condition should the nurse prioritize in further assessments to rule out?
Phenylketonuria
A nurse is caring for a newborn who is determined to be small-for-gestational-age with intrauterine growth restriction. Which finding would lead the nurse to also question if this infant has asymmetric growth restriction?
The head is large in comparison with the body
Which congenital condition is an immediate emergency requiring notification of the health care provider?
Tracheoesophageal fistula
erythroblastosis fetalis
a disorder that results from the incompatibility of a fetus with Rh-positive blood and a mother with Rh-negative blood, causing red blood cell destruction in the fetus; a blood transfusion is necessary to save the fetus Rogam prevents the antibodies Do a cord workup
Necrotizing Enterocolitis (NEC)
acute inflammation of the bowel that leads to bowel/intestines necrosis
In the child diagnosed with hydrocephalus, an obstruction occurs that blocks the normal process of?
cerebrospinal fluid
A nurse is performing a newborn assessment and notes the blood pressures in the upper extremities are higher than the lower extremities. The nurse should suspect which congenital newborn abnormality?
coarctation of the aorta
Which assessment findings are most prominent in the infant with tetralogy of Fallot and significant pulmonary stenosis?
dyspnea on limited exertion, fatigue, cyanosis
The nurse is feeding a 2-day-old in the nursery when the infant begins choking and becomes cyanotic. Frothy sputum is observed coming from the mouth. What congenital malformation does the nurse understand these symptoms indicate?
esophageal atresia
The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition?
hemolytic disease
The nurse caring for a newborn notes a distended abdomen approximately 24 hours after birth. Which action should the nurse take after review of the medical record reveals an apparent healthy newborn at birth but no documentation of a bowel movement?
inform the healthcare provider immediately
The nurse is weighing and measuring a term newborn. Which assessment findings would indicate that this newborn is suffering from asymmetrical growth restriction?
is pale with loose dry skin
The nurse cares for preterm infants and assesses them for potential complications to provide adequate countermeasures to prevent father complications. Which complication should the nurse prioritize and initiate proper measures to protect the newborn?
loss of body heat
The nurse is providing education to the parents of an infant who was just diagnosed with transposition of the great arteries. The parents ask, "Which vessels were involved?" The nurse is correct to educate about:
the aorta and pulmonary artery
The nurse is caring for neonates in the neonatal intensive care unit (NICU). In reviewing the records of the neonates, the nurse notes that one of the infants has a common congenital heart defect. She recognizes that the most common of the congenital heart defects is
ventricular septal defect