New Fam exam 3 Prep U
A client's membranes rupture. The nurse observes the fetal heart rate drop from 156 to 110. The nurse inspects the client's perineum and sees a loop of umbilical cord. What is the nurse's priority concern in this situation?
Decreased fetal oxygenation
A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage?
Demonstrating how to do cord care on the newborn
Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?
Dry the newborn and place it skin-to-skin on mother.
Newborns receive an antibiotic in their eyes within the first hour after birth to prevent neonatorum ophthalmia. Which type of bacteria is most likely to cause this condition?
Neisseria gonorrhoeae
A 24-year-old primigravida has been laboring longer than 24 hours. She has entered the second stage of labor, and the baby is at +2 station. The fetal heart rate has been 90 bpm for the last 2 minutes. The physician applies a Kiwi vacuum; after 3 attempts (pop-offs), the baby is not delivered, and the fetal heart rate is still 90 bpm. What should the nurse do next? Choose the best answer.
Prepare for an emergency cesarean delivery
Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?
a respiratory rate of 15 breaths per minute with nasal flaring
What is the best way for the nurse to assess the newborn's heartbeat?
auscultating the apical pulse for 60 seconds
The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?
conduction
The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism?
evaporation
The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?
increased heart rate
The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation?
instructing her to apply ice packs to both breasts every other hour
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?
radiation, convection, and conduction
At what point should the nurse expect a healthy newborn to pass meconium?
within 24 hours after birth
A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize?
100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum
The nurse is explaining to the parents about the various laboratory tests which will be conducted on their newborn. The nurse should point out that testing for phenylketonuria will be conducted in which time frame?
24 to 72 hours after birth.
The maternal health nurse is caring for multiple women who wish to attempt a vaginal birth after cesarean (VBAC). Which client will not be able to attempt a VBAC due to contraindications?
28-year-old with a placenta previa
A hypoglycemic newborn will have a blood glucose reading of what value on a heel stick?
45 mg/dL
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?
500 mL
When teaching a woman about ingesting drugs while breastfeeding, which of the following statements is most accurate?
Almost all drugs are excreted to some extent in breast milk.
The nurse is caring for a newborn whose mother tested positive for hepatitis B surface antigen (HBsAg). Which intervention(s) will the nurse perform? Select all that apply.
Bathe the newborn thoroughly. Give Hepatitis B immune globulin. Obtain consent from the mother. Administer Hepatitis B vaccination.
A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?
Bilirubin level went from 15 to 11.
A young woman comes into the clinic in the eighth month of her pregnancy. She is requesting information regarding cesarean delivery and wants to discuss this method of delivery. The nurse knows that the rate of cesarean deliveries has increased because of which reasons? Select all that apply.
Change in perception of risk by patients and physicians Rise in the number of older pregnant women Increased incidence of maternal obesity Increased use of induction for nonmedical reasons
A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response?
Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals.
The nurse is admitting a client in labor. The nurse determines that the fetus is in a transverse lie by performing Leopold maneuvers. What intervention should the nurse provide for the client?
Prepare the client for a cesarean birth.
A neonate has been administered a prescribed dose of vitamin K. What outcome would most clearly indicate to the nurse that the medication has had the intended effect?
The infant remains free of bleeding
The nurse has administered erythromycin ointment to a newborn. What outcome indicates this nursing intervention has been effective?
The newborn does not contract ophthalmia neonatorum.
Which statement is true regarding fetal and newborn senses?
The rooting reflex is an example that the newborn has a sense of touch.
After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching?
When I put on a new pad, I'll start at the back and go forward."
The nurse is explaining the care 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?
Within one hour
A postpartum mother is experiencing sore nipples. The woman asks the nurse what she is doing wrong that is causing this problem. The nurse identifies which breastfeeding technique or condition may result in sore nipples? Select all that apply.
allowing the newborn to stay latched on to the breast for a prolonged period after feeding not assessing that the newborn has a highly arched palate that interferes with proper latching setting the breast pump on a higher pressure setting to empty milk faster
The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:
are unable to shiver effectively to increase heat production.
The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?
cannot be palpated
A new mother calls the clinic on her fourth day after delivery and reports difficulty urinating and defecating because of the perineal pain. What does the nurse suspect is causing these problems?
episiotomy
The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?
limited voluntary muscle activity
When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?
massaging the fundus firmly
A nursing student correctly identifies that an episiotomy that extends straight down into the true perineum is which of the following?
midline episiotomy
The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?
nasal flaring
Which is the best place to perform a heel stick on a newborn?
the fat pads on the lateral aspects of the foot
When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed?
"I can use talc powders to prevent diaper rash."
After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?
Dry the newborn thoroughly.
Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication?
At 8 hours postdelivery she has voided a total of 100 mL in four small voidings
How should the nurse counsel a patient who has arrived for a scheduled repeat cesarean delivery?
"An IV catheter will be placed, and we will do some preoperative blood work. Then we will give you some antibiotics."
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?
"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes."
A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions?
"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."
The nurse is instructing a primipara who has concerns about the need for a cesarean section due to her sister's obstetrical history. Which statement by the client needs further instruction?
"My sister had a cesarean section with the first and then needs it for all subsequent pregnancies."
A new mother asks the nurse why her newborn must get a vitamin K injection. Which response made by the nurse is best?
"Newborns need vitamin K to prevent hemorrhage. They cannot produce it themselves right after birth because of the lack of normal flora in their intestines."
A patient who had a previous cesarean birth asks the nurse if all future births must occur the same way. Which response should the nurse make to support the 2020 National Health Goals regarding cesarean births?
"Not if you fulfill the criteria for vaginal birth after cesarean."
A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching?
"Place the newborn on the back to sleep and stomach to play."
A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be:
"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."
A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?
"The baby's sucking releases a hormone that causes the uterus to contract."
The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means?
"The opening of his urethra in located on the under surface of the tip of the penis."
A parent asks the nurse how to swaddle the newborn because the parent heard that it helps newborns calm down. Which statement will the nurse include in the teaching?
"Wrapping the newborn too tightly can impair breathing."
A postpartum mother is recovering from a cesarean delivery and is reporting incisional and abdominal pain at a level of 8. Morphine sulfate is ordered as follows: Morphine Sulfate 8 mg IV q 4 hours prn for pain greater than 6. Morphine Sulfate comes in 10 mg/mL. How many milliliters of morphine would the nurse administer to this client using slow push over 5 minutes? Record your answer using one decimal place.
0.8
A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?
A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.
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?
Caput succedaneum
The nurse is caring for a newborn immediately following birth. Which body system is priority for the nurse to monitor during the transition phase?
Cardiopulmonary
The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program?
Caregivers can demonstrate competency in caring for the infant and ask questions.
What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?
Cephalohematoma
The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?
Injecting the medication into the vastus lateralis
A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?
Inspect the clamp to insure that it is tightly closed and applied correctly.
The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply.
Inspect the episiotomy for sutures and to ensure that the edges are approximated. Gently palpate for any hematomas. Note any hemorrhoids.
Which of the following is an advantage of breastfeeding that directly benefits the mother?
It aids in uterine involution.
A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding?
It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel.
A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time?
Look for late decelerations on monitor, which is associated with fetal anoxia.
The nurse is assessing vital signs on the client and notes a normal blood pressure along with an elevated pulse when the patient moves from a lying to a standing or sitting position. What would this indicate?
Low fluid volume
To prevent tearing of the perineum of a client during birth, a physician performs a mediolateral episiotomy. The nurse recognizes that an advantage of a mediolateral episiotomy over a midline episiotomy is which of the following?
Lower risk for rectal mucosal tear
The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide?
Mongolian spot noted on left upper outer thigh. -Birth mark
The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. Which action should the nurse prioritize?
Move the infant away from the window.
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?
No interventions are needed. This will resolve on its own over the next several days.
The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern?
Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably.
During the early postpartum period, the nurse is evaluating a client's attachment to her neonate. Which type of parent has the most difficulty attaching to her newborn?
One whose father recently died
What should the nurse expect for a full-term newborn's weight during the first few days of life?
There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.
A client opts to feed formula to her newborn baby. Which instruction should the nurse give to the client regarding the proper procedure for bottle-feeding?
Tilt the bottle while feeding
When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:
less than after a vaginal birth.
After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement?
"I can't wait for these stretch marks to disappear after I give birth."
A patient who gave birth 2 hours ago expresses concern about her baby developing jaundice. How should the nurse respond? Choose the best response.
"I understand your concern because as many as 50% of babies can develop jaundice."
A woman in active labor with a history of two previous cesarean births is being monitored frequently as she tries to have a vaginal birth. Suddenly, the woman grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes her blood pressure is 80/50 mm Hg, pulse rate is 130 bpm and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication?
uterine rupture
A woman has just given birth vaginally to a newborn. Which action will the nurse do first?
Suction the mouth and nose.
The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?
lochia rubra
Which statement regarding newborn circumcision is accurate?
An advantage of circumcision is a decreased risk of penile cancer.
A nurse correctly recognizes which of the following as a current trend within the population of birthing women?
Increased rates of cesarean sections.
Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate?
Rewarm the newborn gradually.
While the nurse is assessing the prenatal client's understanding of the information provided at a recent appointment, the client states, "I want to avoid the pain and long hours of labor, so I'm electing to have a cesarean birth." How should the nurse respond?
"A cesarean birth is a method to be used when vaginal birth is not possible—it is not a true option."
When counseling a patient about maternal risks and benefits of cesarean delivery, which of the following would not apply?
"A surgical incision may be made at the perineum to enlarge the vagina just before delivery of the baby."
The nurse asks a new mother how she is planning on feeding her newborn. The mother responds that she is planning on formula feeding her baby. Which of the following is the best response for the nurse to give the mother?
"Have you considered breastfeeding? There are some real benefits that it can offer you and your baby."
A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement?
"I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged."
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?
"It is a normal skin finding in a newborn."
A 26-year-old new mother says to her nurse, "I am so disappointed. I gained 25 pounds with my baby. Just what the doctor said I should gain. But after I had my baby I only lost 12 pounds." What is the best response by the nurse?
"It is normal to lose between 12 and 14 pounds after the baby delivers. You should be back to your pre-pregnancy weight by the time your baby is about 6 months old."
A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase?
"It sounded like you had quite a time getting here. Would you like to continue your story?"
A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?
"It takes about 3 days after birth for milk to begin forming."
A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response?
"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."
A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements?
"Transverse lie is the same as when the fetal buttocks present to the birth canal.
Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding?
Two fingerbreadths below the umbilicus
It was once thought that an episiotomy made the birth less painful and heal faster than a spontaneous laceration of the perineum. Research has not shown these assumptions to be true. What is another finding in the research on episiotomies?
Increases risk of blood loss immediately after delivery
A pregnant woman at term is in the obstetrics unit for induction in the morning. Her membranes rupture, and the external fetal monitor shows deep variable decelerations. For what should the nurse immediately check the patient?
Umbilical cord prolapse
A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant?
6
Mrs. Atkins is 40 weeks' pregnant by ultrasound, and the induction of labor is being discussed by Mrs. Atkins and her birth attendant. The birth attendant tells Mrs. Atkins, "I am going to do a pelvic exam so that I can assess your readiness for labor. I will obtain what is known as a Bishop Score, and it will tell me how ready you are to go into labor." What Bishop Score would indicate a favorable response to oxytocin-induced labor?
8 or above
The nurse is assisting with a birth, and the client has just delivered the placenta. Suddenly, bright red blood gushes from the vagina. The nurse recognizes that which occurrence is the most likely cause of this postpartum hemorrhage?
A cervical laceration
One assessment parameter that the LPN/LVN is responsible for is fluid volume loss. It would be important to assess the umbilical cord for any sign of bleeding. What would be important to assess for if the infant has an unusually large cord?
A loose clamp
A woman who has had a cesarean birth asks you if she will always need to have cesarean births in the future. Which of the following would be your best response?
Although there are some exceptions, surgical techniques allow for vaginal birth after cesarean birth."
A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse?
Always wash your hands before you pick up or provide care to your newborn."
The nurse is caring for a patient recovering from a cesarean birth. Which assessment should the nurse make a priority for this patient?
Abdominal texture
What is the most effective way to stimulate circulation after cesarean birth?
Ambulation within 4 hours of birth
The nurse is doing discharge teaching with the parents of a baby. It is their second child. The nurse explains about sibling regression and offers ways to deal with regressive behavior. What is this called?
Anticipatory guidance
A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema?
Apply ice.
A laboring woman is receiving oxytocin IV to augment her labor and 2 hours later begins having contractions every 2 minutes lasting 60 to 90 seconds each with little, if any, rest time in between the contractions. At this time, which interventions would be the priority for the nurse caring for this client? Select all that apply.
Apply oxygen to the woman via mask at 8 to 10 L/min. Administer an IV bolus of fluids. Discontinue the oxytocin infusion.
A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do?
Ask to see the woman' hospital identification badge.
While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first?
Aspirate the oral and nasal pharynx with a bulb syringe.
A woman has just entered the recovery room after cesarean birth of a baby weighing 9 lb 14 oz. After connecting the client to the blood pressure monitor, it is noted her HR is 120 and BP is 80/40. What nursing action should be a priority?
Assess for bleeding
A postpartum patient has a history of thrombophlebitis. What should the nurse do to determine if the patient is developing this after delivery?
Assess for calf redness and edema.
A 35-year-old P1001 has been admitted for a scheduled repeat cesarean. As the nurse prepares the patient for surgery, what is the best way to begin preoperative teaching?
Assess how much the woman already knows about cesarean.
The maternal health nurse assists the birth attendant in a forceps-assisted birth. After the birth of the infant, what is the nurse's priority?
Assess the infant for trauma
A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate?
Assist the woman in placing ice packs on her breasts.
During the assessment, the nurse observes a separation of the rectus muscle that is more than two fingerbreadths wide. Which instruction should the nurse offer the client?
Avoid lifting heavy objects
A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?
Blood Pressure should be 80/40
A nurse is conducting an in-service education program for a group of nurses working in the newborn nursery. The nurse has explained the events that occur as fetal circulation transitions to newborn circulation. The nurse determines the session is successful after the participants put the chain of events in which order? All options must be used.
Birth occurs. Pulmonary blood flow increases, and pulmonary venous return to the left side of the heart increases. The foramen ovale closes. An increase in systemic blood pressure occurs with continued increase in blood flow to the lungs. The ductus arteriosus closes.
A nursing student is asking the instructor how to assess whether a cervix is ready and favorable for labor induction. The nurse informs the student that a score is used known as which of the following?
Bishop score
Following a cesarean birth, a woman has 3000 mL of intravenous fluid ordered. The nurse anticipates in the plan of care that she will be kept NPO except for minimal ice chips until which time?
Until bowel sounds have returned
A client is being prepared for a scheduled cesarean delivery by the medical team. Which intervention will be most critical for the team to monitor in the first 24 hours post cesarean delivery?
Urinary output
A 21-year-old has been in labor for 4 hours; her examination 2 hours ago revealed 6 cm/100%/-3. During a contraction, she spontaneously ruptures her membranes. The doctor checks the patient, finds her to be 9 cm/100%/-3, and states that the cord is palpable. What should the nurse do?
Call for help and prepare the patient for an emergency cesarean delivery.
The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client?
Call her caregiver if lochia moves from serosa to rubra.
The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action?
Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.
A postpartum patient is concerned about loose tissue around the abdominal area. Which exercise should the nurse recommend that the patient begin on postpartum day 2 to strengthen and tighten these muscles?
Chin-to-chest
The experienced nurse notes a new graduate administering a hepatitis B vaccination to a newborn. What action, by the new graduate, will cause the experienced nurse to intervene?
Circularly cleaning the site, outward to inward.
A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take?
Document the data.
A cesarean delivery is a major surgery and carries with it many risks for complications. The most common complication is infection. At what site is the infection likely to occur?
Uterus
An elective induction is when the birth attendant and the pregnant woman agree to the induction of labor without medical indications. What should the birth attendant explain to the woman before she can give informed consent to induce her labor?
Induced labor can result in higher costs for the delivery.
Which is true regarding mineral requirements in the newborn?
Infants who are formula-fed should drink an iron-enriched formula for at least 12 months.
A woman is about to go for her first cesarean delivery and asks the nurse what complications can come from this type of delivery. The nurse correctly identifies which of the following as the number one complication of cesarean delivery?
Infection
The nursing instructor is conducting a class presenting the various aspects of a cesarean delivery. The instructor determines the class is successful after the students correctly choose which complication as the most common postoperative complication?
Infection
The nurse is preparing a newborn male for circumcision. During the assessment, the nurse notes the newborn has a hypospadias. Which action made by the nurse is best?
Inform the practitioner and cancel the procedure.
What instructions should the nurse include when teaching a mother to care for her newborn's umbilical cord?
Keep it dry.
A nurse is caring for a client who has had a cesarean birth and has developed a wound infection. What precautions should be taken by the nurse as a primary prevention measure?
Keep the incisions clean and dry
A woman is scheduled to have epidural anesthesia for a cesarean birth. Which of the following would the nurse anticipate including in the preoperative plan of care while she waits for the anesthetic?
Keeping her turned on her side
Upon examination of the skin, which assessment findings would the nurse recognize as normal findings for a full-term newborn at 3 hours of age? Select all that apply.
Lanugo on the back Milia Acrocyanosis
A patient having a cesarean birth will have a low segment incision. What should the nurse explain to the patient as an advantage for this type of incision?
Vaginal deliveries can occur with future births.
After the abdominal dressing is removed 24 hours following a cesarean delivery, the nurse inspects the incision and observes drainage from the incision, redness along the suture line and moderate edema. Staples are intact. What action would the nurse take?
Let the health care provider know the condition of the incision.
When assessing a postpartum mother, the nurse asks the client how many peripads she has used over the last 4 hours. The mother responds that she has changed her pad 2 to 3 times per hour when they were saturated. What action should the nurse take?
Notify the RN of the finding.
A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action?
Obtain a clean-catch urine specimen
The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as does the infant's forehead and nose. What would the nurse do next?
Obtain a transcutaneous bilirubin level.
The nurse encourages a patient recovering from a cesarean birth to begin early ambulation. For which outcome would this action be indicated?
Patient will not develop manifestations of thrombophlebitis.
What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia?
Perform a heel stick to obtain a blood sample for testing for glucose level.
The nursing instructor is teaching about cesarean birth and informs the students that the main reasons for this procedure include which of the following? Select all that apply.
History of previous cesarean birth Fetal malpresentation Non-reassuring fetal status Labor dystocia
A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next?
Identify the newborn.5
A nursing student correctly identifies which of the following as the most important predictor of fetal maturity:
Fetal lung maturity
The client, G5 P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago?
Gently massage the fundus until it tones up
The nurse is caring for a 45-year-old client who will undergo cesarean birth. Which age-related finding should the nurse treat to reduce the client's surgical risk?
Gestational diabetes
The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed?
Harm to self
A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?
Have the client void, and then massage the fundus until it is firm.
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.
Hepatitis B immune globulin Hepatitis B vaccination
The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep?
Place the infant on the back when sleeping.
Eight hours after a cesarean section, a postpartum woman is having heavy lochia. She informs the nurse, who suspects which of the following causes?
Postpartum hemorrhage
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?
Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.
The nurse is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents? Select all that apply.
Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Know when the newborn is scheduled for any tests and how long the procedure will last. Do not remove the identification bands until the newborn is discharged from the hospital.
According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and the newborn has minimal activity or body movement?
Quiet alert
The maternal health nurse is caring for a client in the postoperative period after an uncomplicated cesarean delivery of a full-term infant. The woman tells the nurse, "I have pressure and pain on my incision." Which action(s) will the nurse perform in response to the client's concern? Select all that apply.
Remind the woman to take pain medications as needed. Instruct the woman to use the football hold while breastfeeding.
The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?
Report the finding to the pediatrician.
The nurse is assessing a neonate after a cesarean delivery. Which most common complication should the nurse be prepared for?
Respiratory distress
Which action will the nurse avoid when performing basic care for a newborn male?
Retracting the foreskin over the glans to assess for secretions
The nurse is assisting with a vaginal birth. The patient is fully dilated, 100% effaced and is pushing. The nurse observes the "turtle sign" with each push and there is no progress. What does the nurse suspect may be occurring with this fetus?
Shoulder dystocia
A postpartum patient is experiencing painful hemorrhoids. Which position should the nurse suggest the patient use when resting?
Sims position
"Wrapping the newborn too tightly can impair breathing."
Suctioning the newborn's airway.
The nurse is assessing a 2-hour-old newborn and notes that the infant has irregular patterns of breathing rate, depth, and rhythm. Which is the best action made by the nurse?
Taking no action because these are normal findings in a newborn
A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?
Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.
Dietary needs change from pregnancy to lactation. What should breastfeeding mothers be advised?
That even if a mother has adequate fat stores, calorie intake should increase
Which of the following is true regarding the newborn's fontanelles?
The anterior fontanelle is diamond shaped and measures about 3.5 cm. The posterior fontanelle is triangular shaped and measures about 1 cm.
The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding?
The bladder is distended.
When assessing the postpartum client 2 hours after giving birth, which finding indicates the need for further action?
The fundus is firm and deviated sharply to the right side of the abdomen.
A breast-feeding mother calls the clinic, asking how much water she should be giving her 2-month-old infant. What would the nurse recommend to this mother?
The infant does not need any water supplement if nursing well.
Annie, a new mother, is talking with the nurse about breast-feeding. She asks, "How does lactation work?" The best answer by the nurse is:
The newborn sucking on the breast stimulates the pituitary gland causing the release of prolactin and oxytocin. Prolactin causes synthesis and release of breast milk and oxytocin causes contraction of the smooth muscle around the alveoli of the breast.
The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply.
The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply.
A woman having a cesarean birth will have a low cervical incision. Which of the following would you cite as an advantage?
The skin incision will be just above her pubic hair.
In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 mL with each hourly void. How would the nurse interpret this finding?
The urinary output is normal.
Place the following events in order of occurrence for administration of spinal anesthesia before an elective primary cesarean delivery in a woman who is not in labor.
The woman enters the OR. The nurse instructs the patient to sit and make a C-curve with her back. The anesthesiologist cleanses the back. Spinal anesthesia is administered. The patient lies down on the delivery table, and a wedge is placed.
What supplies would the nursery nurse collect in preparation for bathing a newborn infant? Select all that apply.
Warm tub of water Thermometer A washcloth
A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?
Wear a well-fitting bra.
The experienced RN will intervene if the new graduate is noted to complete which action while caring for newborns?
Wearing artificial nails while caring for multiple newborns.
A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?
You should not lift anything heavier than your infant in its carrier.
Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?
amniotic fluid embolism
On the first day postpartum, a new mother is concerned that her milk has not yet "come in." The nurse would explain to her that:
breast milk normally comes in on the third or fourth postpartum day.
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?
postpartum diuresis
The physician has just examined the patient and determined that she needs to have a cesarean section. He notifies the nurse that he will be doing a low cervical vertical incision into the uterus. The nurse knows that the physician has chosen this type of incision over the classical incision because the low cervical vertical incision:
reduces the risk of uterine rupture.
A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?
sternal retractions
What is the primary goal of nursing care immediately after birth?
to maintain the safety of the neonate from intrauterine to extrauterine life
When assessing the newborn's umbilical cord, what should the nurse expect to find?
two smaller arteries and one larger vein
A postpartum client reports urinary frequency and burning. What cause would the nurse suspect?
urinary tract infection
The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse would monitor the client for which condition?
urinary tract infection