NUR 318 Day 2 Summer PrepU
While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breastfeeding because it is a major source of which immunoglobulin?
IgA
Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis?
redness in lower legs
The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?
Decrease the serum bilirubin level.
When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?
vision
A mother asks the nurse why her newborn is getting a Vitamin K injection in the birth room. The nurse explains that the injection is necessary because:
vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth.
A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two."
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."
The nurse is teaching a group of parents about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed?
"The newborn's sweat glands function fully, just like those of an adult."
A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate?
"This is meconium stool and is normal for a newborn."
A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?
"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid."
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?
10%
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.
One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for?
Consistency, shape, and location
The father of a stillborn infant tells the nurse he wants to hold the child. What is the nurse's best response?
Dress the infant in a T-shirt and diaper and let him hold the infant.
After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?
Dry the newborn thoroughly.
A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply.
Fundus one fingerbreadth below the umbilicus Moderate saturation of peripad every 3 hours
Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be?
Mongolian spot
A woman gave birth yesterday to a child with a cleft palate. The newborn is in the special care nursery, and the mother has seen the newborn only at birth. Which intervention would be the priority?
Provide time for the mother to grieve for the loss of the perfect baby.
Which action would most make the nurse believe that a postpartum woman is accepting a child well?
She turns her face to meet the infant's eyes when she holds her.
During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this?
Urinary elimination
What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?
To check for postpartum hemorrhage
Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as:
a good time to initiate breast-feeding.
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
It has been 2 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's uterine fundus, the nurse would expect to find it at:
between the umbilicus and symphysis pubis.
A newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which substance in response to cold exposure?
brown fat
The nurse is questioning the effective bonding of a client and her 2-day-old infant after noting signs of impaired bonding and attachment. Which actions does the nurse find concerning?
calling the baby "it" or "they"
A nurse is assessing a term neonate and notes transient tachypnea. When reviewing the mother's history, which conditions would the nurse most likely find as contributing to this finding? Select all that apply.
cesarean birth use of heavy sedation during labor
A nurse is making a home visit to a postpartum woman who gave birth to a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as:
engorgement.
What are common risk factors for developing newborn jaundice? Select all that apply.
fetal-maternal blood group incompatibility prematurity breastfeeding certain drugs maternal gestational diabetes
A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply.
history of diabetes hemoglobin level 10 mg/dL placenta requiring manual extraction
When conducting an assessment, the nurse observes fine, downy hair covering the newborn's shoulders and back. The nurse documents this finding as:
lanugo
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
A newborn is passing greenish-black stool of tarry consistency. The nursing student correctly identifies this type of stool as:
meconium stool.
A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:
normal progression of behavior.
A postpartum client reports urinary frequency and burning. What cause would the nurse suspect?
urinary tract infection
After a class for expectant parents on the various forms of birth control after the birth of their infant, the nurse realizes more training is needed when a participant makes which comment?
"I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months."
A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client? Select all that apply.
Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow.
The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform pelvic floor muscle training or Kegel exercises. The nurse includes this information for which reason?
improve pelvic floor tone
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?
uterine atony
A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?
uterine atony
A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize?
"After birth it is easier to develop an infection in the urinary system; we need to see you today."
The parents of a newborn male ask the nurse about circumcision. They are undecided as to what to do. Which response by the nurse is best?
"I recommend you discuss the pros and cons of circumcision with the newborn's health care provider."
A newborn develops physiologic jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate?
"Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed."
A postpartum woman who has experienced diastasis recti asks the nurse about what to expect related to this condition. Which response by the nurse would be most appropriate?
"Exercise will help to improve the muscles."
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?
"His stomach can hold approximately 10 ounces."
The nurse is providing discharge education for a new mother regarding constipation. Which statement by the mother indicates that she understands what the nurse explained to her?
"I will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow."
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 postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate?
"It varies, but you can estimate it returning in about 7 to 9 weeks."
A nursing student observes that the babies in the nursery are wrapped up warmly and are wearing knit caps. Which explanation by the nursery staff would be correct?
"Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes."
A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents make which statement?
"We should avoid using any kind of baby powder."
A nurse is teaching a postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching?
"The cord stump should change from brown to yellow."
A mother is concerned because her 2-day-old newborn's birth weight was 8 lb (3584 g) and his current weight is 7 lb 8 oz (3360 g). What would be the nurse's response to the mother's concern?
"The weight loss is a normal finding, since newborns lose 5% to10% of their birth weight in the first few days after birth."
Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis?
"Try applying warm compresses to your breasts to encourage the milk to be released."
On the third day postpartum, which temperature is internationally defined as a postpartum infection?
100.4°F (38°C)
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?
1000 mL
What is the expected range for respirations in a newborn?
30 to 60 breaths per minute
The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest?
68 breaths per minute
A nurse tests a newborn's nervous functioning by stroking the sole of the baby's foot in an inverted "J" curve from the heel upward. The baby responds by fanning his toes. Which reflex has just been demonstrated?
Babinski reflex
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.
While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next?
Document this as pseudo menstruation.
When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected? Select all that apply.
Edema Slight bruising
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?
Empty the breasts frequently.
A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?
Endometritis
The nurse administers methylergonovine 0.2 mg to a postpartum woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication?
Her blood pressure is below 140/90 mm Hg.
A nurse is educating the mother of a newborn about feeding and burping. Which strategy should the nurse offer to the mother regarding burping?
Hold the newborn upright with the newborn's head on the mother's shoulder.
A client gives birth to a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home?
Keep the newborn wrapped in a blanket, with a cap on its head.
A nurse is developing a plan of care for a woman who has had a spontaneouls vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on which information?
Labor of 1 1/2 hours Labor induction with oxytocin Forceps birth
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 client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client?
No action is need; this is normal.
A postpartum client reports stress incontinence. What information should the nurse suggest to the client to overcome stress incontinence?
Perform Kegel exercises.
When teaching an unlicensed assistant personnel (UAP) how to provide perineal care on a postpartum woman, the nurse would include which steps? Select all that apply.
Place a protective pad under the client's buttocks. Remove perineal pad in the direction of front to back.
A nurse is caring for a 5-hour-old newborn. The primary care provider has asked the nurse to maintain the newborn's temperature between 97.7° F and 99.5° F (36.5° C and 37.5° C). Which nursing intervention would be the best approach to maintaining the temperature within the recommended range?
Place the newborn skin-to-skin with the mother.
A nurse is assisting a postpartum client out of bed to the bathroom for the first time. Which interventions would be most appropriate? Select all that apply.
Walk alongside the client to the bathroom. Elevate the head of the bed for several minutes before getting her up. Frequently ask the client how her head feels.
The infant has Apgar scores of 7 at 1 minute and 9 at 5 minutes. What is the indication of this assessment finding?
adjusting to extrauterine life
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 places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?
conduction
Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?
convection
A newborn's axillary temperature is 97.6° F (36.4° C). He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn?
convection and evaporation
A young mother is at the office for her 6-week visit. She is still experiencing mild loch alba and is concerned that she has an infection. Which finding would the nurse interpret as supporting this suspicion?
foul odor
One of the nurse's responsibilities is to educate new parents on the best method to prevent infections in the newborn environment. Which method would the nurse identify as best to control infection?
handwashing
The nurse is caring for a client is who 24-hours post delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time?
hemoglobin and hematocrit
When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?
hypothermia
While trying to decide whether to bottle feed or breastfeed her newborn infant, a new mother questions the lactation specialist concerning the greatest benefit of breastfeeding her infant. What would be the best response?
immunity against many different bacteria
A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?
improves pelvic floor tone
When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection?
in the reproductive tract
The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness?
increased coagulation factors
While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect?
laceration
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?
nonshivering thermogenesis
When the nurse is applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate?
over the liver
During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention?
peribottle and warm water
After teaching a group of nurses during an in-service program about risk factors associated with postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which risk factors? Select all that apply.
placenta previa hydramnios labor augmentation
The nurse is concerned that the parents are having difficulties relating to their newborn. In an effort to assist with and encourage attachment, which activity should the nurse suggest?
promoting skin-to-skin contact on the chest
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.
When assessing a newborn's reflexes, the nurse strokes the newborn's cheek, and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive?
rooting reflex
A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?
sternal retractions
The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long?
the first 6 months
A mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that:
this is a normal finding.
Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which condition?
thromboembolism
The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding?
two arteries and one vein
A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment?
yellow sclera
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."
