Maternity Test #3
On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? A) At 1 minute after birth and 5 minutes after birth B) Immediately at birth, 3 minutes after birth, and 10 minutes after birth C) At 1 minute after birth, 5 minutes after birth, and 10 minutes after birth D) At 1 minute after birth, after the cord is cut, and after the mother delivers the placenta
A) At 1 minute after birth and 5 minutes after birth
A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client regarding care of her infant. Which client statement indicates the need for further instruction? A) "I will be sure to wash my hands before and after bathroom use." B) "I need to breast-feed, especially for the first 6 weeks postpartum." C) "Support groups are available to assist me with understanding my diagnosis of HIV." D) "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."
B) "I need to breast-feed, especially for the first 6 weeks postpartum."
The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference? A) Wrap the tape measure around the infant's head, and measure just below the eyebrows. B) Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows. C) Place the tape measure under the infant's head at the base of the skull, and wrap around to the front just below the eyes. D) Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.
B) Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows.
The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? A) Bring the infant to the clinic. B) This is a normal occurrence. C) Increase the number of times that the cord is cleaned per day. D) Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.
A) Bring the infant to the clinic.
The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? A) Make a loud, abrupt noise to startle the newborn. B) Stimulate the ball of the foot of the newborn by firm pressure. C) Stimulate the perioral cavity of the newborn infant with a finger. D) Stimulate the pads of the newborn infant's hands by firm pressure.
A) Make a loud, abrupt noise to startle the newborn.
An initial assessment on a large-for-gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma? A) Palpate the clavicles for a fracture. B) Auscultate the heart for a cardiac defect. C) Blanch the skin for evidence of jaundice. D) Perform Ortolani's maneuver for hip dislocation.
A) Palpate the clavicles for a fracture.
The nurse is caring for a term newborn. Which assessment finding would alert the nurse to suspect the potential for jaundice in this infant? A) Presence of a cephalhematoma B) Infant blood type of O negative C) Birth weight of 8 pounds 6 ounces D) A negative direct Coombs' test result
A) Presence of a cephalhematoma
The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? A) Tachypnea and retractions B) Acrocyanosis and grunting C) Hypotension and bradycardia D) Presence of a barrel chest and acrocyanosis
A) Tachypnea and retractions
The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions? A) The mother bathes the newborn infant after a feeding. B) The mother states that she would gather all supplies before the bath is started. C) The mother states that she would never leave the newborn infant in the tub of water alone. D) The mother fills a clean basin or sink with 2 to 3 inches of water and then checks the temperature with her wrist.
A) The mother bathes the newborn infant after a feeding.
The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which would the nurse expect to note in the neonate? A) Tremors B) Bradycardia C) Flaccid muscles D) Extreme lethargy
A) Tremors
The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care? A) Monitoring the newborn's vital signs routinely B) Maintaining standard precautions at all times while caring for the newborn C) Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems D) Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment
B) Maintaining standard precautions at all times while caring for the newborn
The nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way? A) Thin and gelatinous, with increased subcutaneous fat B) Thin and gelatinous, with increased amounts of brown fat C) Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat D) With fine downy hair on thin epidermal and dermal layers, with increased amount of brown fat
C) Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat
The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique would assist to support the newborn's diagnosis? A) Monitoring the urine for blood B) Monitoring the urinary output pattern C) Testing for contractures of the extremities D) Stimulating for reflex responses in the extremities
D) Stimulating for reflex responses in the extremitie
The nurse is preparing to instruct a client in how to bathe a newborn. Which statement should the nurse include in the instruction? A) "Begin with the eyes and face." B) "Begin with the feet and work upward." C) "Do the back side first, and then the front side." D) "Start with the chest, move to the face, and then finish the rest of the body."
A) "Begin with the eyes and face."
Butorphanol tartrate (Stadol) is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which most appropriate response? A) "The medication provides pain relief during labor." B) "The medication will help prevent any nausea and vomiting." C) "The medication will assist in increasing the contractions." D) "The medication prevents respiratory depression in the newborn infant."
A) "The medication provides pain relief during labor."
An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action? A) Elevates the gastrostomy tube B) Tapes the gastrostomy tube to the bed linens C) Attaches the gastrostomy tube to low suction D) Connects the gastrostomy to the feeding pump
A) Elevates the gastrostomy tube
A newborn infant is diagnosed with gastroesophageal reflux (GER), and the infant's mother asks the nurse to explain the diagnosis. On what description should the nurse plan to base the response? A) Gastric contents regurgitate back into the esophagus. B) The esophagus terminates before it reaches the stomach. C) Abdominal contents herniate through an opening of the diaphragm. D) A portion of the stomach protrudes through the esophageal hiatus of the diaphragm.
A) Gastric contents regurgitate back into the esophagus.
The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take? A) Document the findings. B) Contact the health care provider. C) Apply an oxygen mask to the newborn infant. D) Cover the newborn infant with blankets and reassess the respiratory rate in 15 minutes.
A) Document the findings
The nurse is preparing to bathe a 1-day-old newborn. Which action should the nurse avoid when performing the procedure? A) Immersing the newborn in water B) Supporting the newborn's body during the bath C) Ensuring that the water temperature is warm D) Ensuring that the water temperature does not exceed 100° F
A) Immersing the newborn in water
The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should most appropriately document which Apgar score for the newborn? A) 3 B) 5 C) 7 D) 10
B) 5 Rationale: One of the earliest indicators of successful adaptation of the newborn is the Apgar score. Scores range from 0 to 10. Five criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 = 1; greater than 100 = 2. Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0; some extremity flexion = 1; active, moving, and well flexed = 2. Irritability or reflexes (measured by bulb suctioning): no response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of extremities = 1; pink = 2. Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more vigorous resuscitation.
The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely finding? A) A depressed anterior fontanel B) A soft and flat anterior fontanel C) An anterior fontanel measuring 1 cm D) An anterior fontanel measuring 7 cm
B) A soft and flat anterior fontanel
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? A) Length of 19 inches B) Abnormal palmar creases C) Birth weight of 6 lb, 14 oz D) Head circumference appropriate for gestational age
B) Abnormal palmar creases
A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL. The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn? A) Applying lotions to exposed newborn skin B) Assessing skin integrity and fluid status of the newborn C) Having minimal contact with the newborn to prevent stimulation D) Advising the mother to limit the newborn's oral intake during phototherapy
B) Assessing skin integrity and fluid status of the newborn
The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother? A) Feed the newborn less frequently. B) Continue to breast-feed every 2 to 4 hours. C) Switch to bottle-feeding the infant for 2 weeks. D) Stop breast-feeding and switch to bottle-feeding permanently
B) Continue to breast-feed every 2 to 4 hours.
The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4325 g. The nurse determines that this infant may be at risk for which complications? Select all that apply. A) Retinopathy B) Hypoglycemia C) Fractured clavicle D) Hyperbilirubinemia E) Congenital heart defect D) Necrotizing enterocolitis
B) Hypoglycemia C) Fractured clavicle E) Congenital heart defect
A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? A) Positive for HIV B) Indicates the presence of maternal infection C) Indicates that the newborn will develop AIDS later in life D) Positive for acquired immunodeficiency syndrome (AIDS)
B) Indicates the presence of maternal infection
The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which assessment finding should the nurse expect to note? A) Lethargy B) Irritability C) Higher-than-normal birth weight D) A greater-than-normal appetite when feeding
B) Irritability
The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? A) Developmental delays because of excessive size B) Maintaining safety because of low blood glucose levels C) Choking because of impaired suck and swallow reflexes D) Elevated body temperature because of excess fat and glycogen
B) Maintaining safety because of low blood glucose levels
The nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made by the mother, indicates a need for further instructions? A) "The cord will fall off in 1 to 2 weeks." B) "Alcohol may be used to clean the cord." C) "I should cleanse the cord two or three times a day." D) "I need to fold the diaper above the cord to prevent infection."
D) "I need to fold the diaper above the cord to prevent infection."
The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? A) "I should retract the foreskin and clean the penis every time I change the diaper." B) "I need to retract the foreskin and clean the penis every time I give my infant a bath." C) "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." D) "I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."
C) "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."
The nurse is caring for a post-term, small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? A) Urinary output B) Total bilirubin levels C) Blood glucose levels D) Hemoglobin and hematocrit levels
C) Blood glucose levels
Which would be considered a normal finding in a newborn less than 12 hours old? A) Grunting respirations B) Heart rate of 190 beats/min C) Bluish discoloration of the hands and feet (Acrocyanosis) D) A yellow discoloration of the sclera and body
C) Bluish discoloration of the hands and feet (Acrocyanosis)
The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn? A) Lethargy B) Sleepiness C) Constant crying D) Cuddles when being held
C) Constant crying
The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? A) Apply gentle pressure. B) Reinforce the dressing. C) Document the findings. D) Contact the health care provider (HCP).
C) Document the findings.
The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? A)Warming the crib pad B) Closing the doors to the room C) Drying the infant with a warm blanket D) Turning on the overhead radiant warmer
C) Drying the infant with a warm blanket
The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? A)Document the findings. B) Arrange for hearing testing. C) Notify the health care provider. D) Cover the ears with gauze pads.
C) Notify the health care provider. Rationale: Low or oddly placed ears are associated with various congenital defects and should be reported immediately.
The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes an Apgar score of 6. On the basis of this score, what should the nurse determine? A) The newborn requires vigorous resuscitation. B) The newborn is adjusting well to extrauterine life. C) The newborn requires some resuscitative interventions. D) The newborn is having some difficulty adjusting to extrauterine life.
C) The newborn requires some resuscitative interventions.
A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action? A) Determine Apgar score. B) Auscultate the heart rate. C) Thoroughly dry the newborn. D) Take the newborn's rectal temperature.
C) Thoroughly dry the newborn
The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? A) "Your newborn needs vitamin K to develop immunity." B) "The vitamin K will protect your newborn from being jaundiced." C) "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel." D) "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
D) "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
The mother of a 1-month-old infant is bottle-feeding her infant and asks the nurse about the stomach capacity of an infant. What should the nurse tell the client is the stomach capacity of a 1-month-old infant? A) 10 to 20 mL B) 30 to 90 mL C) 75 to 100 mL D) 90 to 150 mL
D) 90 to 150 mL
A nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside? A) A rectal thermometer B) A blood pressure cuff C) A specific gravity urinometer D) A bottle of sterile normal saline
D) A bottle of sterile normal saline
Methylergonovine (Methergine) has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? A) Peripads B) Tape measure C) Reflex hammer D) Blood pressure cuff
D) Blood pressure cuff
The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings would the nurse most specifically expect to note in the infant? A) Excessive oral secretions B) Bowel sounds heard over the chest C) Hiccups and spitting up after a meal D) Coughing, wheezing, and short periods of apnea
D) Coughing, wheezing, and short periods of apnea
The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? A) A suture split greater than 1 cm B) A hard, rigid, immobile suture line C) Swelling of the soft tissues of the head and scalp D) Edema resulting from bleeding below the periosteum of the cranium
D) Edema resulting from bleeding below the periosteum of the cranium
An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant? A) Hepatitis B vaccine given within 24 hours after birth B) Immune globulin (IG) given as soon as possible after delivery C) Hepatitis B immune globulin (HBIG) given within 14 days after birth D) Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth
D) Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. A) Avoid stimulation. B) Decrease fluid intake. C) Expose all of the newborn's skin. D) Monitor skin temperature closely. E) Reposition the newborn every 2 hours. D) Cover the newborn's eyes with eye shields or patches.
D) Monitor skin temperature closely. E) Reposition the newborn every 2 hours. D) Cover the newborn's eyes with eye shields or patches
The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. While performing an assessment, where should the nurse document the location of the viscera in this condition? A) Inside the abdominal cavity and under the skin B) Inside the abdominal cavity and under the dermis C) Outside the abdominal cavity and not covered with a sac D) Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane
D) Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane
The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? A) Protects the newborn's eyes from possible infections acquired while hospitalized. B) Prevents cataracts in the newborn born to a woman who is susceptible to rubella. C) Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. D) Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.
D) Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.
The nurse is preparing to administer an injection of vitamin K to a newborn. Which injection site should the nurse select? A) The gluteal muscle B) The lower aspect of the rectus femoris muscle C) The medial aspect of the upper third of the vastus lateralis muscle D) The lateral aspect of the middle third of the vastus lateralis muscle
D) The lateral aspect of the middle third of the vastus lateralis muscle
