MATERNITY/PED 26 - 30

5) An infant was born at 31 weeks' gestation and weighed 1430 g. What number of calories should this infant receive each day? 1. 72 2. 143 3. 200 4. 258

Answer: 3 Explanation: 1. This is using the formula 50 kcal/g/day, which is not sufficient for this infant's growth. 2. This is using the formula 100 kcal/g/day, which is not sufficient for this infant's growth. 3. This is using the formula 140 kcal/g/day, which is appropriate for this infant's growth. 4. This is using the formula 180 kcal/g/day, which is too many calories for this infant's weight and size to support normal growth. Page Ref: 580

6. In neonatal resuscitation management, which of the following is not included as critical assessment data? a. Respiratory rate b. Skin color c. Heart rate d. Pulse oximetry measurement

Answer: b. Skin color Feedback: Skin color is not included as critical assessment data in neonatal resuscitation management. Respiratory rate, heart rate, and pulse oximetery measurement are critical data included.

A nurse has assessed a 4cm vaginal hematoma on a client who is 6 hours postpartum. What initial nursing intervention would be most appropriate? a. Administer anti-inflammatory medication. b. Apply hot packs. c. Insert an indwelling Foley catheter. d. Apply ice packs every 4 hours.

Answer: d. Apply ice packs every 4 hours. Feedback: Application of ice packs helps reduce pain and swelling, and is the most appropriate initial action for a vaginal hematoma. Analgesic medication may be appropriate, but not as the initial action, as its onset is not immediate. Hot packs may increase swelling in the early postpartum period. An indwelling catheter is only required if the client is unable to void.

The nurse assesses an 8-hour-postpartum client. Findings include lochia rubra, with a firm fundus at the level of the umbilicus. What nursing action is indicated? a. Massage the fundus to prevent early postpartum hemorrhage. b. Administer Methergine to stop the bleeding. c. Call the primary healthcare provider/CNM and prepare for a pelvic exam. d. Document findings and continue to monitor.

Answer: d. Document findings and continue to monitor. Feedback: The client's findings are within normal limits. Document findings and continue to monitor. Early postpartum hemorrhage presents with a boggy, nonfirm fundus. Massage is used to encourage the fundus to contract, and therefore is not indicated with this client's findings. Administering Methergine to control excessive bleeding is not necessary in this situation.

The nurse is researching the relationship between estrogen and lactation. The nurse discovers that the lactating client is more susceptible to: a. Hemorrhage. b. Infection. c. Diastasis recti. d. Dyspareunia.

Answer: d. Dyspareunia. Feedback: Lactation puts breastfeeding women in a hypoestrogenic state due to ovarian suppression, which could lead to dyspareunia (painful intercourse). There is no correlation between lactation and hemorrhage, infection, or diastasis recti.

20) The nurse is instructing a postpartum client on the use of perineal pads. Which statements should the nurse include in the teaching session? Select all that apply. 1. "Apply the pad from back to front." 2. "Change the pad after each perineal cleansing." 3. "Place the pad so that it applies pressure to the perineum." 4. "Change the pad each time you use the bathroom." 5. "Your pad should be loose to allow the perineum to 'breathe.' "

Answer: 2, 4 Explanation: 1. The perineal pad should be applied from front to back, not back to front, to decrease the risk of contamination. 2. The perineal pad should be changed after each perineal cleansing. 3. The perineal pad should be placed snugly against the perineum but should not produce pressure. 4. The perineal pad should be changed after urination and defecation. 5. The perineal pad should be placed snugly against the perineum. If the pad is worn too loosely, it may rub back and forth, irritating perineal tissues and causing contamination between anal and vaginal areas.

7) The hospital is developing a new maternity unit. What aspects should be included in the planning of this new unit to best promote family wellness? 1. Normal newborn nursery centrally located to all client rooms 2. A kitchen with refrigerator stocked with juice and sandwiches 3. Small, cozy rooms with a client bed and rocking chair 4. A nursing model based on providing couplet care

Answer: 4 Explanation: 1. Rooming-in better promotes family wellness than does having newborns in the nursery. 2. Although having snacks is good for postpartum clients, some cultures prohibit drinking cold liquids after birth; warm liquids must also be available for optimal family wellness. 3. Small rooms can become overly crowded when siblings and grandparents come to visit. Larger rooms that facilitate family attachment are better. 4. Couplet care, where the nurse cares for both the mother and the infant, best promotes family wellness. Having one nurse care for the mother and another nurse care for the baby is much less family-centered.

18) The nurse is reviewing the medical record for a postpartum client. Which findings would necessitate the need for the nurse to monitor the client closely for the development of thrombophlebitis? Select all that apply. 1. Vaginal birth 2. 25 years of age 3. History of diabetes mellitus 4. Current smoker 5. Laboratory values indicating anemia

Answer: 3, 4, 5 Explanation: 1. A cesarean, not vaginal, birth increases the postpartum client's risk for the development of thrombophlebitis. 2. Advanced maternal age increases the postpartum client's risk for the development of thrombophlebitis. The 25-year-old postpartum client does not have an increased risk for thrombophlebitis. 3. A history of diabetes mellitus is a risk factor for the development of thrombophlebitis during the postpartum period. 4. Cigarette smoking is a risk factor for thrombophlebitis during the postpartum period. 5. Anemia is a risk factor for the development of thrombophlebitis during the postpartum period.

The nurse is assessing a postpartum client who gave birth 10 hours ago. What assessment finding would need further investigation? a. Fundus is at the level of the umbilicus. b. Fundus is above the umbilicus and deviated to the right. c. Fundus is firm and midline. d. Fundus is 2-3 cm below umbilicus.

Answer: b. Fundus is above the umbilicus and deviated to the right. Feedback: A fundus that is above the umbilicus and deviated to the right is not a normal finding, and may be due to a full bladder. A fundus that is at the level of the umbilicus or 2-3 cm below, firm, and midline is normal.

Which woman is most at risk for bladder distention after a normal vaginal delivery? a. A woman who had IV fluids running during labor b. A woman who had a midline episiotomy c. A woman who had epidural anesthesia d. A woman who had an active labor lasting 12 hours

Answer: c. A woman who had epidural anesthesia Feedback: Every woman is at risk following delivery, and the nurse must assess voiding patterns after delivery. However, the biggest risk factor is anesthesia, which affects the sensory nerves, because the woman is unaware of the need to empty her bladder. Nerve blocks also may affect motor nerves, making micturition difficult. IV fluids may cause more urine to be produced, but should not promote retention of urine. A midline episiotomy will not promote urinary retention, and a 12-hour labor is not abnormal.

What suggestion should the nurse provide to the client who complains of severe afterpains? a. Stay in bed with your feet elevated. b. Assume a prone position at intervals. c. Try to nurse more frequently. d. Apply ice to your abdomen for 20 minutes.

Answer: b. Assume a prone position at intervals. Feedback: Afterpains are severe in multiparous women. The prone position puts pressure on the uterus, which stimulates uterine contraction. Ambulation is more helpful than bedrest, and nursing intensifies afterpains. Ice will not be useful.

2. Identify a potential long-term complication of the small-for-gestational-age newborn. a. Hyperglycemia b. Cognitive difficulties c. Leukocytosis d. Hyperthermia

Answer: b. Cognitive difficulties Feedback: SGA newborns often subsequently exhibit learning disabilities. The disabilities are characterized by hyperactivity, short attention span, and poor fine motor coordination. Some hearing loss and speech defects also occur. The SGA newborn is at risk for hypoglycemia and decreased temperatures. High white blood cell count is a sign of acute infection and is not a long-term complication.

Regarding neurologic conditions, which of the following is true of headaches during the postpartum period? a. Headaches are the most common neurologic symptoms demonstrated by postpartum clients. b. Spinal anesthesia is not associated with a risk for headache. c. Migraine headaches are more common during pregnancy. d. Hypertension is not associated with headaches.

Answer: a. Headaches are the most common neurologic symptoms demonstrated by postpartum clients. Feedback: It is true that headaches are the most common neurologic symptoms demonstrated by postpartum clients. Spinal anesthesia is associated with a risk for headache; migraine headaches are not more common during pregnancy; and hypertension is associated with headaches.

4. The physiologic alterations of RDS (respiratory distress syndrome) can produce: a. Hypoxia. b. Respiratory alkalosis. c. Hemoglobinopathies. d. Metabolic alkalosis.

Answer: a. Hypoxia. Feedback: RDS can cause hypoxia, respiratory acidosis, and metabolic acidosis. RDS specifically does not cause hemoglobinopathies.

Which of the following laboratory findings would most likely be considered normal in the immediate postpartum period? a. Increased white blood cell (WBC) count b. Decreased erythrocyte sedimentation rate (ESR) c. Decreased hematocrit d. Increased platelet (PLT) count

Answer: a. Increased white blood cell (WBC) count Feedback: Increased white blood cell is the only one of these choices that would be considered normal in the immediate postpartum period.

2) A client is experiencing excessive bleeding immediately after the birth of her newborn. After increasing the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse anticipates which prescriptions from the healthcare provider? Select all that apply. 1. methylergonovine maleate (Methergine) 2. butorphanol tartrate (Stadol) 3. misoprostol (Cytotec) 4. betamethasone (Diprolene) 5. fentanyl (Duragesic)

Answer: 1, 3 Explanation: 1. Methylergonovine maleate is a drug of choice for postpartum hemorrhage. 2. Stadol is an analgesic, and is not used for postpartum hemorrhage. 3. Misoprostol is commonly administered rectally for postpartum hemorrhage. 4. Betamethasone is a glucocorticoid used for preterm labor in an attempt to decrease respiratory distress in the preterm infant. 5. Fentanyl is an analgesic, and is not used for postpartum hemorrhage.

15) The nurse is assessing a postpartum client's risk for early postpartum hemorrhage. Which findings in the client's health history place this client at an increase risk for early postpartum hemorrhage? Select all that apply. 1. Microsomia 2. Grand multiparity 3. African American heritage 4. Oxytocin induction of labor 5. History of anorexia nervosa

Answer: 2, 4 Explanation: 1. Macrosomia, not microsomia, increases the postpartum client's risk for early hemorrhage. 2. Grand multiparity is one risk factor for early postpartum hemorrhage. 3. Asian or Hispanic, not African American, heritage places the postpartum client at an increased risk for hemorrhage. 4. The use of oxytocin to augment, or induce, labor is a risk factor for early postpartum hemorrhage. 5. Obesity, not a history of anorexia nervosa, is a risk factor for early postpartum hemorrhage.

17) The nurse is teaching a postpartum client when light housekeeping can be resumed. Which response by the client indicates accurate understanding of the information provided? 1. "I can resume light housekeeping after the 6-week postpartum checkup." 2. "I can resume light housekeeping during my first week at home." 3. "I can resume light housekeeping during my second day at home." 4. "I can resume light housekeeping after my second week at home."

Answer: 4 Explanation: 1. It is not necessary to wait until after the 6-week postpartum checkup to resume light housekeeping. 2. Within the first week is too early to resume even light housekeeping activity. 3. The second day is too early to resume even light housekeeping activity. 4. The postpartum client can resume light housekeeping after the second week at home.

9) The nurse is revising the care plan of a postpartum client who develops mastitis. Which nursing diagnosis is most appropriate for inclusion in this client's updated plan of care? 1. Ineffective Peripheral Tissue Perfusion related to obstructed venous return 2. Risk for Trauma related to lack of information about appropriate breastfeeding practices 3. Deficient Knowledge related to self-care after discharge on anticoagulant therapy 4. Acute Pain related to tissue hypoxia and edema secondary to vascular obstruction

Answer: 2 Explanation: 1. This nursing diagnosis is more appropriate for a client who develops thrombophlebitis not mastitis. 2. In relation to the client's mastitis, the most appropriate nursing diagnosis is Risk for Trauma related to lack of information about appropriate breastfeeding practices. 3. This nursing diagnosis is more appropriate for a client who develops thrombophlebitis not mastitis. 4. This nursing diagnosis is more appropriate for a client who develops thrombophlebitis not mastitis.

4) The postpartum client presents to the maternity clinic with complaints of urinary urgency and dysuria 3 days after hospital discharge. Which statement is most important for the nurse to make? 1. "Void into this sterile cup without touching the inside of the cup." 2. "Be sure to wipe from back to front after you have a bowel movement." 3. "Call the clinic if you develop nausea and vomiting or constipation." 4. "Decrease your fluid intake for a few days, but eat a lot of vegetables."

Answer: 1 Explanation: 1. A clean-catch urine sample will need to be obtained for urinalysis to determine if the client has developed a urinary tract infection. 2. Clients should be taught to wipe from front to back after bowel movements in order to prevent contamination of the urethra and bladder with normal bowel flora. 3. A lower urinary tract infection can progress into pyelonephritis, the signs of which are fever and flank pain. Constipation is not associated with urinary tract infections. 4. Clients should increase their fluid intake but decrease their consumption of carbonated beverages. Cranberries, or cranberry juice, are helpful, as they acidify the urine. Vegetables do not help clear or prevent urinary tract infections.

6) A postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks if there is something she can do to prevent mastitis this time. Which response by the nurse is most appropriate? 1. "Massage your breasts on a daily basis, and if you find a hardened area, massage it toward the nipple to unblock that duct." 2. "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." 3. "Apply cold packs to any areas that feel thickened or firm in order to relieve the swelling and stasis of the milk in that area." 4. "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe."

Answer: 1 Explanation: 1. A hardened area could indicate a blocked duct. Massage of the blocked duct toward the nipple will help to unplug the duct and relieve stasis of the milk, thereby preventing mastitis. 2. It is not unusual for mothers to develop complications similar to those experienced in prior pregnancies. 3. Warm packs, not cold packs, should be applied to areas that are warm, red, or hardened. 4. The onset of mastitis is quite rapid, and taking the temperature daily is not likely to be helpful for detecting early onset of the infection. Massaging the area to unplug the duct and relieve milk stasis is much more effective.

16) Which safety device is most appropriate for the nurse who conducts home care visits to postpartum mothers? 1. Cellular phone 2. Map of the area 3. Personal handgun 4. Can of Mace

Answer: 1 Explanation: 1. Cellular phones provide a means of contact, and are advisable for the nurse to carry. 2. A map of the area should be checked before leaving for a visit, and the route traced. 3. Personal handguns are not permissible or legal for nurses to carry on home visits. 4. Mace is not permissible or legal for nurses to carry on home visits.

3) The postpartum client who delivered a newborn 2 days ago develops endometritis. Which entry in the medical record would the nurse expect to find when reviewing the client's history? 1. "Cesarean birth performed secondary to arrest of dilation." 2. "Rupture of membranes occurred 2 hours prior to delivery." 3. "External fetal monitoring used throughout labor." 4. "History of pregnancy-induced hypertension."

Answer: 1 Explanation: 1. Cesarean birth is the greatest predictor of postpartum endometritis. The frequent cervical examinations necessary to assess for arrest of dilation are another risk factor for postpartum infection. 2. Prolonged rupture of membranes (longer than 12 hours) is a risk factor for postpartum endometritis. 3. Internal fetal monitoring (both internal fetal scalp electrode and intrauterine pressure catheter) are risk factors for postpartum endometritis. 4. Pregnancy-induced hypertension is not a risk factor for development of postpartum endometritis. Page Ref: 0720

6) The nurse is teaching a postpartum client information regarding weaning her infant from breastfeeding. Which client statement suggests a need for further teaching? 1. "Slow weaning should take place over a period of several months." 2. "By weaning my baby slowly, I'm giving him time to change his eating method at his own pace." 3. "If I wean my baby slowly, I am less likely to develop breast engorgement." 4. "Slowly weaning my baby is recommended to allow time for my psychologic adjustment."

Answer: 1 Explanation: 1. During slow weaning, over a period of several weeks, the mother substitutes more cup feedings or bottlefeedings for breastfeedings. 2. The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychologic adjustment. 3. The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychologic adjustment. 4. The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychologic adjustment.

13) The nurse is providing care to a postpartum client 24 hours after delivery who has been diagnosed with metritis. Which response by the nurse is accurate when the client asks what made her sick? 1. "Early infections such as this are often caused by group beta strep (GBS)." 2. "Most infections are often caused by a chlamydial infection. Do you practice safe sex?" 3. "You must have already been sick when you came to deliver your baby." 4. "There is no way to knowing why you got sick. Sometimes it just happens."

Answer: 1 Explanation: 1. Most early metritis infections are caused by group beta strep (GBS). 2. Most late, not early, metritis infections are caused by chlamydia. Also, it is not appropriate to ask her about safe sex practices at this time. 3. Telling the client that she was sick when she came to deliver the baby is often not true and does not specifically address the client's question. 4. This response is inaccurate as most cases of early metritis are attributed to a GBS infection.

12) The charge nurse is reviewing the plan of care for maternal clients currently admitted for postpartum care. During the course of the medical record review, which intervention requires immediate consideration for revision? 1. Daily prothrombin time (PT) measurements for coagulation assessment in a client receiving heparin for treatment of thrombophlebitis. 2. Use of the REEDA (redness, edema, ecchymosis, discharge, approximation) scale for assessment every 8 hours in the care of a client diagnosed with puerperal infection. 3. Misoprostol (Cytotec) administration to a client who demonstrates uterine atony and bleeding after receiving oxytocic medications. 4. Inserting a straight catheter to drain the overdistended bladder of a client during the early postpartum period of her care.

Answer: 1 Explanation: 1. Prothrombin time (PT) evaluates the anticoagulation effects of warfarin (Coumadin); the effects of heparin are assessed by way of activated partial thromboplastin time (aPTT). 2. The nurse should inspect the woman's perineum every 8 to 12 hours for signs of early infection. The REEDA scale helps the nurse remember to consider redness, edema, ecchymosis, discharge, and approximation. 3. Misoprostol (Cytotec) is used to prevent and treat uterine atony after failed attempts to control bleeding with oxytocics. 4. Overdistention in the early postpartum period is often managed by draining the bladder with a straight catheter as a one-time measure.

3) The postpartum client, who delivered 4 hours ago, has a mediolateral episiotomy and large hemorrhoids. The client currently rates her pain at 7 on a scale of 1 to 10. She has a history of anaphylactic reaction to acetaminophen (Tylenol). Which nursing action is most appropriate? 1. Offering 800 mg ibuprofen (Advil) orally with food 2. Providing two oxycodone with acetaminophen tablets (Percocet) by mouth 3. Encouraging use of the prescribed topical anesthetic spray 4. Running very warm water into the tub and assisting her into the bath

Answer: 1 Explanation: 1. This is the best option because the client is experiencing moderately severe pain with inflammation. Ibuprofen is a nonsteroidal anti-inflammatory drug that both reduces inflammation and provides pain relief. 2. This medication is contraindicated because of the client's allergic reaction to acetaminophen. 3. Topical anesthetic sprays can be a helpful adjunct in pain relief, but are not sufficient when a client has moderately severe pain. 4. Ice packs would be better at this stage because they will cause vasoconstriction to reduce edema and pain relief.

7) Which assessment data support the nurse's suspicion that a postpartum client has mastitis? Select all that apply. 1. Pain in the nipple during breastfeeding described as "shooting" 2. Late onset of nipple pain 3. Pink, flaking, pruritic skin of the affected nipple 4. Nipple soreness when the infant latches on

Answer: 1, 2 Explanation: 1. The pain associated with mastitis is described as "shooting" pain that occurs during breastfeeding. 2. Mastitis is characterized by late-onset nipple pain. 3. The skin of the affected breast, not nipple, becomes pink, flaking, and pruritic. 4. Nipple soreness often occurs if the infant is not latching onto the breast correctly. This is not a symptom associated with mastitis. 5. Breast engorgement prior to each feeding is not a clinical manifestation associated with mastitis.

16) The nurse is assessing a postpartum client who is 36 hours post delivery. Which findings cause the nurse to suspect a reproductive tract infection? Select all that apply. 1. Temperature of 38.0°C (100.4°F) or higher 2. Foul-smelling lochia 3. Uterine tenderness 4. Leg edema and erythema 5. Breast engorgement

Answer: 1, 2, 3 Explanation: 1. A temperature of 38.0°C (100.4°F) or higher is an indication that the postpartum client is experiencing a reproductive tract infection. 2. Foul-smelling lochia is an indication that the postpartum client is experiencing a reproductive tract infection. 3. Uterine tenderness is an indication that the postpartum client is experiencing a reproductive tract infection. 4. Leg edema and erythema is an indication of thrombophlebitis, not a reproductive tract infection. 5. Breast engorgement is not an indication of a reproductive tract infection.

21) The nurse is conducting discharge teaching for a postpartum client who has an episiotomy. Which client actions indicate correct understanding of the information presented? Select all that apply. 1. Using topical anesthetics regularly 2. Remaining in the sitz bath for 20 minutes 3. Using the peri-bottle to cleanse the site after urination 4. Stating that she will loosen her buttocks prior to sitting down 5. Stating that she will continue to use an ice pack for pain after discharge

Answer: 1, 2, 3 Explanation: 1. The use of topical anesthetics regularly after an episiotomy is a client action that indicates correct understanding of episiotomy care. 2. The postpartum client who remains in a sitz bath for 20 minutes is correctly caring for an episiotomy. 3. The use of a peri-bottle each time the postpartum client urinates indicates correct understanding of episiotomy care. 4. The postpartum client who states she will loosen her buttocks prior to sitting down will require additional education regarding episiotomy care. The client should tighten her buttocks prior to sitting down. 5. The postpartum client who states she will continue to use an ice pack for pain after discharge will require additional education regarding episiotomy care. Ice packs are only used for the first 24 hours.

22) Which will the nurse include in the family assessment for the postpartum client? Select all that apply. 1. Parental roles 2. Bonding behaviors 3. Sibling adjustment 4. Signs and symptoms of infection 5. Level of comfort with newborn care

Answer: 1, 2, 3, 5 Explanation: 1. The nurse assesses parental role adjustment during the family assessment for the postpartum client. 2. The nurse assesses bonding behaviors during the family assessment for the postpartum client. 3. The nurse assesses sibling adjustment during the family assessment for the postpartum client. 4. Clinical manifestations of infection are assessed during the physical assessment, not the family assessment, for the postpartum client. 5. The nurse assesses level of comfort with newborn care during the family assessment for the postpartum client.

18) Which is the obese postpartum client at a greater risk for experiencing? Select all that apply. 1. Injury 2. Infection 3. Breast engorgement 4. Deep vein thrombosis 5. Respiratory complications

Answer: 1, 2, 4, 5 Explanation: 1. The obese postpartum client is at a greater risk for injury. 2. The obese postpartum client is at a greater risk for infection. 3. The obese postpartum client is not at a greater risk for breast engorgement. 4. The obese postpartum client is at a greater risk for thromboembolic disease, such as deep vein thrombosis (DVT). 5. The obese postpartum client is at a greater risk for respiratory complications.

19) The nurse is providing care to a lesbian postpartum client and her life partner. Which nursing actions are appropriate when providing care to this couple? Select all that apply. 1. Providing the couple with the same rights and care as those given to heterosexual couples 2. Educating the couple about heterosexual contraception during the postpartum period 3. Teaching the couple about when it is safe to resume sexual relations 4. Encouraging the couple to join a support group of other postpartum lesbian couples 5. Expecting the nonpregnant partner to assume the role of father

Answer: 1, 3, 4 Explanation: 1. Lesbian couples should be given the same rights and care as heterosexual couples in the acute care environment. 2. Contraception teaching during the postpartum period will differ for the lesbian client versus the heterosexual client as there is no need to educate about heterosexual contraception. 3. Lesbian couples require education regarding the safe resumption of sexual relations. 4. Lesbian couples should be encouraged to seek support, including joining a support group with other postpartum lesbian couples. 5. Evidence shows that the nonpregnant partner will assume the comothering role, not the role of the father.

5) The nurse is caring for a postpartum client who is 4 hours postoperative following a cesarean birth. Which nursing interventions are appropriate based on these data? Select all that apply. 1. Administering the prescribed analgesics, as needed 2. Encouraging ambulation to the bathroom to void 3. Encouraging leg exercises every 2 hours 4. Encouraging coughing and deep breathing every 2 to 4 hours 5. Encouraging the use of breathing, relaxation, and distraction

Answer: 1, 3, 4, 5 Explanation: 1. Administering the prescribed analgesics, as needed, addresses the client's nursing care needs, which are similar to those of other surgical clients. 2. Encouraging the client to ambulate to the bathroom to void is not an appropriate intervention for a postpartum client who is 4 hours postoperative for a cesarean birth. 3. Encouraging leg exercises addresses the client's nursing care needs, which are similar to those of other surgical clients. 4. Encouraging coughing and deep breathing every 2 to 4 hours addresses the client's nursing care needs, which are similar to those of other surgical clients. 5. Encouraging the use of breathing, relaxation, and distraction addresses the client's nursing care needs, which are similar to those of other surgical clients.

20) The nurse is conducting teaching for a postpartum client who is approaching discharge. Which topics will the nurse include in the educational session regarding the prevention of postpartum hemorrhage? Select all that apply. 1. Using the peri-bottle 2. Applying ice to the breasts 3. Wearing cotton underwear 4. Performing fundal massage 5. Inspecting the episiotomy site

Answer: 1, 4, 5 Explanation: 1. The nurse includes education on the use of the peri-bottle during discharge instructions regarding the prevention of postpartum hemorrhage. 2. Application of ice is an appropriate topic when teaching the postpartum client to avoid engorgement. This information is not appropriate when teaching methods to prevent postpartum hemorrhage. 3. The use of cotton underwear is an appropriate topic when teaching the postpartum client to avoid a urinary tract infection (UTI), not postpartum hemorrhage. 4. The nurse includes education on performing fundal massage during discharge instructions regarding the prevention of postpartum hemorrhage. 5. The nurse includes education on inspecting the episiotomy site during discharge instructions regarding the prevention of postpartum hemorrhage.

11) The nurse is making a visit to the home of a new mother. Which observation indicates that the mother and infant are in the phase of mutual regulation? 1. The infant grasps the mother's finger while nursing. 2. The mother vocalizes feelings of frustration with her infant. 3. The infant begins to seek out the mother over other individuals. 4. The mother spends more time making eye-to-eye contact with the infant.

Answer: 2 Explanation: 1. Actions that make the infant more attractive to the mother, such as grasping a finger, usually occur during the acquaintance phase. 2. The mother is most likely to vocalize her negative maternal feelings during the phase of mutual regulation, when both the mother and infant are determining the amount of control each partner will have in the relationship. 3. When the relationship between mother and infant reaches reciprocity, the infant will seek to interact with the mother more. 4. Holding the infant in the en face position is likely to occur most often in the acquaintance phase.

20) The nurse decides that a family with a newborn would benefit from a Social Services consultation. What statements were made by family members that caused the nurse to make this decision? Select all that apply. 1. "I think we're getting along better." 2. "I'm not going to let a baby make me fat." 3. "My mother could care less about this baby." 4. "At least help me if you don't want to get a job." 5. "That's fine. Go to work. Leave me here to do all of the work."

Answer: 2, 3, 4, 5 Explanation: 1. The statement about getting along would indicate adapting to the new infant. 2. Preoccupation with physical status or weight could indicate adjustment difficulties. 3. Lack of support systems could indicate adjustment difficulties. 4. Unemployment could indicate adjustment difficulties. 5. Marital problems could indicate adjustment difficulties.

1) The nurse completes a postpartum assessment on a client who gave birth to her first child 12 hours ago. Assessment findings include: the client nauseated, but has not vomited in the last 2 hours; fundus was boggy but firmed with massage to 1 FB ↓ the uterus; client is experiencing moderately heavy lochia rubra and the perineum ecchymotic and edematous. The client's pain rating is 6 on scale of 1 to 10. Her partner is present and supportive. Breastfeeding has been successful 3 times. Which nursing diagnosis has the highest priority for this client? 1. Acute Pain related to perineal trauma 2. Risk for Deficient Fluid Volume related to uterine bleeding and nausea 3. Readiness for Enhanced Family Coping related to vaginal childbirth experience 4. Knowledge Deficit related to newborn care

Answer: 2 Explanation: 1. Although this nursing diagnosis is applicable, pain is a lower priority than is risk for fluid volume deficit. 2. Adequate fluid volume is a critical physiologic need; therefore, this is the highest-priority nursing diagnosis. 3. Although this nursing diagnosis may be applicable, family coping is a lower priority than is risk for fluid volume deficit. 4. Although this nursing diagnosis may be applicable, a knowledge deficit is a psychosocial issue, and therefore a lower priority than is the physiologic need for adequate fluid volume.

9) Every time the nurse enters the client's room, the client, who delivered 3 hours ago, asks the nurse something else about the birth experience. What action should the nurse take? 1. Answer questions quickly and try to divert attention to other subjects. 2. Review documentation of the birth experience and discuss it with the client. 3. Contact the healthcare provider because of changes in the client's memory. 4. Submit a referral to Social Services because of concerns about obsessive behavior.

Answer: 2 Explanation: 1. Answering questions quickly and trying to divert attention to other subjects trivializes the questions and does not allow the client to sort out the reality from the subjective experience. 2. Reviewing the documentation of the birth experience and discussing it with the client helps the client integrate the experience and talk about perceptions of the labor and delivery experience. 3. The client is not demonstrating changes in memory. The healthcare provider does not need to be contacted. 4. Submitting a referral to Social Services because of obsessive behavior is not appropriate. The client is demonstrating normal behavior.

14) The nurse is conducting discharge instruction for a postpartum client. Which client response indicates accurate understanding of when to notify the healthcare provider? 1. "If I am having trouble getting the baby to latch on, I should call my doctor." 2. "If I continue to have pain after taking my prescribed analgesic, I should call my doctor." 3. "If I saturate one pad every 8 hours, I should call my doctor." 4. "If I don't have a bowel movement within 24 hours of going home, I should call my doctor."

Answer: 2 Explanation: 1. Issues with getting the baby to latch on during breastfeeding should be reported but not to the doctor. The client would be instructed to contact a lactation consultant. This statement indicates the need for further education. 2. Pain that is not alleviated by the prescribed analgesic is cause for concern and would require healthcare provider notification. This statement indicates accurate understanding of the information presented. 3. Saturation of one peripad every hour, not every 8 hours, would indicate the need to contact the healthcare provider. This statement indicates the need for further education. 4. The return of bowel function varies with every woman after childbirth. Not having a bowel movement within 24 hours of discharge is not an indication of a problem and would not require the client to contact the healthcare provider. This statement indicates the need for further education.

1) The nurse is assisting a multiparous postpartum woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. Which is the priority nursing action? 1. Assist the client to empty her bladder. 2. Help the client back to bed to check her fundus. 3. Assess her blood pressure and pulse. 4. Begin an IV of lactated Ringer infusion.

Answer: 2 Explanation: 1. The client might be experiencing a postpartum hemorrhage. Her fundus is not contracting well. Although this might be due to a full bladder, the priority nursing action is to assess and massage the fundus. 2. Massaging the fundus is the priority because of the excessive blood loss. If the fundus is boggy, fundal massage may stimulate toning of the uterus and prevent further blood loss. 3. Massaging the fundus is the top priority because of the excessive blood loss. Blood pressure and pulse do not change until 1000 to 2000 mL of blood has been lost. Massaging the fundus will prevent further blood loss. 4. Massaging the fundus is the top priority because of the excessive blood loss. An IV might need to be started if the client becomes symptomatic.

10) A new mother rarely interacts with the infant unless the infant begins to cry vigorously and she appears relieved when the nurse comes to check on the infant. What is the appropriate nursing intervention for this patient? 1. Contact Social Services with concerns of neglect. 2. Teach the client how to interact appropriately with the infant. 3. Take the infant to the nursery so the baby can receive more consistent care. 4. Provide the care the infant needs while continuing to evaluate the mother's actions.

Answer: 2 Explanation: 1. The mother may only need some education on how to care for her infant. If the nurse consistently teaches the mother and encourages mother-infant interaction and the mother continues to ignore the child, then it may be appropriate to contact Social Services in extreme circumstances. 2. New mothers may be hesitant to care for the infant because of feelings of inadequacy. Taking time to talk to the mother and teach her how to care for her baby is the proper nursing intervention. 3. Instead of encouraging mother-infant bonding, this action may emotionally distance the mother from her child even more. It may also confirm the mother's feelings of inadequacy. 4. While this action does provide for the needs of the newborn during the hospital stay, it does not help the mother know how to care for her child once she returns home.

8) The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." Which response by the nurse is most appropriate? 1. "We'll take good care of you and your baby. You'll be home before you know it." 2. "You'll be wearing sequential compression devices to prevent blood clots from forming in your legs." 3. "You will have a lot of pain, but there are medications that we give when it gets bad." 4. "You won't be able to nurse until the baby is 12 hours old because of your epidural."

Answer: 2 Explanation: 1. This response focuses on the nurse, and does not provide specific information to answer the client's question. 2. Sequential compression devices (SCDs) are used until the client is up and walking to prevent thrombus formation. 3. Focusing on the pain is a negative emphasis. In addition, pain medications work best when they are taken as the pain is intensifying; medication should not be delayed until the pain is severe, as less relief will be obtained. 4. Epidural anesthesia prevents leg function, and therefore ambulation, but does not impact a mother's ability to breastfeed. She might need some assistance with positioning the infant due to bed rest, but should be encouraged to breastfeed as soon as possible.

5) Which method of initial assessment would best indicate whether a postpartum client is experiencing a urinary complication? 1. Urine pH 2. Calculation of urine output 3. Urine specific gravity 4. Calculation of intake

Answer: 2 Explanation: 1. Urine pH and urine specific gravity can be used to identify certain conditions, but would not be part of the initial assessment. 2. Calculation of output would provide a better assessment of complete emptying of the bladder, because overdistention can cause trauma to the bladder, displace the uterus, and cause infection. 3. Urine pH and urine specific gravity can be used to identify certain conditions, but would not be part of the initial assessment. 4. Monitoring intake is an intervention that may help prevent urinary complications but calculating the intake itself would not indicate a complication. Page Ref: 0711

10) The nurse is performing wellness checks for postpartum clients after hospital discharge via the telephone. Which client should be seen immediately? 1. The client who at 4 weeks postpartum describes feeling sad all the time. 2. The client who at 2 weeks postpartum reports hearing voices talking about the baby. 3. The client who at 1 week postpartum states that she has no appetite and feels tired all the time. 4. The client with a history of depression who states she needs a refill on her sertraline (Zoloft) in 1 week.

Answer: 2 Explanation: 1. While this may indicate postpartum blues or postpartum depression, this client does not require an immediate appointment to be seen. 2. This is an indication the client is experiencing postpartum psychosis, and is the highest priority, because the voices might tell her to harm her baby. 3. While this may indicate postpartum blues or postpartum, this client does not require an immediate appointment to be seen. 4. A client on medications needs refills on time, but right now she has medication, and therefore is not a high priority.

17) The nurse is planning care for a postpartum client. Which data in the client's history increase the risk for postpartum depression? Select all that apply. 1. Type 1 diabetes mellitus (DM) 2. Bipolar disorder 3. Premenstural dysphoric disorder (PMDD) 4. Recent relocation to a new city 5. Family history of hypertension

Answer: 2, 3, 4 Explanation: 1. A personal or family history of type 1 DM is not a risk factor for postpartum depression. 2. A personal or family history of bipolar disorder is a risk factor for postpartum depression. 3. A personal history of PMDD is a risk factor for postpartum depression. 4. Poor support from family and friends, which can occur due to a recent relocation to a new city, is a risk factor for postpartum depression. 5. A family history of hypertension is not a risk factor for postpartum depression. Page Ref: 0735

9) The nurse is caring for a client who delivered by cesarean birth and during which she received a general anesthetic. Which will the nurse encourage to prevent or minimize abdominal distention? Select all that apply. 1. Increasing intake of cold beverages 2. Participating in leg exercises every 2 hours 3. Tightening the abdominal muscles 4. Ambulating as often as possible 5. Eating a high-protein general diet

Answer: 2, 3, 4 Explanation: 1. Increased intake of cold beverages would increase the distention through increase of gas and constipation. 2. Participating in leg exercises every 2 hours serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 3. Abdominal tightening serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 4. Ambulating as often as possible serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 5. Eating a high-protein general diet would increase the distention through increase of gas and constipation.

12) The nurse is caring for a client who plans to relinquish her baby for adoption. Which nursing actions are appropriate based on this information? Select all that apply. 1. Encourage the client to see and hold her infant. 2. Encourage the client to express her emotions. 3. Respect any special requests for the birth. 4. Acknowledge the grieving process in the client. 5. Allow for access to the infant if the client requests it.

Answer: 2, 3, 4, 5 Explanation: 1. Encouraging the client to see and hold her infant does not respect the client's right to refuse interaction, and might make her feel guilty for not wanting to see the infant. 2. Encouraging the client to express emotions is an aspect of providing care for the client who decides to relinquish her infant. 3. Respecting any special request for the birth is an aspect of providing care for the client who decides to relinquish her infant. 4. Acknowledging the grieving process is an aspect of providing care for the client who decides to relinquish her infant. 5. Allowing for access to the infant at the client's request is an aspect of providing care for the client who decides to relinquish her infant.

19) The nurse conducts discharge teaching for a postpartum client who is diagnosed with deep vein thrombosis (DVT). Which statements indicate accurate understanding of the information presented? Select all that apply. 1. "I will cross my legs while I sit and watch TV in the evening." 2. "I will wear supportive stockings if I have to stand for long periods of time." 3. "I will only have to continue taking Coumadin for 1 month once I am home." 4. "If I develop bleeding gums, I should contact my healthcare provider." 5. "I should plan to elevate my legs during times of rest."

Answer: 2, 4, 5 Explanation: 1. The client would be instructed not to cross the legs while sitting as this can increase venous stasis which further increases the client's risk for more DVTs. This statement indicates the need for further education. 2. The use of supportive stockings if the client has to stand for long periods of time is recommended when diagnosed with DVT. This statement indicates correct understanding of the information presented. 3. Clients diagnosed with a DVT will require warfarin (Coumadin) therapy for 2 to 6 months, not 1 month, after discharge. This statement indicates the need for further education. 4. Bleeding of the gums while on warfarin (Coumadin) therapy can be an indication of a dose that is too large and would be reported to the healthcare provider. This statement indicates correct understanding of the information presented. 5. The postpartum client who is diagnosed with DVT should plan to elevate the legs during times of rest. This statement indicates correct understanding of the information presented.

17) During a home visit the nurse is concerned that a new mother is experiencing postpartum blues. What did the nurse assess to make this clinical determination? Select all that apply. 1. Fear 2. Anger 3. Euphoria 4. Anorexia 5. Weepiness

Answer: 2, 4, 5 Explanation: 1. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. Fear is not commonly associated with postpartum blues. 2. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by anger. 3. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. Euphoria is not commonly associated with postpartum blues. 4. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by anorexia. 5. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by weepiness.

8) The postpartum client is diagnosed with thrombophlebitis in the right leg. Which assessment finding requires immediate intervention by the nurse? 1. Acute pain 2. Redness 3. Chest pressure 4. Edema

Answer: 3 Explanation: 1. Acute pain often accompanies diagnosis of thrombophlebitis. While the pain is important and should be addressed, this finding does not require priority nursing intervention. 2. Redness often accompanies diagnosis of thrombophlebitis. While the redness should be noted and monitored, this does not require priority nursing intervention. 3. A sudden onset of chest pain or pressure might indicate pulmonary embolus, which is a life-threatening complication of thrombophlebitis. This is the most abnormal finding, and requires immediate intervention by the nurse. 4. Edema often accompanies diagnosis of thrombophlebitis. While the swelling should be noted and monitored, this does not require priority nursing intervention.

10) The nurse is caring for an adolescent client who gave birth to her first child yesterday. Which nursing action indicates accurate understanding of adolescent parenting concepts? 1. The client's mother is included in all discussions and demonstrations. 2. The father of the baby is encouraged to change a diaper and give a bottle. 3. The nurse explains the characteristics and cues of the baby during the assessment. 4. A discussion on contraceptive methods is the first topic of teaching.

Answer: 3 Explanation: 1. Although the parents of adolescents are often involved with child care and childrearing, this action is only appropriate if the client desires to have her mother present for teaching and discussions. 2. Involvement of the father is important, but having the mother learn more about her new baby and what the behavior cues are is a higher priority. 3. This helps the client learn about her baby and understand the baby as an individual, and facilitates maternal-infant attachment. This is the highest priority. 4. Adolescents are statistically more likely to have another child during their adolescence, but establishing a rapport and facilitating understanding of and attachment to the newborn is a higher priority

11) The maternal nurse educator is conducting a presentation for antepartum clients describing the identification and care of women diagnosed with postpartum psychiatric disorders. Which information should the maternal nurse educator include in the teaching content? 1. Postpartum depression occurs in as many as 50% to 70% of mothers and is characterized by mild depression interspersed with happier feelings. 2. Postpartum depression is typically mild and usually self-limiting, lasting up to 6 weeks. 3. Even if she is asymptomatic, a woman with a history of postpartum depression should be referred to a mental health professional for counseling and biweekly visits postpartum. 4. Women with postpartum depression have a history of exposure to an extremely traumatic personal event that involves actual or threatened death or serious injury and evokes intense fear, helplessness, or horror.

Answer: 3 Explanation: 1. As many as 50% to 70% of mothers develop adjustment reaction with depressed mood, which is also known as postpartum blues or as maternal or baby blues. Unlike postpartum depression, this condition is characterized by mild depression interspersed with happier feelings. 2. Postpartum blues typically manifest as mild symptoms that are transient and self-limiting. Postpartum depression is severe and poses major threats to the woman and the infant, as well as to the father/partner. 3. Women with a history of postpartum psychosis or depression or other risk factors should be referred to a mental health professional for counseling and biweekly visits between the second and sixth week postpartum for evaluation. 4. Posttraumatic stress disorder, or PTSD (also called posttraumatic stress syndrome), is associated with exposure to an extremely traumatic event involving direct personal experience with actual or threatened death or serious injury, and evokes a reaction of intense fear, helplessness, or horror.

4) On the second day postpartum, the client who is bottlefeeding experiences engorgement. Which should the nurse encourage to enhance the client's comfort? 1. Removing her bra 2. Applying heat to her breasts 3. Applying ice packs to her breasts 4. Limiting breastfeeding to twice daily

Answer: 3 Explanation: 1. Removing her bra will only serve to increase breast milk production. A tight-fitting bra should be worn at all times for 5 to 7 days and only removed when showering. 2. Applying heat will promote breast milk production. 3. Applying ice packs to the breasts relieves discomfort through the numbing effect of ice. 4. Limiting breastfeeding to twice per day actually would decrease the flow of breast milk eventually, and would not serve to decrease the discomfort of the mother.

13) The maternal home care nurse, who is orienting a new nurse, discusses maternal psychologic adaptations and stressors. Which statement by the maternal home care nurse reflects the correct approach to addressing potential and actual postpartum depression in maternal clients? 1. "Because emotional disorders and imbalances are a very sensitive subject, we try not to offend clients by routinely bringing up the topic of postpartum depression." 2. "For women with a history of depression, we include education about postpartum depression." 3. "Teaching about postpartum depression is a routine part of education for all maternal clients." 4. "If we suspect a woman may have developed postpartum depression, then we provide specialized education about that topic."

Answer: 3 Explanation: 1. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women. 2. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women. 3. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women. 4. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women.

14) During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate? 1. "Current research suggests there are no physical risks related to cosleeping, and this recommended as a healthy psychologic approach to family bonding. 2. "Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on the stomach." 3. "Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines." 4. "Cosleeping is not recommended; however, if you wish to do this, place your baby on a comforter, as opposed to directly on the mattress."

Answer: 3 Explanation: 1. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for sudden infant death syndrome (SIDS). 2. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Families who practice cosleeping require appropriate teaching measures, which include making sure the baby is sleeping on the back, not on the stomach. 3. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Some families and cultures, however, may still participate in this practice and thus warrant appropriate teaching measures. Cosleeping families should be counseled to follow specific safety guidelines 4. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Safety guidelines related to cosleeping include placing the infant on a firm mattress, never on comforters, pillows, or a waterbed.

13) The nurse is performing an assessment of early attachment. Which action indicates that the client is pleased with the baby's appearance and sex? 1. The mother enfolds the infant in her arms. 2. The mother feeds the infant every 2 to 3 hours as instructed. 3. The mother points out family traits she sees in the newborn. 4. The mother asks questions about how to properly bathe her infant.

Answer: 3 Explanation: 1. This action can be used to assess if the mother is attracted to her newborn and is forming emotional attachments with the newborn. 2. This action can be used to assess the ability of the mother to care for the infant's needs as they arise. 3. This action will help determine if the mother is pleased with her baby's appearance. She may point out both positive and negative traits. 4. This action helps assess the mother's willingness to learn how to care for her infant.

12) The nurse is preparing material to instruct a client who has given birth to her first child. What aspect of teaching is most important? 1. Determine if father-infant attachment is taking place. 2. Discuss adaptation to grandparenthood by her parents. 3. Describe the likely reaction of siblings to the new baby. 4. Assist the mother in identifying behavior cues of the baby.

Answer: 4 Explanation: 1. Although father-infant attachment is important, the mother is the main client, and teaching her directly is a higher priority. 2. Adaptation to grandparenthood is a task for her parents and not a high priority for teaching the new mother. 3. This is not appropriate because the baby has no siblings. 4. Helping the mother to identify her baby's behavior cues facilitates the acquaintance phase of maternal-infant attachment.

11) The nurse is providing care to a postpartum client who is relinquishing custody of her newborn through an open adoption. Which nursing action is most important? 1. Assigning the client a room on the GYN surgical floor instead of the postpartum floor 2. Preparing to have teaching done in time for discharging the client at 24 hours postdelivery 3. Making an effort not to bring up the topic of the baby, and discuss the mother's health instead 4. Asking the client if she wants to feed her baby, and how much contact she wants to have

Answer: 4 Explanation: 1. Clients relinquishing their newborns should be given options for what their contact with the infant will be and where they would feel most comfortable. Make no assumptions, but assess instead. 2. Not all clients who relinquish their infants want early discharge. Make no assumptions, but assess instead. 3. The client's preferences determine how much she wants to talk about her birth, her newborn, or her decision to relinquish the child. Make no assumptions, but assess instead. 4. Assess the client's preferences by respectfully asking questions and making no assumptions to facilitate a more positive experience for the birth mother.

15) A new mother is concerned about spoiling her newborn. Which statement should the home care nurse include in this teaching session with the new mother? 1. "Spoiling occurs when an infant is rocked to sleep every night." 2. "Newborns can be manipulative, so caution is advised." 3. "Crying is good for an infant, and letting them cry it out is advised." 4. "It is important to meet your infant's needs to develop a trusting relationship."

Answer: 4 Explanation: 1. The new mother should be taught that an infant cannot be spoiled, especially by rocking the infant to sleep each night. This statement is inappropriate for the nurse to include in the teaching session. 2. Newborns are not manipulative. This statement is inappropriate for the nurse to include in the teaching session. 3. An infant should not be allowed to "cry it out" because this does not meet the infant's needs to develop a trusting relationship. This statement is inappropriate for the nurse to include in the teaching session. 4. Meeting the infant's needs develops a trusting relationship. Picking babies up when they cry teaches them that adults try to meet their needs and are responsive to them. This helps build a sense of trust in humankind.

2) During a home care visit, the new breastfeeding mother reports breast engorgement. Which statement by the home care nurse is most appropriate based on this information? 1. "Apply an ice compress to your breast before nursing." 2. "Encourage your baby to suckle for an average of 5 minutes per feeding." 3. "Apply warm compresses to your breast after you finish feeding your baby." 4. "When you are not nursing, wear a well-fitted nursing bra at all times, even when you sleep."

Answer: 4 Explanation: 1. Warm, not ice, compresses before nursing stimulate let-down and soften the breast so that the infant can grasp the areola more easily. 2. For women with breast engorgement, the infant should suckle for an average of 15 minutes per feeding and should feed at least 8 to 12 times in 24 hours. 3. Cool, not warm, compresses after nursing can help slow refilling of the breasts and provide comfort to the mother. 4. The mother should wear a well-fitted nursing bra 24 hours a day to support the breasts and prevent discomfort from tension.

Which question from a postpartum client indicates a need for further teaching about managing afterpains? a. "Can I get an ice pack for my belly to help with these cramps?" b. "Should I have my mom bring me a lysine supplement? She says it might help." c. "The baby's due to nurse in about an hour. Can I have some ibuprofen?" d. "I guess we can expect this to be worse after having twins that it was with my singleton, right?"

Answer: a. "Can I get an ice pack for my belly to help with these cramps?" Feedback: Application of heat is helpful in managing afterpains. Ice may make them feel worse. Lysine supplements and taking an analgesic an hour before feeding are helpful. Increased discomfort with afterpains can be expected following overdistention of the uterus, such as multiple gestation.

2. The highest-priority intervention the nurse must perform before resuscitating a newborn with asphyxia is: a. Inserting an endotracheal tube. b. Measuring oxygen saturation. c. Establishing effective ventilations. d. Initiating chest compressions.

Answer: c. Establishing effective ventilations. Feedback: Suctioning is always performed before resuscitation so that mucus, blood, or meconium is not aspirated into the lungs.

Immediately after delivery, the nurse performs a fundal assessment on the new mother. Which of the following findings is considered to be normal? a. The top of fundus is in the midline and at the level of the umbilicus. b. The top of fundus is in the midline and one fingerbreadth below the umbilicus. c. The top of fundus remains in the midline and descends about one fingerbreadth per day. d. The top of fundus is in the midline about midway between the symphysis pubis and umbilicus.

Answer: d. The top of fundus is in the midline about midway between the symphysis pubis and umbilicus. Feedback: The top of fundus in the midline about midway between the symphysis pubis and umbilicus is the only finding that would be considered normal immediately after delivery.

13) The day after a vaginal delivery, a client develops painful vesicular lesions on the perineum and vulva which are diagnosed as a primary herpes type 2 infection. What care should the newborn receive? 1. Intravenous acyclovir (Zovirax) and contact precautions 2. Cultures of blood and cerebrospinal fluid and serial chest x-rays every 12 hours 3. Parental rooming-in and four intramuscular injections of penicillin 4. Meticulous hand washing and antibiotic eye ointment administration

Answer: 1 Explanation: 1. For a herpes type 2 infection, intravenous acyclovir (Zovirax) is indicated. Contact precautions should be implemented. 2. These cultures are appropriate, but chest x-rays are not indicated. Chest x-rays are obtained if the neonate is thought to have group B streptococcal pneumonia. 3. Parental rooming-in is encouraged, but penicillin does not treat viral illness. Penicillin is the drug of choice for syphilitic infections. 4. Although meticulous hand washing by staff and parents is important, antibiotic eye ointment is used for conjunctivitis of gonorrhea or Chlamydia.

1) The nurse is reviewing clients scheduled for prenatal care. Which client should the nurse identify as being most likely to have a newborn at risk for mortality or morbidity? 1. 37-year-old G8 P2323, works in a chemical factory 2. 16-year-old primipara, began prenatal care at 30 weeks 3. 28-year-old G2 P1001, history of gestational diabetes 4. 23-year-old primipara, low socioeconomic status, unmarried

Answer: 1 Explanation: 1. This client is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic. 2. This client has two risk factors: young age and late onset of prenatal care. 3. This client has gestational diabetes history as the only risk factor. 4. The main risk factor for this client is a low socioeconomic status.

18) During a home visit the nurse suspects that a newborn is experiencing chlamydial conjunctivitis. What did the nurse assess to make this clinical determination? Select all that apply. 1. Eyelid swelling 2. Yellow discharge 3. Eye inflammation 4. Purulent discharge 5. Corneal ulcerations

Answer: 1, 2, 3 Explanation: 1. Manifestations of chlamydial conjunctivitis include eyelid swelling 5 to 14 days after birth. 2. Manifestations of chlamydial conjunctivitis include yellow discharge. 3. Manifestations of chlamydial conjunctivitis include eye inflammation. 4. Purulent discharge is a manifestation of ophthalmia neonatorum caused by gonorrhea. 5. Corneal ulceration is a manifestation of ophthalmia neonatorum caused by gonorrhea. Page Ref: 635

12) The nurse is caring for a newborn born to a client who abused drugs while pregnant. Which assessment findings would be common for this newborn? Select all that apply. 1. Hyperirritability 2. Transient tachypnea 3. Exaggerated reflexes 4. Decreased muscle tone 5. Depressed respiratory effort

Answer: 1, 2, 3 Explanation: 1. The newborn of a woman who abused drugs during her pregnancy is predisposed to hyperexcitability. 2. The newborn of a woman who abused drugs during her pregnancy is predisposed to transient tachypnea. 3. The newborn of a woman who abused drugs during her pregnancy is predisposed to exaggerated reflexes. 4. The newborn of a woman who abused drugs during her pregnancy will not routinely demonstrate decreased muscle tone. 5. The newborn of a woman who abused drugs during her pregnancy will not routinely demonstrate depressed respiratory effort.

13) What should be considered as potentially infectious when providing care to a newborn of a client who is HIV positive? Select all that apply. 1. Feces 2. Urine 3. Blood 4. Soiled linens 5. Feeding bottle

Answer: 1, 2, 3, 4 Explanation: 1. Body fluids such as feces are considered potentially infectious. 2. Body fluids such as urine are considered potentially infectious. 3. Body fluids such as blood are considered potentially infectious. 4. Because body fluids are considered potentially infectious, soiled linens are also potentially infectious. 5. A feeding bottle is not identified as being potentially infectious.

17) A newborn is admitted to the neonatal intensive care unit with suspected meconium aspiration. What care should the nurse expect to provide to this client? Select all that apply. 1. Dopamine infusion 2. High-pressure ventilation 3. High-level oxygen therapy 4. Surfactant replacement therapy 5. High-volume intravenous fluids

Answer: 1, 2, 3, 4 Explanation: 1. For meconium aspiration, dopamine may be prescribed to maintain systemic blood pressure. 2. High-pressure ventilation may be needed to cause sufficient expiratory expansion of obstructed terminal airways or to stabilize airways that are weakened by inflammation. 3. Treatment of meconium aspiration usually involves delivery of high levels of oxygen. 4. Surfactant replacement therapy is most effective when given as a prophylactic measure. 5. Fluids may be restricted in the first 48 to 72 hours because of the risk of cerebral edema.

14) A newborn is diagnosed with tetralogy of Fallot. What findings indicate that this client is experiencing heart failure? Select all that apply. 1. Tachypnea 2. Diaphoresis 3. Tachycardia 4. Hepatomegaly 5. Splenomegaly

Answer: 1, 2, 3, 4 Explanation: 1. Manifestations of heart failure in a newborn include tachypnea. 2. Manifestations of heart failure in a newborn include diaphoresis. 3. Manifestations of heart failure in a newborn include tachycardia. 4. Manifestations of heart failure in a newborn include hepatomegaly. 5. Splenomegaly is not a manifestation of heart failure in a newborn.

4) The nurse is caring for an infant who delivered in a car on the way to the hospital and has developed cold stress. Which finding requires immediate intervention? 1. Blood glucose level of 45 2. Vasoconstriction and pallor 3. Room temperature IV running 4. Positioned under radiant warmer

Answer: 3 Explanation: 1. This is an adequate blood sugar in a neonate. Less than 40 is hypoglycemic. 2. Vasoconstriction is the first physiologic response to a lowering temperature and will cause pallor. 3. IV fluids should be warmed prior to administration and wrapped in a blanket or other insulating material to keep them warm. Room temperature IV fluids will increase the cold stress. 4. Radiant warmers are used to gradually increase the neonate's temperature.

20) The nurse is concerned that a new mother is going to have difficulty caring for her newborn once the baby is discharged from the neonatal intensive care unit. What client behaviors are consistent with nonadaptive responses? Select all that apply. 1. Refusing to touch the infant 2. Grimacing when holding the infant 3. Expressing fear of taking the infant home 4. Asking staff questions about the infant's care 5. Blaming spouse for the infant's health problems

Answer: 1, 2, 3, 5 Explanation: 1. Nonadaptive responses include a lack of interaction with the infant during hospitalization. 2. Nonadaptive responses include a negative view of the infant. 3. Nonadaptive responses include a fear of going home with the infant. 4. Asking staff questions about the infant's care is an adaptive response. 5. Nonadaptive responses include blaming others for the infant's condition.

10) The nurse is caring for a newborn born to a client who experienced abruptio placentae. Which assessment findings suggest that the infant is experiencing anemia? Select all that apply. 1. Pallor 2. Tachypnea 3. Tachycardia 4. Elevated blood pressure 5. Capillary refill 6 seconds

Answer: 1, 2, 3, 5 Explanation: 1. Pallor is a manifestation of anemia in a newborn. 2. Tachypnea is a manifestation of anemia that is compromised in a newborn. 3. Tachycardia is a manifestation of anemia in a newborn. 4. Low blood pressure is a manifestation of anemia in a newborn. 5. Capillary refill greater than 3 seconds is an indication of anemia in a newborn.

16) A newborn has just been admitted to the special care nursery. What criteria should the nurse use to determine this newborn's classification and neonatal mortality risk? Select all that apply. 1. Length 2. Birth weight 3. Gestational age 4. Amount of lanugo 5. Occipital-frontal head circumference

Answer: 1, 2,3, 5 Explanation: 1. A newborn is assigned to a category depending on length. 2. A newborn is assigned to a category depending on birth weight. 3. A newborn is assigned to a category depending on gestational age. 4. Amount of lanugo is not used to determine the newborn's classification and neonatal mortality risk 5. A newborn is assigned to a category depending on occipital-frontal head circumference.

9) The nurse is assessing a 36-week gestational age newborn. What assessment findings indicate that a cardiac defect is present? Select all that apply. 1. Cyanosis 2. Abdominal bruit 3. Peripheral pulses 4. Signs of heart failure 5. Presence of a heart murmur

Answer: 1, 4, 5 Explanation: 1. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is cyanosis. 2. An abdominal bruit is not a sign of a cardiac defect in a newborn. 3. Peripheral pulses are not assessed to determine the presence of a cardiac defect in a newborn. 4. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is signs of heart failure. 5. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is the presence of a heart murmur.

2) What amount of weight loss, in pounds, should the nurse expect in an average postpartum client? 1. 5 to 8 2. 10 to 12 3. 12 to 15 4. 15 to 20

Answer: 2 Explanation: 1. A loss of 5 to 8 lb might occur after a preterm birth. 2. A loss of 10 to 12 lb is the usual initial weight loss. This weight is lost with the birth of the infant and the expulsion of the placenta and the amniotic fluid. 3. A loss of 12 to 15 lb does not match the usual weight of placenta, amniotic fluid, and full-term infant weight. 4. A loss of 15 to 20 lb might occur after a multiple birth.

6) An infant with type O Rh-positive blood becomes visibly jaundiced at 12 hours of age. The mother with type O Rh-negative blood asks why this has occurred. How should the nurse respond? 1. "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." 2. "Your body has made antibodies against the baby's blood that are destroying her red blood cells." 3. ""The red blood cells of your baby are breaking down because you both have type O blood." 4. "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."

Answer: 2 Explanation: 1. Although this statement is true, the term "alloimmunization" is not likely to be understood by the client. It is better to explain what is happening using more understandable terminology. 2. Alloimmune hemolytic disease, also known as erythroblastosis fetalis, occurs when an Rh-negative mother is pregnant with an Rh-positive fetus and maternal antibodies cross the placenta. Maternal antibodies enter the fetal circulation, then attach to and destroy the fetal RBCs. The fetal system responds by increasing RBC production. Jaundice is the result. 3. Mother and baby's both having type O blood is not a problem. ABO incompatibility occurs if the mother is O and the baby is A or B. 4. The infant's liver is indeed too immature to eliminate red blood cells, but the hemolysis from the maternal antibodies is the cause of the jaundice.

15) The newborn of a mother with type 2 diabetes mellitus is experiencing tremors. What nursing action has the highest priority? 1. Obtain a bilirubin level. 2. Obtain a blood calcium level. 3. Measure the newborn's temperature. 4. Place a pulse oximeter on the newborn.

Answer: 2 Explanation: 1. Bilirubin level also might be necessary to monitor, but will not cause tremors in the newborn. 2. Tremors are the classic sign for hypocalcemia. Clients with diabetes who deliver newborns tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant. 3. Body temperature also might be necessary to monitor, but will not cause tremors in the newborn. 4. Oxygen saturation also might be necessary to monitor, but will not cause tremors in the newborn.

4) On the first postpartum day, the nurse teaches a client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. What should the nurse identify as the reason for the client's memory lapse? 1. Epidural anesthesia 2. The taking-in phase 3. The taking-hold phase 4. Postpartum hemorrhage

Answer: 2 Explanation: 1. Epidural anesthesia is a pharmacologic approach to pain control. 2. The taking-in phase, which occurs during the first day or two following birth, is characterized by a passive and dependent affect. The mother also might be in need of food and rest. 3. The taking-hold phase occurs by the second or third day, when the mother is ready to resume control of life and is open to teaching. 4. Postpartum hemorrhage is a serious complication and will need medical intervention.

7) A student nurse is caring for a neonate undergoing intensive phototherapy. Which action indicates that the student understands how to provide care for an infant undergoing intensive phototherapy? 1. Assesses temperature every 6 hours 2. Assesses urine specific gravity with each voiding 3. Removes eye coverings to help keep the baby calm 4. Removes the infant from the Isolette for diaper changes

Answer: 2 Explanation: 1. Every 6 hours is too infrequent; the temperature should be assessed every 4 hours to assess for hyperthermia or hypothermia. 2. When excreted, the newborn's urine will be much darker in color/appearance because of the excreted higher conjugated bilirubin content. Darker urine can also indicate dehydration. Assessing the specific gravity will help differentiate the reason for the change in urine color. 3. Eyes should be covered at all times. 4. The infant's care should be clustered to keep the infant under the lights as much as possible. The diaper should have been changed while under the lights in the Isolette.

3) The nurse caring for a newborn on a ventilator for respiratory distress syndrome (RDS) informs the parents that the newborn is improving. Which of the following supports the nurse's assessment? 1. Increased PCO2 2. Increased urination 3. Decreased urine output 4. Increased pulmonary vascular resistance

Answer: 2 Explanation: 1. Increased PCO2 results from alveolar hypoventilation. 2. In babies with respiratory distress syndrome (RDS) who are on ventilators, increased urination may be an early clue that the baby's condition is improving. As fluid moves out of the lungs into the bloodstream, alveoli open, and kidney perfusion increases; this results in increased voiding. 3. As fluid moves out of the lungs and into the bloodstream, alveoli open, and kidney perfusion increases, thereby increasing urine output. 4. Pulmonary vascular resistance increases with hypoxia. Page Ref: 615

3) A 38-week newborn is small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? 1. Assess for facial paralysis 2. Maintain a warm environment 3. Monitor for feeding difficulties 4. Monitor for signs of hyperglycemia

Answer: 2 Explanation: 1. Large-for-gestational age (LGA) newborns often are prone to birth trauma, such as facial paralysis, due to cephalopelvic disproportion. 2. Hypothermia is a common complication of the SGA newborn; therefore, the newborn's environment must remain warm to decrease heat loss. 3. LGA newborns are more difficult to arouse to a quiet alert state and can have feeding difficulties. 4. SGA newborns are more prone to hypoglycemia.

4) A client with type 2 diabetes mellitus delivered a fetus weighing 7 lb, 14 oz 2 hours ago. The infant's blood glucose is currently 45 mg/dL. What should the nurse do? 1. Begin an IV of 10% dextrose. 2. Document the findings in the chart. 3. Feed the baby 1 oz of formula. 4. Recheck the blood sugar in 4 hours.

Answer: 2 Explanation: 1. The blood glucose of 45 mg/dL is considered a normal blood sugar reading for a neonate. No IV is needed. 2. A blood sugar of 45 mg/dL is a normal finding; documentation is an appropriate action. 3. Feeding would be appropriate if the infant's blood sugar were below 40, but this infant's reading is 45 mg/dL. 4. Infants of diabetic mothers should be fed frequently and should have their blood sugar assessed frequently. Four hours is too long a time frame.

8) A postpartum client is not going to breastfeed her newborn. What should the nurse include when teaching this client about breast care? 1. The let-down reflex 2. Lactation suppression 3. The purpose of fundal massage 4. The cause of afterpains

Answer: 2 Explanation: 1. The let-down reflex is an important teaching point for breastfeeding patients. 2. It is important to teach nonbreastfeeding patients about lactation suppression after delivery. 3. The purpose of fundal massage should be addressed when assessing the uterus and fundus, not when assessing the breasts. 4. Afterpains can be stimulated by breastfeeding. The nurse will not likely teach a nonbreastfeeding primipara about afterpains.

1) The nurse is preparing to assess assigned clients on a postpartum unit. Which client should be seen first? 1. Multipara, second day postcesarean, moderate lochia serosa 2. Primipara, day of delivery, fundus firm 2 cm above umbilicus 3. Multipara, first postpartum day, 4 cm diastasis recti abdominis 4. Primipara, first postpartum day, hypoactive bowel sounds all quadrants

Answer: 2 Explanation: 1. This client is not experiencing any unexpected findings. 2. This client is the top priority. The fundus should not be positioned above the umbilicus after delivery. This high location could indicate an overdistended bladder or uterine atony and excessive bleeding. 3. This finding is normal, especially in a multiparous client. 4. Bowel sounds are often decreased after delivery.

5) The nurse is observing a graduate nurse's assessment of a postpartum client. For which action by the graduate nurse should the nurse intervene? 1. Asking the client to void before applying clean gloves 2. Instructing visitors to leave the room prior to beginning the assessment 3. Requesting the client lie flat in bed with the head on a pillow prior to the fundal assessment 4. Discussing the effectiveness of comfort measures while performing the perineal assessment

Answer: 2 Explanation: 1. Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids. 2. The nurse should allow the client to choose whether visitors leave or remain in the room during the assessment. 3. The supine position prevents a falsely high assessment of fundal height. 4. The assessment provides an excellent opportunity for teaching about good healthcare practices in both the short and long term, including comfort measures.

7) The nurse is working with a family that just experienced the birth of their first child at 34 weeks. Which statements indicate that additional teaching is needed? Select all that apply. 1. "Our baby will be in an Isolette to keep him warm." 2. "The growth of our baby will be faster than if he were term." 3. "Breathing might be harder for our baby because he is early." 4. "Tube feedings will be required because his stomach is small." 5. "Because he came early, he will not produce urine for 2 days."

Answer: 2, 4, 5 Explanation: 1. Preterm infants have little subcutaneous fat and have difficulty maintaining their body temperature. An Isolette or overhead warmer is used to keep the baby warm. 2. Preterm infants grow more slowly than do term infants. 3. Surfactant production might not be complete at 34 weeks, which leads to respiratory distress syndrome. In addition, respiratory effort is increased when the ductus arteriosus remains patent, which is common in preterm infants. 4. Although tube feedings might be required, it would be because preterm babies lack sufficient suck and swallow reflexes to prevent aspiration. 5. Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they will make urine.

12) A newborn delivered via cesarean birth at 32 weeks to a mother who experienced placenta previa has a low pulse rate, low blood pressure, and a capillary filling time of 3.6 seconds. Which interventions are indicated for the care of this newborn? Select all that apply. 1. Start the infant on phototherapy. 2. Start the infant on iron supplements. 3. Have isotonic saline ready for transfusion. 4. Draw several vials of blood for laboratory testing. 5. Monitor the infant's cardiac and respiratory status. 6. Have O-negative packed red cells ready for a transfusion.

Answer: 2, 5, 6 Explanation: 1. Phototherapy should only be started if the infant has jaundice. 2. Iron supplements should be given to help increase red blood cell production. 3. Isotonic saline transfusion is not used to treat anemia. 4. Blood draws should be kept to a minimum for clients with anemia. 5. This is an appropriate nursing intervention. Monitoring the infant's cardiac and respiratory status will allow the nurse to detect symptoms of shock and assess the effectiveness of treatment. 6. Clients with severe anemia will need a blood transfusion. If the infant's blood type is not known, O-negative packed red cells can be used for transfusions. If the infant's blood type is known, the appropriate typed and cross-matched packed red cells should be used.

2) A client has delivered a small-for-gestational-age (SGA) infant. What long-term effect should the nurse recognize that this infant is at risk for experiencing? 1. Permanent disfiguration 2. Paralysis below the hips 3. Poor fine motor coordination 4. Thin and underweight as a child to overweight or obese as an adolescent

Answer: 3 Explanation: 1. Although it may occur, disfiguration is not commonly associated with SGA infants. Instead, disfiguration is more likely to remain in infants with congenital anomalies such as cleft lip/cleft palate, even after corrective surgery. 2. Many infants with myelomeningocele will suffer life-long paralysis below the site of the cyst. Paralysis is not generally associated with SGA infants. 3. SGA infants are likely to develop cognitive disabilities such as poor fine motor coordination, hyperactivity, learning disabilities, and hearing loss. 4. This long-term effect is often seen in children with fetal alcohol syndrome, not SGA.

11) A newborn is diagnosed with fetal alcohol syndrome (FAS). Which statement indicates that the parents require additional teaching about this health problem? 1. "He might be a fussy baby because of this." 2. "His face looks like it does due to this problem." 3. "Cuddling and rocking will help him stay calm." 4. "Our baby's heart murmur is from this syndrome."

Answer: 3 Explanation: 1. FAS babies are easily overstimulated and have feeding difficulties, leading to more crying than an average baby does. 2. Facial characteristics of the FAS child include a broad and flat nasal bridge, wide-set eyes, small chin, and smooth philtrum. 3. FAS babies are easily overstimulated and tend to cry more if swaddled, cuddled, or rocked. A dark and quiet environment helps keep the child calm. 4. Ventral and atrial septal defects are common in babies with FAS.

8) The nurse is caring for an infant with abdominal contents protruding at the location of the umbilicus. What statement differentiates between omphalocele and gastroschisis? 1. With omphalocele, the abdominal contents are not covered with a sac; with gastroschisis, the abdominal contents are covered by a sac. 2. With omphalocele, the abdominal contents are covered with a sac; with gastroschisis, the abdominal contents are not covered by a sac. 3. With omphalocele, the abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord. 4. With omphalocele, the abdominal contents protrude to the right of an intact umbilical cord; with gastroschisis, the abdominal contents protrude into the base of the umbilical cord.

Answer: 3 Explanation: 1. If the abdominal contents are covered by a sac, it is omphalocele. However, if the abdominal contents are not covered by a sac, it could be either omphalocele or gastroschisis. The better way to differentiate between omphalocele and gastroschisis is that the abdominal contents protrude into the base of the umbilical cord in omphalocele but protrude to the right of the umbilical cord in gastroschisis. 2. If the abdominal contents are covered by a sac, it is omphalocele. However, if the abdominal contents are not covered by a sac, it could be either omphalocele or gastroschisis. The better way to differentiate between omphalocele and gastroschisis is that the abdominal contents protrude into the base of the umbilical cord in omphalocele but protrude to the right of the umbilical cord in gastroschisis. 3. This is the correct way to differentiate between omphalocele and gastroschisis. 4. This is the opposite description of gastroschisis and omphalocele. With omphalocele, the abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord.

10) In the special care nursery, the nurse places an infant with hydrocephalus in the prone position and is careful to thoroughly cleanse the perineum after bowel movements. What was this infant most likely born with? 1. Omphalocele 2. Gastroschisis 3. Myelomeningocele 4. Diaphragmatic hernia

Answer: 3 Explanation: 1. Omphalocele is a herniation of abdominal contents into the base of the umbilical cord. Positioning on the abdomen would be detrimental. Hydrocephalus is not associated with omphalocele. 2. Gastroschisis is a full-thickness defect of the abdominal wall, resulting in the abdominal organs' being located on the outside of the body. Positioning on the abdomen would be detrimental. Hydrocephalus is not associated with this condition. 3. Myelomeningocele is a neural tube defect in which the meninges and spinal cord are exposed. Surgical repair is undertaken to prevent encephalitis. Meticulous cleaning of the perineum helps prevent infection. The infant is positioned prone to prevent pressure on the defect. Hydrocephalus often is present. 4. Diaphragmatic hernia is incomplete formation of the diaphragm, resulting in bowel and sometimes stomach extending upward through the defect and being located in the chest cavity. Respiratory distress is the primary symptom. Surgical repair is required for normal respiratory function if the lungs have not been compromised by crowding from abdominal organs. Positioning should be high Fowler to facilitate respiratory efforts. Hydrocephalus is not associated with this condition.

9) The mother of a 4-day-old infant is concerned that the infant's skin tone is yellow and asks if the baby should be hospitalized. What should the nurse consider as being the cause of this infant's skin color change? 1. Pathologic jaundice 2. Physiologic jaundice 3. Acute bilirubin encephalopathy 4. Hemolytic disease of the newborn

Answer: 3 Explanation: 1. Pathologic jaundice usually appears before 24 hours of life and is the result of a more serious underlying condition. 2. Infants can develop physiologic jaundice 4 to 5 days after birth as a result of a shortened red blood cell life span, slow uptake of bilirubin by the liver, a lack of intestinal bacteria, or poorly established hydration from initial breastfeeding. 3. Acute bilirubin encephalopathy, or kernicterus, is a serious medical condition resulting from very high bilirubin levels as a result of pathologic jaundice. This is unlikely to occur with physiologic jaundice. 4. Hemolytic disease of the newborn occurs as a result of blood incompatibility between the mother and infant and is usually diagnosed shortly after birth.

8) An infant born to a client with type 2 diabetes mellitus is lethargic, has a high-pitched cry, and has an initial plasma glucose level of 19 mg/dL. What should the nurse do immediately? 1. Have the mother breastfeed the infant. 2. Start an IV with D5W dextrose solution. 3. Start an IV with D10W dextrose solution. 4. Wait 30 minutes and retest plasma glucose levels.

Answer: 3 Explanation: 1. This is an appropriate nursing action if the infant's plasma glucose levels are between 25 and 40 mg/dL. This infant needs more aggressive treatment. 2. D5W dextrose is primarily use to either prevent hypoglycemia or titrate down the concentration of administered glucose when the infant is transitioning off the glucose. A higher concentration of glucose is required for severely hypoglycemic infants. 3. This is the proper nursing action. Infants with severe hypoglycemia should be aggressively treated with IV infusion of D10W dextrose. 4. This infant is suffering from severe hypoglycemia. Aggressive treatment with D10W dextrose by IV is recommended. Page Ref: 624

7) A postpartum client becomes concerned when a gush of blood occurs during the fundal assessment. What should the nurse explain about this occurrence? 1. "Do not worry. I will make sure everything is fine." 2. "We see this from time to time. It's not a big deal." 3. "Blood has pooled in the vagina while you were in bed." 4. "The gush is an indication that your fundus is not contracting."

Answer: 3 Explanation: 1. This response is not therapeutic because it focuses on the nurse and has a "do not worry" aspect that is demeaning. 2. Although a gush of blood during fundus assessment is fairly common, this response is not therapeutic because it does not address the client's concern. 3. Because of the angle of the vagina, lochia pools in the vagina while a woman is lying or semisitting in bed, which leads to a gush when fundal massage is performed. 4. The fundus might be contracting well. The gush is from pooled lochia in the vagina.

5) Place the following nursing interventions related to resuscitation in the correct order according to complexity of the method and seriousness of the infant's condition. 1. Perform chest compressions. 2. Administer epinephrine. 3. Rub the infant's back with a blanket. 4. Administer 21% oxygen in a positive-pressure ventilator. 5. Administer 100% oxygen in a positive-pressure ventilator

Answer: 3, 4, 5, 1, 2 Explanation: 1. Chest compressions should only be performed if the infant's heart rate is below 60 beats/min despite 30 seconds of effective positive-pressure ventilation. 2. Epinephrine should be administered when the heart rate remains below 60 beats/min despite 45 to 60 seconds of chest compressions and ventilation. 3. Rubbing the infant's back is the least invasive therapy and should be attempted before any other resuscitation method. 4. If rubbing the back does not establish adequate breathing, the infant should be placed on 21% oxygen with a positive-pressure ventilator. 5. Oxygen should be increased from 21% to 100% before chest compressions begin.

6) A client pregnant at 41 weeks asks if labor induction is necessary. Which response is best for the nurse to make? 1. "The healthcare provider wants to be proactive in preventing any problems with your baby if the baby gets any bigger." 2. "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." 3. "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." 4. "Babies can develop postmaturity syndrome, which increases their chances of having complications after birth." Answer: 4

Answer: 4 Explanation: 1. Although this is true, the answer is incomplete. The risk of postmaturity syndrome is also an issue. 2. Although this statement is true, it is too vague. It is better to be specific and call postmaturity syndrome by its name. 3. Although this statement is partially true, meconium-stained amniotic fluid is not always present or the only complication of postmaturity syndrome. 4. This statement is correct. Babies older than 41 weeks' gestation are prone to developing postmaturity syndrome. Page Ref: 575

1) At birth, an infant newborn has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best? 1. Assess blood pressure. 2. Deep suction the airways. 3. Begin chest compressions. 4. Begin bag-and-mask ventilation.

Answer: 4 Explanation: 1. Establishment of airway and breathing take priority over assessment of blood pressure. 2. This would be appropriate if there were meconium-stained fluid. There is no information about the amniotic fluid. 3. Chest compressions are not initiated until the heart rate is less than 60 and respirations have been established. 4. When an infant is not breathing and has poor muscle tone, bag-and-mask ventilation is the appropriate resuscitation measure.

14) The mother of a severely premature infant is being prepared to see her baby for the first time. The infant has an IV and a feeding tube, is receiving phototherapy, and is being monitored for cardiac and respiratory functioning. What information would be the least supportive for the mother at this time? 1. Wash hands before holding the infant. 2. The infant has tubes and monitoring equipment in place. 3. The appearance of the different machines and tubes attached to the infant. 4. Avoid touching the infant because the baby's skin is fragile and could be easily hurt.

Answer: 4 Explanation: 1. If the mother is going to hold her infant, she will need to thoroughly wash her hands to decrease the risk of infection. 2. The nurse should prepare the mother for what her infant will look like, especially if the infant is hooked up to several machines or tubes. 3. Seeing her child for the first time can be emotionally difficult for a mother, but a description of the equipment and its purpose will help the mother understand the care her child is receiving and help ease her anxiety. 4. Physical contact between the mother and infant will facilitate bonding and should be encouraged.

11) A newborn is diagnosed with sepsis. What finding should the nurse use to suspect this health problem? 1. Irritability and flushing of the skin at 8 hours of age 2. Respiratory distress syndrome developed 48 hours after birth 3. Bradycardia and tachypnea develop when the infant is 36 hours old 4. Temperature of 97.0°F 2 hours after warming the infant from 97.4°F

Answer: 4 Explanation: 1. Irritability or lethargy with pallor after the first 24 hours might indicate sepsis, especially if skin is cool and clammy. 2. Respiratory distress developing at 12 to 24 hours of age might indicate sepsis. 3. Tachycardia and periods of apnea are seen with sepsis, especially within the first 24 hours of life. 4. Temperature instability is often seen with sepsis. Fever is rare in a newborn.

3) What should the nurse assess to determine healing of the uterus at the placental site? 1. Laboratory values 2. Uterine size 3. Blood pressure 4. Type, amount, and consistency of lochia

Answer: 4 Explanation: 1. Laboratory values are too vague, since the actual values are not identified. 2. Uterine size alone is not enough to assess the placental site. 3. Blood pressure varies slightly in the normal postpartum client and would not affect the placental site. 4. Type, amount, and consistency of lochia determine the stage of healing of the placental site, which occurs by a process of exfoliation.

2) A 2-hour-old newborn delivered by cesarean section at 38 weeks with clear amniotic fluid has a respiratory rate of 80 with grunting and nasal flaring. The mother experienced preeclampsia while pregnant. What is the most likely cause of this infant's condition? 1. Prematurity of the neonate 2. Respiratory distress syndrome 3. Meconium aspiration syndrome 4. Transient tachypnea of the newborn

Answer: 4 Explanation: 1. The infant is not premature. Prematurity alone does not cause respiratory distress; the lack of surfactant causes respiratory distress syndrome. 2. The infant is not premature and therefore is not likely to be experiencing respiratory distress syndrome. 3. There was no meconium in the amniotic fluid, which rules out meconium aspiration syndrome. 4. The infant is term and born by cesarean section. The baby is most likely experiencing transient tachypnea of the newborn.

1. What factors influence the outcomes of the at-risk newborn? (Select all that apply.) a. Birth weight b. Gestational age c. Type and length of newborn illness d. Environmental factors e. Maternal factors

Answer: a. Birth weight; b. Gestational age; c. Type and length of newborn illness; d. Environmental factors; e. Maternal factors Feedback: All are correct. Maternal factors such as age and parity, newborn weight, and gestational age also influence outcomes, as do environmental factors such as exposure to environmental dangers (toxic chemicals and illicit drugs).

What is the nurse's chief concern when a mother who delivered 2 hours ago has a blood pressure change from 112/70 to 142/94? a. Developing preeclampsia b. Fluid overload c. Puerperal hypertension d. Worsening systolic heart murmur

Answer: a. Developing preeclampsia Feedback: This is a significant increase in the blood pressure, and the most dangerous complication at this point is the occurrence of preeclampsia. In a postpartum woman, diuresis should control the fluid volume and hypertension should not develop. A heart murmur would more likely cause symptoms of heart failure.

1. The need for resuscitation of the newborn at risk can be anticipated if what risk factors are present? (Select all that apply.) a. Difficult birth b. Fetal scalp/capillary blood sample pH > 7.3 c. Prolonged labor d. Significant intrapartum bleeding

Answer: a. Difficult birth; c. Prolonged labor; d. Significant intrapartum bleeding Feedback: Neonatal risk factors for resuscitation are as follows: Nonreassuring fetal heart rate pattern; difficult birth; fetal scalp/capillary blood sample acidosis; history of meconium in amniotic fluid; apneic episode; inadequate ventilation; male infant; prematurity; SGA; multiple births; structural lung abnormality; congenital heart disease; and sepsis with cardiovascular collapse.

8. The nurse is caring for a baby in the special care nursery whose mother did not have prenatal care. His gestational age is estimated to be 34 weeks and he displays features and behaviors that are consistent with Fetal Alcohol Spectrum Disorder. When reviewing his orders, which of the following should the nurse be sure is included? a. Echocardiogram (ultrasound of the heart) b. Thyroid function panel c. IV pyelogram (scan of the kidneys with contrast) d. Ophthalmology consult

Answer: a. Echocardiogram (ultrasound of the heart) Feedback: Fetal Alcohol Spectrum Disorder is associated with congenital heart malformations, so this infant should have the structure of his heart examined by ultrasound. FASD is not associated with thyroid, kidney, or eye abnormalities. .

Which parameters would the nurse use to judge how well postpartum involution is progressing? (Select all that apply.) a. Fundal height b. Fundal position c. Amount of lochia d. Odor of lochia

Answer: a. Fundal height; b. Fundal position; c. Amount of lochia; d. Odor of lochia Feedback: The nurse can make the determination that involution is progressing in a normal manner by assessing two parameters: (1) that the fundus is descending into the pelvis at a normal rate and that it is contracted; a firm, midline fundus indicates normal involution; and (2) the amount and character of lochia. Excessive or foul-smelling lochia indicates problems.

A nurse is assigned to care for four postpartum clients. Which client would be least likely to request relief for afterpains? a. Gravida 1, para 1 with a 16-hour labor b. Gravida 2, para 1 with hydramnios c. Gravida 5, para 4 with twins d. Gravida 3, para 2 who is breastfeeding

Answer: a. Gravida 1, para 1 with a 16-hour labor Feedback: Afterpains are intermittent uterine contractions, and since a primipara's uterus is able to maintain a steady contracted state, afterpains are not as severe. Afterpains may result from hydramnios with an overdistended uterus, multiparity caused by an overdistended uterus, or breastfeeding, which stimulates the release of oxytocin during suckling. In these situations, the uterus works harder to maintain a contracted state, causing afterpains.

3. Understanding the transition from intrauterine to extrauterine life, what intervention is most appropriate when working with an infant of a diabetic mother? a. Make frequent blood glucose checks. b. Obtain lab work to look for infection. c. Administer IV fluids. d. Place under a radiant warmer bed immediately

Answer: a. Make frequent blood glucose checks. Feedback: Lab work, IV fluids, and the radiant warmer bed may all be required for interventions for the infant of a diabetic mother, if the infant is experiencing signs of respiratory distress or sepsis. Frequent blood glucose checks need to be completed to ensure that blood glucose levels are being maintained.

A nurse is assessing a client 2 hours postpartum. Her blood pressure is 98/60, pulse is 90, and she has saturated two pads in the last hour. What should be the immediate nursing action? a. Massage the fundus until firm. b. Increase the rate of the intravenous infusion. c. Notify the primary healthcare provider or nurse-midwife. d. Obtain an order to catheterize the client.

Answer: a. Massage the fundus until firm. Feedback: The initial action is to assist the fundus to remain contracted, which will decrease bleeding. The fundus is checked frequently for firmness, and if it is boggy, the fundus is massaged until firm. Increasing the rate of the intravenous infusion may be necessary, but it is not the immediate action. The primary healthcare provider or nurse-midwife is notified only if fundal massage is not effective. A catheterization will help if the bladder is overdistended, but would not be an initial intervention.

A client is 24 hours postpartum and saturating a pad every 2 hours with lochia rubra. Her fundus is at the umbilicus. Based on these findings, what medication would the nurse anticipate the primary healthcare provider or nurse-midwife ordering for this client? a. Methylergonovine maleate (Methergine) b. Oxycodone (Percodan) c. Ibuprofen (Motrin) d. Carboprost (Hemabate)

Answer: a. Methylergonovine maleate (Methergine) Feedback: Methergine is the treatment of choice for subinvolution. Percodan and Motrin are ordered for pain management. Hemabate is used for immediate postpartum hemorrhage related to uterine atony.

A nurse is caring for a 48-hour-postpartum client who complains of urinary frequency and dysuria. Her temperature is 100.2°F, pulse 72, respirations 18, and blood pressure 108/72. What is the most appropriate nursing intervention? a. Obtain a clean-catch urine specimen. b. Administer antibiotics. c. Obtain a catheterized urine specimen for culture and sensitivity. d. Administer anti-inflammatory medication for discomfort.

Answer: a. Obtain a clean-catch urine specimen. Feedback: Frequency and dysuria warrant further investigation, and a clean-catch urine specimen could identify the causative organism if an infection were present. It is inappropriate to administer antibiotics before confirming presence of infection. Collecting a catheterized specimen would be inappropriate because the procedure may increase the chance of introducing an infection through the catheter into the bladder. Administering an anti-inflammatory medication at this time is inappropriate, although an antispasmodic medication may be helpful.

Obesity places women at increased risk for which postpartum complication? a. Thrombophlebitis b. Uterine atony c. Postpartum depression d. Low milk production

Answer: a. Thrombophlebitis Feedback: Obese women are at increased risk for thrombophlebitis in the postpartum period because of decreased mobility and preexisting vascular problems. Uterine atony is caused by a full bladder, retained products of conception, or failure of the uterus to contract after overdistention from multiple pregnancy or hydramnios. Obesity does not contribute to this. Postpartum depression is multifactorial and caused by hormonal changes or psychosocial factors. Low milk production is caused by inadequate breast stimulation, postpartum hemorrhage, or breast abnormalities.

The nurse knows that the client understands the discharge instructions after receiving a rubella vaccination when she overhears her client tell her husband: a. "I will need to keep out of the sun for 1 month." b. "I must avoid getting pregnant for 28 days." c. "I must be very cautious when I get out of bed." d. "I should avoid foods and beverages that contain caffeine."

Answer: b. "I must avoid getting pregnant for 28 days." Feedback: A client receiving a rubella vaccination must avoid getting pregnant for 28 days following administration.

11. The parents of a preterm baby express concern that vaccinations will "overload" the baby's immune system and tell the nurse they are thinking of declining them. What is the nurse's best response? a. "That's a wise idea. Talk to your pediatrician about a delayed vaccination schedule for when the baby is stronger." b. "Preterm babies tolerate vaccines very well and are at higher risk from vaccine-preventable diseases." c. "There is mounting evidence that vaccine safety is unproven, so many people are avoiding them altogether." d. "Not vaccinating your baby is irresponsible. Declining will trigger an inquiry from child protection agencies."

Answer: b. "Preterm babies tolerate vaccines very well and are at higher risk from vaccine-preventable diseases." Feedback: The parents should be informed that, because preterm infants have immature immune systems, it is especially important for them to be vaccinated according to American Academy of Pediatrics recommendations. There is no evidence in favor of a delayed vaccination schedule. The risk/benefit ratio of childhood vaccinations is well established in their favor. It is important for the nurse to avoid judgmental and threatening language that may alienate the parents and make them less receptive to teaching

The nurse is counseling a woman who has been diagnosed with mastitis. Which statement from the client indicates a need for further teaching? a. "I will call if I have any more fevers over 100.4°F." b. "So, now I have to go get some formula, since the baby won't be able to nurse until this gets better." c. "I'll make sure to massage the area so it will drain better." d. "I'll let you know if it's not better in a couple of days."

Answer: b. "So, now I have to go get some formula, since the baby won't be able to nurse until this gets better." Feedback: The client should nurse the baby as much as possible because milk stasis is a factor in the development of mastitis. The microorganism responsible for the infection is likely to have come from the infant's mouth, so the baby is at no risk from continuing to nurse. Stating that breast massage and calling with fever or lack of symptom resolution are necessary indicates the client has understood the nurse's teaching.

11. The nurse is caring for an infant born precipitously at 29 weeks' gestation. The mother presented for care in active labor and was hospitalized for approximately 4 hours before the baby was born. On day 1 of life, the infant is diagnosed with respiratory distress syndrome and the mother asks what is causing this problem. What is the nurse's best response? a. "When babies are born very small, they are not strong enough to breathe properly." b. "Term babies produce a substance that allows the air sacs in their lungs to inflate. Your baby doesn't have that yet." c. "Since your baby can't nurse, low blood sugar has depressed the respiratory centers in his brain." d. "Preterm babies are very susceptible to infection. Your baby has a lung infection similar to pneumonia."

Answer: b. "Term babies produce a substance that allows the air sacs in their lungs to inflate. Your baby doesn't have that yet." Feedback: Respiratory distress syndrome (RDS) in the preterm infant is precipitated by inability to ventilate the lungs due to a lack of alveolar surfactant. Lung maturity has a much larger impact on outcomes for preterm infants than size at birth. Low blood sugar may exacerbate any problems the preterm infant is experiencing but is not the cause of RDS. Preterm babies have immature immune systems and are susceptible to infection, but this is not the cause of RDS.

Which women are at increased risk of developing endometritis after giving birth? (Select all that apply.) a. A woman giving birth to her first child b. A woman who had a cesarean delivery c. A woman who had an intrauterine pressure device used during labor d. A woman who had a forceps-assisted vaginal birth e. A woman who has a grand multiparity

Answer: b. A woman who had a cesarean delivery; c. A woman who had an intrauterine pressure device used during labor; A woman who had a forceps-assisted vaginal birth Feedback: Parity, being either a first-time mother or the mother of many children, is not a risk factor for uterine infection. Use of any instrumentation, such as in a cesarean birth, in a forceps-assisted delivery, or an intrauterine pressure catheter, greatly increases the chances of infection.

A nurse is caring for a 6-hour-postpartum client who is experiencing perineal discomfort. Which intervention is most appropriate for the nurse to implement? a. Application of warm compresses to the perineum b. Application of an ice pack to the perineum c. Administration of Methergine 0.2 mg d. Contacting the primary healthcare provider/CNM for new orders

Answer: b. Application of an ice pack to the perineum Feedback: Ice packs applied to the perineum for the first 24 hours help reduce edema and promote comfort. Warm compresses do not help reduce edema. Methergine is used to stimulate the uterus to contract, and is not indicated for relief of perineal discomfort. There is no indication to call the primary healthcare provider/CNM, because perineal discomfort is common in postpartum women.

The nurse caring for a postpartum client with an episiotomy notes that the client complains of rectal pressure and increasing perineal pain. What is the priority assessment for the nurse to make at this time? a. Assess bowel status for timing of last bowel movement. b. Assess for a vaginal hematoma. c. Assess the approximation of sutures. d. Assess for incomplete bladder emptying.

Answer: b. Assess for vaginal hematoma. Feedback: An enlarging vaginal hematoma causes rectal pressure and perineal pain, particularly if the hematoma is on the posterior vaginal area. If the sutures become disrupted, the client will have severe perineal pain, but usually will not have rectal pressure. Incomplete emptying of the bladder may cause increased bleeding and abdominal discomfort. The nurse may want to assess bowel habits, but the determination of hemorrhage takes priority over bowel movements.

5. When transitioning a preterm, SGA infant to oral feeding, the most important nursing consideration is: a. Limiting calories to avoid overloading the GI system. b. Closely observing for signs of fatigue to avoid calorie expenditure greater than intake. c. Limiting parental involvement to be sure the proper technique is maintained. d. Making the transition as rapid as possible, so gavage feeding can be discontinued.

Answer: b. Closely observing for signs of fatigue to avoid calorie expenditure greater than intake. Feedback: Fatigue is a significant problem for preterm infants, who may expend more energy on attempting to feed than they are able to take in. Preterm infants have increased caloric requirements. Volume and duration of feeding, not calories, may be limited. Parental involvement should be encouraged and any feeding transitions should be gradual.

12. What is the best way for the nurse to determine adequate hydration in the preterm infant? a. Examination of the skin and mucous membranes b. Daily or twice-daily weight c. Urinary catheterization and measurement of urine output d. Observation for a sunken anterior fontanelle

Answer: b. Daily or twice-daily weight Feedback: The most effective method for assessing a preterm infant's hydration status is close monitoring of weight. The skin of preterm infants may be thin and friable, making identification of dehydration based on skin turgor more difficult. Urinary catheterization places the infant at a higher risk for trauma and infection. Sunken fontanelles are a late sign of dehydration. Interventions should be implemented before this occurs.

A nurse is caring for a client who is 4 hours postpartum with postpartum hemorrhage. Which nursing diagnosis has the highest priority? a. Knowledge Deficit related to lack of information about signs of postpartum hemorrhage b. Fluid Volume Deficit related to blood loss secondary to uterine atony c. Fatigue related to anemia from postpartum bleeding d. Activity Intolerance related to enforced bedrest to control postpartum bleeding

Answer: b. Fluid Volume Deficit related to blood loss secondary to uterine atony Feedback: Fluid volume deficit takes priority because blood loss can cause more severe and more life-threatening problems. Knowledge Deficit may be appropriate for delayed postpartum hemorrhage, but is not a priority. Fatigue and activity intolerance are not priorities over fluid volume deficit.

Which of the following is the best strategy for minimizing discomfort associated with milk production for a formula-feeding mother? a. Encourage the woman to pump milk from her breasts several times a day to relieve swelling. b. Instruct her to wear a tight-fitting bra as much as possible. c. Suggest she apply heat to her breasts to relieve soreness. d. Tell her that letting the shower run on her breasts every morning will help discourage milk production.

Answer: b. Instruct her to wear a tight-fitting bra as much as possible. Suppression of milk production is best achieved by minimizing stimulation to the breasts. Pumping, applying heat, and letting the shower run on the breasts stimulate milk production and letdown.

9. The preterm newborn is experiencing vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea. What is the best explanation for these symptoms? a. Traumatic birth b. Maternal substance abuse c. Sepsis d. Gestational diabetes

Answer: b. Maternal substance abuse Feedback: The severity of withdrawal that an infant experiences can be assessed by using a scoring system. These symptoms are based on observations and measurement of the responses to neonatal abstinence from substances. It evaluates the infant on potentially life-threatening signs such as vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea.

A nurse is assessing four postpartum clients with vaginal births. Which one is most at risk for uterine atony? a. The client who had epidural anesthesia b. The client who had an oxytocin induction c. The client who had a cerclage d. The client who had a breech presentation

Answer: b. The client who had an oxytocin induction Feedback: Oxytocin inductions may cause uterine atony after delivery. Epidural anesthesia and breech presentations are more likely to be risk factors for perineal lacerations. A cerclage is performed for an incompetent cervix, which is not a risk factor for uterine atony.

7. Which of the following may indicate hemolytic disease of the newborn? a. The placenta is decreased in size. b. The neonate demonstrates pleural and pericardial effusion. c. The infant's bilirubin level is decreased. d. The neonate's spleen and liver are abnormally small.

Answer: b. The neonate demonstrates pleural and pericardial effusion. Feedback: The neonate demonstrating pleural and pericardial effusion may indicate hemolytic disease. A decrease in size of the placenta, decreased bilirubin level, and abnormally small spleen and liver are not indicators of this disease.

A nurse is caring for a couple in the birthing center. Which parent-infant behaviors should the nurse investigate further? a. The parents change diapers when needed. b. The parents complete activities silently without looking at the baby. c. The parents position the baby comfortably. d. The parents demonstrate eye-to-eye contact with the baby.

Answer: b. The parents complete activities silently without looking at the baby. Feedback: Good attachment behaviors include seeking eye contact with the baby and talking to the baby during caretaking activities; the nurse should investigate the behaviors when these are not observed. Changing diapers, positioning the baby comfortably, and eye-to-eye contact are additional appropriate behaviors that enhance parent-infant attachment.

9. Why would a primary healthcare provider order a Coombs' test? a. To determine the blood type of the infant b. To determine whether jaundice is due to Rh or ABO incompatibility c. To determine a positive left shift indicating possible infection d. To check hemoglobin and hematocrit levels

Answer: b. To determine whether jaundice is due to Rh or ABO incompatibility Feedback: The Coombs' test is performed to determine whether jaundice is due to Rh or ABO incompatibility. The actual blood type of the infant does not affect Coombs' testing, and hemoglobin and hematocrit testing will also not effect Coombs' tests. A left shift has to do with a complete blood count; a primary healthcare provider would look at a left shift if considering sepsis as a diagnosis.

Which woman having unprotected sex is most at risk for an unintentional pregnancy during the postpartum period? a. A non-nursing mother who is 4 weeks postpartum b. A nursing mother who is 6 weeks postpartum c. A non-nursing mother who is 8 weeks postpartum d. A nursing mother who is 10 weeks postpartum

Answer: c. A non-nursing mother who is 8 weeks postpartum Feedback: In non-nursing mothers, menstrual periods generally return in 6-10 weeks. They may ovulate prior to the first period. Nursing mothers usually have their first menstrual period delayed for at least 3 months, and they are prone to anovulatory cycles, putting them at lower risk for pregnancy. However, any mother can ovulate before her first period, so every mother should use protection if she wishes to delay a subsequent pregnancy.

A 24-year-old primipara is rooming in with her new infant. Which behavior indicates a need for further assessment? a. Verbalizing concerns over the shape of the baby's head b. Reluctance to hand the baby to staff for assessment c. Allowing the baby to cry in the bassinette and learn self-soothing d. Keeping the baby constantly on her chest

Answer: c. Allowing the baby to cry in the bassinette and learn self-soothing Feedback: The mother should be responsive to the newborn at this time. Failure of the mother to respond to the infant's needs may indicate disordered bonding or the need for further teaching on normal newborn behavior. Being reluctant to give the baby to staff for assessments, verbalizing concern about possible injury to the baby, and holding it for long periods are signs of appropriate bonding

The nurse receives a distressed phone call from a new father. He reports his wife is "not herself", "doesn't know what's going on", and has "said some crazy things." What is the most appropriate advice for this father? a. Make sure the mother spends as much time with the baby as possible to improve bonding. b. Reassure him that this will improve once she gets adequate sleep. c. Arrange care for the baby and take her to the emergency department for immediate evaluation. d. Advise him that a psychiatric referral will be arranged in the upcoming week.

Answer: c. Arrange care for the baby and take her to the emergency department for immediate evaluation. Feedback: Bizarre behavior, confusion, and irrational speech are signs of postpartum psychosis, which requires immediate evaluation and treatment due to the risk of harm to the client or baby. The father should not attempt to intervene at home and treatment cannot be delayed by outclient referral.

A nurse is assessing the lochia in a 24-hour-postpartum client, and expresses blood clots with fundal massage. What would be the most appropriate initial nursing action? a. Assess activity pattern. b. Monitor vital signs. c. Ask the client to empty her bladder. d. Administer analgesics.

Answer: c. Ask the client to empty her bladder. Feedback: It is important to empty the bladder and monitor urine output to assess whether the bladder is emptying regularly, as a distended bladder may prevent the uterus from contracting, leading to a collection of blood and the formation of blood clots. Increasing activity too soon may cause persistent lochia rubra but not blood clots. Assessment of vital signs is important, but not the most immediate intervention for increased vaginal flow, especially if signs and symptoms of infection are present. Administering analgesics is an important intervention for cramping.

12. The nurse is assisting at the birth of a term baby after a normal prenatal and labor course. The membranes rupture spontaneously during the second stage and there is significant meconium staining. At birth, the baby is fully flexed and centrally pink with a lusty cry. What is the most appropriate nursing action? a. Call for transfer to the neonatal intensive care unit for further evaluation. b. Place the baby on a radiant warmer and deep suction the nose and pharynx. c. Dry the baby and continue assessment on the mother's chest. d. Place the baby on a radiant warmer and administer oxygen by mask.

Answer: c. Dry the baby and continue assessment on the mother's chest. Feedback: Newborns who are vigorous at birth in the setting of meconium-stained fluid do not require any special intervention. They are able to clear meconium from their lungs effectively and, if the Apgar scores are reassuring, are very unlikely to develop meconium aspiration syndrome. Evaluation in a special care nursery, suctioning, and supplemental oxygen are only required if the infant shows signs of asphyxia at birth.

4. Which is the most appropriate nursing diagnosis for a newborn who has meconium aspiration syndrome? a. Pain b. Hyperthermia c. Impaired Gas Exchange d. Altered Nutrition: More than Body Requirements

Answer: c. Impaired Gas Exchange Feedback: Meconium aspiration syndrome causes respiratory issues. Pain, increased temperature, and nutritional status generally are not issues identified at the time the syndrome is diagnosed.

The nurse is reviewing laboratory values and flowsheet data for her client on postpartum day 1. Which of the following would the nurse point out to the nurse-midwife or primary healthcare provider? a. WBC count of 25,000/mm3 b. Urine output of 3000 ml in 24 hours c. Decrease in hematocrit from 32% to 31% d. Maternal heart rate of 120 bpm

Answer: d. Maternal heart rate of 120 bpm Feedback: 120 bpm is tachycardia, which may indicate hypovolemia. Mild physiologic bradycardia is expected in the postpartum period. WBC counts of 25,000-30,000/cubic mm, increased urine output, and mild anemia with a slight decrease in hematocrit are expected findings.

8. What is true of physiologic jaundice? a. Jaundice usually stays visible for 20-25 days. b. Jaundice is considered an abnormal process that occurs during transition from intrauterine to extrauterine life and appears before 24 hours of life. c. It is considered a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life. d. There is no statistical difference between breastfed and bottle-fed babies regarding bilirubin levels.

Answer: c. It is considered a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life. Feedback: Jaundice stays visible until around the 10-day mark. There is a marked difference between breastfed and bottle-fed babies and bilirubin levels; breastfed babies tend to be higher. Physiologic jaundice appears after 24 hours of life. Pathologic jaundice usually occurs before 24 hours of life.

3. What is the correct way to perform external cardiac massage on an infant with a detectable heart rate? a. Place two fingers one finger-width below the nipple line and compress one half to one inch. b. Place one thumb one finger-width below the nipple line and compress at a 5:1 ratio. c. Place both thumbs over the lower third of the sternum with fingers wrapped around and supporting the back. d. Use the heel of one hand at the nipple line and compress at a ratio of 5:1.

Answer: c. Place both thumbs over the lower third of the sternum with fingers wrapped around and supporting the back. Feedback: The infant is placed properly on a firm surface. The resuscitator stands at the foot of the infant and places both thumbs over the lower third of the sternum, with the fingers wrapped around and supporting the back. The two-thumb method is preferred because it may provide better coronary perfusion pressure; however, it decreases thoracic expansion during ventilation and makes access to the umbilical cord for medication administration more difficult.

A nurse is reviewing the lab reports of a 24-hour-postpartum client. The admission hematocrit was 41% and the current hematocrit is 30%. What should be the initial nursing action? a. Notify the lab for another blood draw to verify accuracy of the report. b. Increase the intravenous infusion rate. c. Report the lab values to the primary healthcare provider or nurse-midwife. d. Administer two units of typed and crossmatched blood.

Answer: c. Report the lab values to the physician primary healthcare provider or nurse-midwife. Feedback: This is an abnormal finding, and warrants further investigation by the physician or midwife. The lab reading should be accurate, so it would be inappropriate and unnecessary to have the lab redrawn. Increasing the infusion rate may be appropriate if there are symptoms of hypovolemia, but it is not the initial action. Administering two units of blood would not be the initial action, but may be ordered later.

10. What are common symptoms of polycythemia? a. Apnea, hypotension, and hyperthermia b. Orthopnea, tachypnea, and hyperbilirubinemia c. Tachycardia, respiratory distress, and hyperbilirubinemia d. Bradycardia, hypotension, and leukopenia

Answer: c. Tachycardia, respiratory distress, and hyperbilirubinemia Feedback: The following are documented symptoms of polycythemia: tachycardia and congestive heart failure due to the increase in blood volume; respiratory distress with grunting, tachypnea, and cyanosis, increased oxygen need, or respiratory hemorrhage due to pulmonary venous congestion, edema, and hypoxemia; hyperbilirubinemia due to increased numbers of red blood cells breaking down, and a decrease in peripheral pulses, discoloration of extremities, alteration in activity or neurologic depression, renal vein thrombosis with decreased urine output, hematuria, or proteinuria due to thromboembolism.

A nurse is caring for four postpartum clients who each have an order for Methergine (methylergonovine maleate). Based on the data collected during the nurse's initial shift assessment, which client would not receive the medication? a. The client with a temperature of 101°F b. The client with a hematocrit of 33% c. The client with a blood pressure of 156/94 d. The client with a white blood cell count of 22,000

Answer: c. The client with a blood pressure of 156/94 Feedback: Hypertension is a side effect of this medication; therefore, Methergine is contraindicated for women with high blood pressure. Elevated temperature and elevated blood count are not contraindications for administering Methergine. Because Methergine is given to prevent or reverse postpartum hemorrhage, it may also help prevent a decrease in hematocrit levels.

7. What is the best intervention a nurse can utilize to promote parent-infant attachment? a. Allow for privacy. b. Contact support families that have been through the same diagnosis with their own child and allow time to discuss the situation. c. Provide an extensive handbook with information related to the preterm newborn. d. Encourage rooming in.

Answer: d. Encourage rooming in. Feedback: All will help strengthen the attachment bond, but the best answer would be to encourage rooming in. Rooming in can provide a great opportunity for the stable preterm infant and family to get acquainted; it offers both privacy and readily available help.

The nurse is talking with a mother during a routine follow-up call on postpartum day 3. The mother reports waking up with the baby every 2 hours; nipple tenderness with latch that resolves during the course of the feeding; seeing small, dime-sized blood clots on her pad when waking in the morning; and a nagging cramp in her right leg, which she attributes to her position while giving birth. Which report from the mother does the nurse need to assess further? a. Her report of nipple tenderness b. Her report of the baby's frequent night waking c. Her description of the blood clots d. Her report of leg cramps

Answer: d. Her report of leg cramps Feedback: Unilateral calf pain is a sign of thrombophlebitis or DVT. Mild nipple tenderness without persistent pain, cracking, or abrasions is common and transient in the first few days postpartum. Blood may pool in the vagina at night and form small clots that are passed when the mother arises or changes position. Frequent night waking is normal newborn behavior and ensures adequate feeding.

5. The highest-priority nursing diagnosis for a neonate experiencing RDS is: a. Altered Nutrition: More than Body Requirements. b. Alterations in Parenting. c. Acute Pain. d. Impaired Gas Exchange related to inadequate lung surfactant.

Answer: d. Impaired Gas Exchange related to inadequate lung surfactant. Feedback: Altered Nutrition: Less than Body Requirements would be appropriate. Impaired Gas Exchange would be the highest priority, although alterations in parenting and pain could be included on the comprehensive list of nursing diagnoses.

A 24-hour-postpartum client who had a cesarean birth with general anesthesia complains of abdominal discomfort and gas pains. What is the most appropriate nursing intervention? a. Administer analgesic medication to the client. b. Encourage the client to drink hot tea. c. Offer carbonated beverages to the client. d. Position the client on the left side.

Answer: d. Position the client on the left side. Feedback: Positioning the client on the left side allows for the gas to rise from the descending colon to the sigmoid colon so it may be expelled. Analgesic medication does not relieve gas, but antiflatulents such as Mylicon may help relieve gas. Hot and carbonated beverages may cause more discomfort and gas.

6. What is the best explanation for correlating the nursing diagnosis Risk for Infection and the preterm infant? a. Preterm babies have immature cardiovascular systems. b. Preterm babies have immature neurological systems. c. Preterm babies have immature gastrointestinal systems. d. Preterm newborns have immature immune systems.

Answer: d. Preterm newborns have immature immune systems. Feedback: The preterm newborn is susceptible to infection because of an immature immune system and thin, permeable skin. Invasive procedures, techniques such as umbilical catheterization and mechanical ventilation, and prolonged hospitalization place the infant at greater risk for infection.

10. The primary goal for the drug-dependent newborn is to reduce withdrawal symptoms and promote adequate respiration, temperature, and nutrition. What intervention best reflects that goal? a. Monitor for hyperthermia. b. NPO status c. Administer medications such as methadone. d. Proper positioning on right side-lying or in semi-Fowler.

Answer: d. Proper positioning on right side-lying or in semi-Fowler. Feedback: Proper positioning on the right side-lying or semi-Fowler helps avoid possible aspiration of vomitus or secretions. The nurse would monitor for hypothermia, the infant would not be made NPO because of the vomiting/diarrhea, and the infant would not be placed on methadone, because of its addictive qualities.

The nurse is at the bedside during the recovery period immediately after a vaginal birth at term. The pregnancy, labor, and birth were uncomplicated. The mother experiences a visible, full body tremor, and states, "Oh no! I can't stop shaking! What's wrong with me?" What are the most appropriate nursing actions? a. Overhead page the nurse-midwife or primary healthcare provider and notify the charge nurse. b. Increase the rate of IV fluid and postpartum Pitocin. c. Recline the head of the bed and elevate the foot. d. Reassure the client and cover her with warm blankets.

Answer: d. Reassure the client and cover her with warm blankets. Feedback: Significant tremors are common immediately postpartum and are thought to be caused by fluid shifts, biochemical changes, and entry of fetal cells into the mother's circulation during birth. No interventions are needed beyond reassuring the mother that this is common and helping her stay warm.