Mtrnl- Exam 2 Practice Questions

What is the ideal fetal position?

Cephalic & facing down -DOA: Direct occiput anterior (Face down) *DOP: Direct occiput posterior (face up)

What would we do if we suspect ROM w/out a big gush?

*Do NST, place speculum in & have mom bear down- she will have the fluid squirt out & we can test it & see if amniotic fluid *Use nitrazine paper & look for ferning

What is the average BG of a baby?

60-70 (<40 = becomes a concern)

Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor? A) scalp edema B) cervical lacerations C) increased intracranial pressure D) vaginal lacerations

A) scalp edema

What is the first thing that comes to your mind when you notice a fetus' temperature repeatedly drop?

ALWAYS THINK SEPSIS until proven otherwise

When is a woman considered in active labor?

Once she reaches 5 cm dilated

What is the normal amount of blood loss for both vaginal births and C-Sections?

*Normal: 500 mL blood loss *C-Section: Tolerate 900 - 1,000 mL blood loss

What are some causes of overdistention of the uterus?

*Polyhydranomous *Multiple passengers

When do we definitely want an IV placed during labor?

*Preeclampsia *Anemic *GBS positive

What are the normal fetal vital signs? Pulse? Respirations? Temp?

*Pulse 110 to 160 beats/min (count full min) *Respirations 30 to 60 respirations/min (count full min) *Temperature normal range 36.5°C to 37.2°C

What are some concerns with using Nitrous Oxide and who should not use it?

*There is some interference w/ nerve cells when it's used *Anyone w/ COPD, emphysema, air trapping, recent eye surgery, GI obstructions are not to use this.

What are most concerned about when a mother gets an epidural?

1. Drop in BP = must preload w/ IV fluids!!! 2. Urinary retention 3. Works by gravity- so mom should not lay down b/c it'll flow upward & she could lose sensation of wanting to breathe

The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement? A) "The newborn's gut is sterile at birth." B) "His stomach can hold approximately 10 ounces." C) "He needs to get food orally to make vitamin K." D) "The muscle opening that leads into the stomach is not mature."

B) "His stomach can hold approximately 10 ounces."

A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching? A) "Some babies latch on and catch on quickly; others take a little more time." B) "Some women just can't breastfeed. Maybe I'm one of these women." C) "Maybe a lactation specialist can help me work through this." D) "Breastfeeding takes time and practice."

B) "Some women just can't breastfeed. Maybe I'm one of these women."

A breastfeeding client informs the nurse that she is unable to maintain her milk supply. What instruction should the nurse give to the client to improve milk supply? A) Perform Kegel exercises B) Empty the breasts frequently C) Take cold baths D) Apply ice to the breasts

B) Empty the breasts frequently

A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse? A) "Newborns are given vitamin K to help the digestion to help them absorb fat-soluble vitamins." B) "This vitamin substitutes vitamin C for newborns to strengthen their immune systems." C) "Newborns are given vitamin K and erythromycin ointment to help prevent ophthalmia neonatorum." D) "Newborns lack the intestinal flora to produce vitamin K, so it is given to prevent bleeding episodes."

D) "Newborns lack the intestinal flora to produce vitamin K, so it is given to prevent bleeding episodes."

The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best? A) "Yes, she is afraid you will drop her." B) "No, it is the blink reflex. It is meant to protect the eyes." C) "No, it is the tonic neck reflex. It signifies handedness." D) "No, it is the Moro reflex. This reflex stimulates the action of warding off an attacker."

D) "No, it is the Moro reflex. This reflex stimulates the action of warding off an attacker."

What are we most worried about for moms during the postpartum period?

Infection and hemorrhage

The nurse is caring for a newborn immediately following birth. Which body system is priority for the nurse to monitor during the transition phase? A) integumentary B) thermoregulatory C) cardiopulmonary D) immunological

C) cardiopulmonary

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman? A) "It is a normal skin finding in a newborn." B) "It is a sign of a group B streptococcus skin infection." C) "It is a self-limiting virus that does not require treatment." D) "It is an indication that the woman has mistreated her newborn."

A) "It is a normal skin finding in a newborn."

New parents are upset their newborn has lost weight since birth. The nurse explains that newborns typically lose how much of their birth weight by 3 to 4 days of age? A) 10% B) 16% C) 12% D) 14%

A) 10%

The nurse suspects that a newborn receiving phototherapy is dehydrated based on assessment of which of the following? A) sunken fontanels (fontanelles) B) 10% weight gain C) eight wet diapers a day D) need for frequent feedings

A) sunken fontanels (fontanelles)

A nurse is assessing a newborn for self-regulation. Which of the following would the nurse interpret as indicating self-regulation? A) infant is crying vigorously B) infant is lying quietly C) infant moves hand to mouth D) infant is making kicking motions

C) infant moves hand to mouth

A young male client asks the nurse about circumcision, since he was never circumcised as an infant. Which rationale would be appropriate for exploring circumcision in an adult male? A) The foreskin appears to cover the glans of the penis. B) The client is experiencing premature ejaculation. C) The client has experienced recurring infections of the glans. D) His scrotum appears uneven with one testicle higher than the other.

C) The client has experienced recurring infections of the glans.

A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which suggestions would the nurse include in the teaching? Select all that apply. A) Supplement with iron if the woman is breastfeeding. B) Feed the newborn on demand or at least every 2 to 4 hours during the day. C) Use feeding time for promoting closeness. D) Provide supplemental water intake with feedings. E) Burp the newborn frequently throughout each feeding.

B) Feed the newborn on demand or at least every 2 to 4 hours during the day. C) Use feeding time for promoting closeness. E) Burp the newborn frequently throughout each feeding.

A nursing student is aware that fetal gas exchange takes place in which area? A) lungs B) placenta C) uterus D) bronchioles

B) placenta

The nurse is explaining the car the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time? A) within 12 hours B) within one hour C) within 72 hours D) any time prior to discharge

B) within one hour

Which action will the nurse avoid when performing basic care for a newborn male? A) Palpating if testes are descended into the scrotal sac. B) Inspecting the genital area for irritated skin. C) Retracting the foreskin over the glans to assess for secretions. D) Determining the location of the urethral opening.

C) Retracting the foreskin over the glans to assess for secretions.

Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents? A) "Covering the newborn with heavy blankets is the best way to keep your newborn warm." B) "Newborns weighing below 8 lb (3,360 g) lack enough brown fat to produce heat." C) "Newborns cannot shiver to produce heat and need to be kept away form sources of heat loss." D) "Windows can be drafty and placing the newborn by one can result in evaporative heat loss."

C) "Newborns cannot shiver to produce heat and need to be kept away form sources of heat loss."

A new mother who is breastfeeding her son asks the nurse, "How do I know if my son is getting enough fluids?" Which response by the nurse would be most appropriate? A) "The amount of fluids is not important. It's the amount of calories he takes in that we watch." B) "Don't worry. He has a natural instinct that tells him when he needs to eat and drink." C) "If you think he's not taking enough, give him 4 to 8 ounces of water each day in addition to what he breastfeeds." D) "The best way is to check the number of diapers he wets. If he wets 6 to 8 times a day, he's getting enough."

D) "The best way is to check the number of diapers he wets. If he wets 6 to 8 times a day, he's getting enough."

A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." What is the nurse's most appropriate response? A) Ask the client if she has any support in the home. B) Tell the client that she must go home as per hospital policy. C) Inform the primary care provider that the client does not want to go home. D) Ask the client to explain why she does not want to go home.

D) Ask the client to explain why she does not want to go home.

What is the best way for the nurse to assess the newborn's heartbeat? A) Palpating the brachial pulse for 60 seconds. B) Palpating the femoral pulse of 30 seconds and multiplying by 2. C) Auscultating the apical pulse for 30 seconds and multiplying by 2. D) Auscultating the apical pulse for 60 seconds.

D) Auscultating the apical pulse for 60 seconds.

After teaching an in-service program to a group of nurses working in newborn nursery about a neutral thermal environment, the nurse determines that the teaching was successful when the group identifies which process as the newborn's primary method of heat production? A) nonshivering thermogenesis B) cold stress C) bilirubin conjugation D) convection

A) nonshivering thermogenesis

Which statement is true regarding fetal and newborn senses? A) The rooting reflex is an example that the newborn has a sense of touch. B) A fetus is unable to hear in utero. C) A newborn cannot experience pain. D) A newborn does not have the ability to discriminate between tastes. E) A newborn cannot see until several hours after birth.

A) The rooting reflex is an example that the newborn has a sense of touch.

Forces of contractions, mild asphyxia, increased intracranial pressure, and cold stress all play a role in the newborn transition by releasing which critical component? A) catecholamines B) epinephrine C) cortisol D) norepinephrine

A) catecholamines

The nurse is caring for a newborn with a mother who has a positive hepatitis B surface antigen (HBsAg) test. Which of the following can the nurse expect the newborn to receive? Select all that apply. A) hepatitis B vaccination B) intravenous immune globulin G C) hepatitis B immune globulin D) hepatitis A vaccination

A) hepatitis B vaccination C) hepatitis B immune globulin

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? A) "It might take up to a week for your bowels to return to their normal pattern." B) "That's unusual. Are you making sure to eat enough?" C) "Let me call your health care provider about this problem." D) "I'll get a laxative prescribed so that you can move your bowels."

A) "It might take up to a week for your bowels to return to their normal pattern."

A nurse obtains an Apgar score on a newborn at 1 and 5 minutes. The nurse determines that the newborn is healthy and adapting to extrauterine life without difficulty based on which score at 5 minutes? A) 8 B) 5 C) 6 D) 3

A) 8

On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed? A) No interventions are needed. This will resolve on its own over the next several days. B) Have the mother massage the scalp twice daily to reduce the swelling. C) An ice pack should be placed on the edematous scalp. D) Place a snug cap on the newborn's head to compress the swelling.

A) No interventions are needed. This will resolve on its own over the next several days.

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature? A) Place electronic temperature probe in the midaxillary area. B) Tape electronic thermistor probe to the abdominal skin. C) Obtain the temperature rectally. D) Obtain the temperature orally.

A) Place electronic temperature probe in the midaxillary area.

The postpartum nurse is receiving report from the labor and delivery nurse regarding a mother having delivered her third baby via cesarean birth. What information should the postpartum nurse clarify? A) The mother had three moderately soaked perineal pads in PACU. B) The mother fed the baby for 20 minutes on left breast. C) Bedside drainage bag emptied of 200 mL clear urine. D) The vital signs are temp 99.2, HR 82, BP 128/72 mmHg.

A) The mother had three moderately soaked perineal pads in PACU.

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR 36, BP 128/78, and Temp 98.6 F (37 C). Which finding would be concerning to the nurse? A) Respiratory rate B) Temperature C) Blood pressure D) Heart rate

C) Blood pressure

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition? A) Harlequin sign B) Increased intracranial pressure C) Caput succedaneum D) Molding

C) Caput succedaneum

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? A) Rocking and talking to the infant B) Gently patting or stroking the infant's back C) Feeding the infant more formula whenever she begins to fuss D) Swaddling the infant before returning to the crib

C) Feeding the infant more formula whenever she begins to fuss

How long is the neonatal period for a newborn? A) 14 days B) 90 days C) 45 days D) 28 days

D) 28 days

Which factor would demonstrate physiologic respiratory adaptation to extrauterine life in a newborn infant? A) Taking a breath within 3 minutes of delivery with stimulation. B) Increase in oxygen levels and decrease in CO2 levels, stimulating respirations. C) Rapid respirations following a cesarean birth to elimination fetal fluids. D) Abrupt temperature change upon delivery, causing a cry.

D) Abrupt temperature change upon delivery, causing a cry.

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description? A) Heart rate remains elevated after the first few moments of birth. B) Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed. C) The cardiac murmur heard at birth disappears by 48 hours of age. D) Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

D) Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

The nurse is weighing an infant and is ensuring that the scale is warmed and the procedure is performed as quickly as possible. Doing so allows the nurse to minimize the effects of heat loss by what method? A) radiation B) evaporation C) convection D) conduction

D) conduction

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common? A) genetic-linked B) skeletal malformations C) vision D) hearing

D) hearing

The nurse is documenting assessment of infant reflexes. She strokes the side of the infant's face, and the baby turns toward the stroke. What reflex has the nurse elicited? A) tonic neck B) Moro C) sucking D) rooting

D) rooting

Assisting in the initiation of breastfeeding is a role of the nurse. When should the nurse recommend that a newborn have his or her initial feeding? A) once the temperature has stabilized B) after the first bath C) after newborn labs are drawn D) within the first 30 minutes after birth

D) within the first 30 minutes after birth