OB2

During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into the mouth. In assessing the problem, the nurse should intervene if the mother: a) pushes only the tip of the nipple into the neonate's mouth. b) uses a nipple with regular size openings. c) strokes the neonate's lips gently with the nipple. d) makes sure that the nipple fills with formula.

pushes only the tip of the nipple into the neonate's mouth. Correct Explanation: The tip of the nipple shouldn't be pushed into the neonate's mouth. To suck effectively, the neonate needs to compress the entire nipple, not just the tip. Filling the nipple with formula reduces air swallowing. Stroking the neonate's lips gently with the nipple usually causes the mouth to open wide enough for nipple insertion. The mother should use a nipple with a regular size opening to avoid having too much formula enter the mouth once the neonate starts to suck

During a neonate's assessment shortly after birth, the nurse observes a large pad of fat at the back of the neck, widely set eyes, simian hand creases, and epicanthal folds. Which action is most appropriate? a) Document these findings as minor deviations. b) Ask the mother to consent to genetic studies. c) Explain these deviations to the newborn's mother. d) Notify the health care provider (HCP) immediately.

Notify the health care provider (HCP) immediately. Correct Explanation: A large pad of fat at the back of the neck, widely set eyes, a simian crease in the hands, and epicanthal folds are typically associated with Down syndrome. The nurse should notify the HCP immediately. The HCP should obtain consent for genetic studies and is responsible for explaining these deviations to the parents. However, the nurse may need to provide additional teaching to the mother and to answer any questions that may arise.

The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: a) peripheral acrocyanosis. b) lethargy. c) jaundice. d) bradycardia.

lethargy. Correct Explanation: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia — not bradycardia — is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia

When assessing a term newborn (6 hours old), the nurse auscultates bowel sounds and documents recent passing of meconium. These findings would indicate: A Abnormal gastrointestinal newborn transition and needs to be reported B An intestinal anomaly that needs immediate surgery C A patent anus with no bowel obstruction and normal peristalsis D A malabsorption syndrome resulting in fatty stools

c. The findings indicate a patent anus with no bowel obstruction and normal peristalsis.

A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority? a) The client will state instructions for discharge during the first postpartum day. b) By the end of the shift, the client will describe a safe home environment. c) By discharge, the family will bond with the neonate. d) The client will demonstrate self-care and infant care by the end of the shift.

The client will demonstrate self-care and infant care by the end of the shift. Correct Explanation: Educating the client about caring for herself and her infant are the two highest priority goals. Following childbirth, all mothers, especially the primigravida, require instructions regarding self-care and infant care. Learning needs should be assessed in order to meet the specific needs of each client. Bonding is significant, but is only one aspect of the needs of this client and the bonding process would have been implemented immediately postpartum, rather than waiting 2 hours. Planning the discharge occurs after the initial education has taken place for mother and infant and the nurse is aware of any need for referrals. Safety is an aspect of education taught continuously by the nurse and should include maternal as well as newborn safety.

A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states that the adverse effects include which symptom? a) epistaxis b) slow pulse c) petechiae d) bleeding gums

slow pulse Correct Explanation: A slow pulse (bradycardia) is normal for the first 7 days postpartum as the body begins to adjust to the decrease in blood volume and return to the prepregnant state. Adverse effects of heparin therapy suggesting prolonged bleeding include hematuria, epistaxis, increased lochial flow, and bleeding gums. Typically, tachycardia, not bradycardia, would be associated with hemorrhage. Petechiae indicate bleeding under the skin or in subcutaneous tissue

A neonate begins to gag and turns a dusky color. What should the nurse do first? a) Notify the physician. b) Provide oxygen via a face mask as ordered. c) Aspirate the neonate's nose and mouth with a bulb syringe. d) Calm the neonate.

Aspirate the neonate's nose and mouth with a bulb syringe. Correct Explanation: The nurse's first action should be to clear the neonate's airway with a bulb syringe. After the airway is clear and the neonate's color improves, the nurse should comfort and calm the neonate. If the problem recurs or the neonate's color doesn't improve readily, the nurse should notify the physician. Administering oxygen when the airway isn't clear would be ineffective.

A nurse is about to give a full-term neonate his first bath. How should the nurse proceed? a) Wash the neonate from feet to head. b) Scrub the neonate's skin to remove the vernix caseosa. c) Bathe the neonate only after his vital signs have stabilized. d) Clean the neonate with medicated soap.

Bathe the neonate only after his vital signs have stabilized. Correct Explanation: To guard against heat loss, the nurse should bathe the neonate only after vital signs have stabilized. To avoid altering the skin pH, the nurse should use only mild soap and water. Scrubbing should be avoided because it may cause abrasions, through which microorganisms can enter. The nurse should wash the neonate from head to feet.

After instructing a primiparous client who is breastfeeding on how to prevent nipple soreness during feedings, the nurse determines that the client needs further instruction when she makes which statement? a) "I should not use a hand breast pump if my nipples get sore." b) "I should position the baby the same way for each feeding." c) "I should air dry my breasts and nipples for 10 to 15 minutes after the feeding." d) "I should make sure the baby grasps the entire areola and nipple."

"I should position the baby the same way for each feeding." Correct Explanation: The mother needs further instruction when she says, "I should position the baby the same way for each feeding." This can contribute to sore nipples. The position should vary for each feeding to prevent repeated pressure on the same area each time. Grasping the entire areola and nipple will help to decrease nipple soreness. Air drying the breasts and not using a hand pump will help to decrease nipple soreness

A prophylactic agent is instilled in both eyes of all newborns to prevent which of the following conditions? A Gonorrhea and chlamydia B Thrush and Enterobacter C Staphylococcus and syphilis D Hepatitis B and herpes

a. The eyes of newborns can be exposed to gonorrhea and/or chlamydial organisms if they are present in the mother's vagina during the birth process, possibly resulting in a severe infection and blindness. Therefore, eye prophylaxis is administered. Thrush and Enterobacter typically do not affect the eyes. Thrush develops in the newborn's mouth after exposure to maternal vaginal yeast infections during the birth process. Infections with Staphylococcus and syphilis are contracted through bloodstream exposure or via the placenta and not by contact with the maternal vagina during birth. Eye treatment would not impact/treat either infectious process. Hepatitis B and herpes are not treatable with eye ointment.

Which findings should lead the nurse to suspect that a client who had a cesarean birth 8 hours earlier is developing disseminated intravascular coagulation (DIC) and report to the health care provider (HCP)? Select all that apply. a) petechiae on the arm where the blood pressure was taken b) abdominal incision dressing with bright red drainage c) temperature of 98.4° F (36.9° C) d) heart rate of 126 bpm e) platelet count of 80,000/mm3 (80 X 109/L) f) urine output of 350 mL in the past 8 hours

heart rate of 126 bpm • platelet count of 80,000/mm3 (80 X 109/L) • petechiae on the arm where the blood pressure was taken • abdominal incision dressing with bright red drainage Correct Explanation: DIC is diagnosed based on clinical symptoms and laboratory findings. Findings such as excessive and unusual bruising or bleeding over areas of tissue trauma, such as IV insertion or incision sites or application of a blood pressure cuff should be reported to the HCP. Tachycardia and diaphoresis also may be noted. Laboratory results reveal low platelet, fibrinogen, proaccelerin, antihemophiliac factor, and prothrombin levels. Bleeding time is normal and partial thromboplastin time is increased. A urine output of 350 mL in 8 hours indicates adequate renal function. Temperature is not an indication of DIC.

A nurse observes a 3-day-old term newborn who is starting to appear mildly jaundiced. What might explain this condition? A Physiologic jaundice secondary to breast-feeding B Hemolytic disease of the newborn due to blood incompatibility C Exposing the newborn to high levels of oxygen D Overfeeding the newborn with too much glucose water

c. Convection is loss of heat from an object to the environment. Using the portholes instead of opening the isolette door prevents rapid heat loss from the inside of the isolette. This action also protects the newborn from drafts. Evaporation is the loss of heat as water is lost from the skin to the environment. Keeping the newborn dry will prevent this type of heat loss. Conduction is the transfer of heat from one object to another when in direct contact, such as placing a newborn onto a cold scale to be weighed. Radiation is the loss of heat between objects that are not in direct contact, such as a cold window near the newborn's isolette.

The nurse is assisting in the birthing room. The physician performs an episiotomy, an incision in the client's perineum to enlarge the vaginal opening and facilitate childbirth. Which interventions should the nurse perform when caring for the client after this procedure? Select all that apply. a) Check the episiotomy repair site. b) Explain perineal care to the client when she can focus on the instructions. c) Apply ice to the perineum. d) Administer pain medication, as prescribed. e) Change the dressings every shift.

Check the episiotomy repair site. • Apply ice to the perineum. • Administer pain medication, as prescribed. • Explain perineal care to the client when she can focus on the instructions. Explanation: Immediately following an episiotomy, the nurse should apply an ice pack to the perineal area to decrease swelling and pain. The nurse should also check the site to ensure that it is intact and assess for hematoma, edema, and drainage. The nurse should assess the client for pain and should administer analgesics as needed and prescribed. When the client is able, the nurse should instruct about perineal care. Episiotomy repair sites are not covered with dressings.

A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which liquid? a) milk b) orange juice c) herbal tea d) grape juice

orange juice Correct Explanation: Iron is best absorbed in an acid environment or with vitamin C. For maximum iron absorption, the client should take the medication with orange juice or a vitamin C supplement. Herbal tea has no effect on iron absorption. Milk decreases iron absorption. Grape juice is not acidic and therefore would have no effect on iron absorption

Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate? a) "Wait until you have breastfed for at least 4 months." b) "Eliminate the baby's favorite feeding times first." c) "Plan to omit the daytime feedings last." d) "Gradually eliminate one feeding at a time."

"Gradually eliminate one feeding at a time." Correct Explanation: The client should wean the infant gradually, eliminating one feeding at a time. The baby can be weaned to a bottle (formula) anytime the mother desires; she does not have to breastfeed for 4 months. Most infants (and mothers) develop a "favorite feeding time," so this feeding session should be eliminated last. The client may wish to begin weaning with daytime feedings when the infant is busy

After the birth of a viable neonate, a 20-year-old primiparous client comments to her mother and the nurse about the baby. Which comment would the nurse interpret as a possible sign of potential maternal-infant bonding problems? a) "I think my mother should give him the first feeding." b) "He has my funny-looking ears!" c) "He is a lot bigger than I expected him to be." d) "I want to buy him a blue outfit to wear when we get home."

"I think my mother should give him the first feeding." Correct Explanation: Avoidance, hostility, or low-key (passive) behavior toward the baby may be a cue to potential bonding problems. The nurse should encourage the client to give the baby the first feeding to begin the bonding process. Expressions of disappointment with the baby's gender may also signal problems with maternal-infant bonding. Comparing the baby's features to her own indicates identification of the neonate as belonging to her, suggesting bonding with neonate. Comparing the actual neonate with the "fantasized neonate" is a normal maternal reaction. Wanting to buy a blue outfit indicates an interest in and connection with the neonate and is a sign of bonding

During a home visit on the fifth postpartum day, the client begins to cry and says that she is worried about her ability to care for her baby adequately. She tells the nurse, "I wish I could just get organized—I need 8 hours of sleep!" The nurse determines that she is experiencing which condition? a) Taking-hold phase of childbearing; she is feeling inadequate about neonatal care. b) Postpartum blues phase of childbearing; she needs psychological counseling. c) Letting-go phase of childbearing; she needs help to assume the maternal role. d) Taking-in phase of childbearing; she is exhibiting typical signs of adaptation.

Taking-hold phase of childbearing; she is feeling inadequate about neonatal care. Correct Explanation: A primipara often has concerns about her ability to care for her infant properly during the taking-hold phase. She is working toward independence and autonomy and wants to be able to perform well in her new role as mother. She needs emotional support, advice on how to manage, reassurance, and reinforcement of appropriate behavior. The taking-in phase occurs from birth up to about the second to third postpartum day. During this phase, the client is focused on herself and not the neonate. Postpartum blues are evidenced by extreme sadness. However, this client is exhibiting usual behavior associated with the taking-hold phase. Psychological counseling is not warranted. In the letting-go phase, the woman redefines her new role. This phase is extended and continues into the child's growing years. This process requires some grief work and readjustment.

A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention? a) Pack the vagina with sterile gauze. b) Insert an indwelling catheter. c) Call the physician. d) Massage the fundus.

Massage the fundus. Explanation: Postpartum hemorrhage results in excessive vaginal bleeding and signs of shock, such as pallor and a rapid, thready pulse. Placental separation causes a sudden gush or trickle of blood from the vagina, rise of the fundus in the abdomen, increased umbilical cord length at the introitus, and a globe-shaped uterus. Uterine involution causes a firmly contracted uterus, which cannot occur until the placenta is delivered. Cervical lacerations produce a steady flow of bright red blood in a client with a firmly contracted uterus. The priority measure to correct postpartum hemorrhage is to massage the fundus. Packing the uterus with sterile gauze is contraindicated. The physician will have to be called but the nurse must first intervene.

The AAP recommends that all newborns be placed on their backs to sleep to reduce the risk of: A Respiratory distress syndrome B Bottle mouth syndrome C Sudden infant death syndrome D GI regurgitation syndrome

c. Research has identified sleeping position and its link to SIDS. Since 1992, the AAP has recommended that all newborns be placed on their backs to sleep. This recommendation has reduced the incidence of SIDS dramatically. Respiratory distress syndrome involves a lack of surfactant in the lungs, not sleeping position. The intake of formula or juice (high lactose exposure) being allowed to sit in the infant's mouth during sleep is the cause of bottle mouth syndrome. Positioning on the back might aggravate the GI regurgitation syndrome rather than help it.

After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she makes which statement? a) "Like most women, I have immunity against the Rh factor." b) "My other baby had a different father." c) "My blood couldn't neutralize antibodies formed from my first pregnancy." d) "Antibodies are not usually formed until after exposure to an antigen."

"Antibodies are not usually formed until after exposure to an antigen." Correct Explanation: The problem of Rh sensitivity arises when the mother's blood develops antibodies after fetal red blood cells enter the maternal circulation. In cases of Rh sensitivity, this usually does not occur until after the first pregnancy. Hence, hemolytic disease of the newborn is rare in a primiparous client. A mismatched blood transfusion in the past or an unrecognized spontaneous abortion could also result in hemolytic disease because the transfusion or abortion would have the same effects on the client. The statement about the other baby having a different father may be true. However, if both fathers were Rh-positive, then sensitization could occur. Most women do not have immunity against the antibodies formed when Rh-positive cells enter the mother's bloodstream. Antibodies are not neutralized by the mother's system

While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time? a) Take the neonate's temperature immediately according to hospital policy. b) Activate the code emergency response system. c) Notify the physician that a cardiac consult is needed. d) Do nothing — acrocyanosis is normal in the neonate.

Do nothing — acrocyanosis is normal in the neonate. Explanation: Acrocyanosis, or bluish hands and feet in the neonate, is a normal finding and shouldn't last more than 24 hours after birth. Activating the code emergency response system, taking the neonate's temperature, and notifying the physician that a cardiac consult is needed are inappropriate actions.

While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth of a viable neonate, the nurse notes that the client's urine has two small blood clots in the measuring container. What should the nurse do next? a) Document this observation as a normal finding. b) Review the client's records for the length of the third stage of labor. c) Massage the client's fundus vigorously. d) Ask the client if she passed clots with her previous births.

Document this observation as a normal finding. Correct Explanation: The passage of two small blood clots from a multiparous woman 1 hour after a vaginal birth is not an unusual occurrence. The nurse should continue to monitor the client and document this as a normal finding. The nurse should never massage a postpartum client's fundus vigorously because of the risk for uterine inversion and discomfort to the mother. Asking whether the client passed clots with her previous births is irrelevant. The length of the third stage of labor has no relation to whether or not the client passes clots.

Which action is the best precaution against transmission of infection? a) Eye prophylaxis with antibiotics for a neonate whose mother has hepatitis B infection b) Strict isolation for a neonate whose mother has cytomegalovirus (CMV) infection c) Eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection d) Strict isolation for a neonate whose mother has human immunodeficiency virus (HIV)

Eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection Correct Explanation: Mothers can transmit gonorrhea during the birth process; untreated, it can cause serious eye damage to the neonate. A neonate whose mother has hepatitis B should receive hepatitis B immunoglobulin within 12 hours of birth, not eye prophylaxis. CMV doesn't require strict isolation; however, the neonate may be treated with I.V. antivirals. HIV is transmitted via blood and body fluids. Contact isolation, not strict isolation, is appropriate.

When caring for the neonate of a mother with gestational diabetes, which finding is most indicative of a hypoglycemic episode? a) Jitteriness b) Hyperalert state c) Positive Babinski's reflex d) Serum glucose level of 60 mg/dl (3.3 mmol/L)

Jitteriness Correct Explanation: Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl (2.2 mmol/L). A hyperalert state suggests neurologic irritability and isn't associated with blood glucose levels. A positive Babinski's reflex is a normal finding in neonates and isn't associated with hypoglycemia. A serum glucose level of 60 mg/dl (3.3 mmol/L) is a normal level

Which infant is most likely to have stable blood glucose levels? a) One delivered by cesarean birth b) One born at 42 weeks' gestation c) One born at 34 weeks' gestation d) One with respiratory distress

One delivered by cesarean birth Explanation: Neonates delivered by cesarean birth without any other contributing factors should have adequate stores of brown fat to control blood glucose levels. Stores of brown fat aren't deposited until 36 weeks, so neonates born at less than 36 weeks won't have the necessary stores to maintain a normal blood glucose level. Neonates who are postdated or have respiratory distress will use up their stores of brown fat as a result of these complications.

Which assessment finding would lead a nurse to suspect dehydration in a preterm neonate? a) Excessive weight gain b) Urine output below 1 ml/hour c) Urine specific gravity below 1.012 d) Bulging fontanels

Urine output below 1 ml/hour Explanation: Urine output below 1 ml/hour is a sign of dehydration. Other signs of dehydration include depressed, not bulging, fontanels; excessive weight loss, not gain; decreased skin turgor; dry mucous membranes; and urine specific gravity above, not below, 1.012.

Which finding is considered normal in the neonate during the first few days after birth? a) Weight gain of 25% b) Weight loss of 25% c) Weight loss then return to birth weight d) Birth weight of 4½ to 5½ lb (2,000 to 2,500 g)

Weight loss then return to birth weight Explanation: Neonates lose approximately 10% of their birth weight during the first 3 or 4 days, because of loss of excess extracellular fluids and meconium and limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 6 to 9 lb (2,700 to 4,000 g).

The client asks the nurse, "How can I tell whether my baby is spitting up or vomiting?" The nurse explains that, in contrast to regurgitated material, vomited material is characterized by: a) one-time occurrence during feeding. b) a curdled appearance. c) usually occurring prior to a feeding. d) a brownish color.

a curdled appearance. Explanation: Vomited material has been digested and looks like curdled milk with a sour odor. Vomiting usually occurs between feedings and empties the stomach of its contents. It also tends to be forceful or projectile. In contrast, regurgitation is undigested material; it does not have a sour odor, and occurs during or immediately after feeding. Vomiting is unrelated to a feeding. Also, vomiting continues until the stomach is empty, while regurgitation is usually only about 5 to 10 mLs. Vomited material is typically white and curdled in appearance. A brownish color suggests old blood. Vomiting usually occurs between feedings, whereas regurgitation occurs during or immediately after feeding.

A nurse assigns to a neonate an Apgar score of 8 at 5 minutes. The nurse understands that this score indicates: a) a neonate who needs additional oxygen to improve the Apgar score. b) a neonate who's mildly depressed. c) a neonate who's moderately depressed. d) a neonate who's in good condition.

a neonate who's in good condition. Correct Explanation: An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.

A postpartum nurse should provide care that is: a) focused on the mother and neonate. b) family-centered. c) focused on the mother. d) centered on the neonate.

family-centered. Explanation: The postpartum nurse is responsible for making assessments that involve the complete family unit and family members' adjustment to their new roles. The family unit includes the mother, neonate, father, and the neonate's siblings.

A neonate is 4 hours of age. Nursing assessment reveals a heart murmur. The nurse should: a) further assess for signs of distress. b) continue routine care. c) feed the neonate. d) call the health care provider (HCP) immediately.

further assess for signs of distress. Explanation: Further assessment for signs of distress is necessary. At 4 hours of age a transient murmur may be heard as the fetal shunts are closing. This is a normal finding. If no other distress is noted, the HCP does not need to be called. Result can be noted on the medical record. Further assessment is needed to know if continuing routine care and feeding are appropriate and safe for the neonate

After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of: a) standard infant formula. b) iron-fortified infant formula. c) sterile water. d) glucose water.

iron-fortified infant formula. Explanation: For a bottle-fed neonate, the first feeding usually consists of iron-fortified formula. It isn't necessary to start with sterile water or glucose water.

While performing a physical assessment on a term neonate shortly after birth, which finding would cause the nurse to notify the health care provider (HCP)? a) frequent sneezing during the assessment b) single crease on each of the palms c) deep creases across the soles of the feet d) absence of lanugo on the skin

single crease on each of the palms Explanation: A single crease across the palm (simian crease) is most commonly associated with chromosomal abnormalities, notably Down syndrome. Deep creases across the soles of the feet is a normal finding in a term neonate. Frequent sneezing in a term neonate is normal. This occurs because the neonate is a nose breather and sneezing helps to clear the nares. An absence of lanugo on the skin of a term neonate is a normal finding.

The nurse recognizes that teaching about the need for an exchange transfusion in a neonate with erythroblastosis fetalis has been effective if the parents describe the purpose of the transfusion is: a) to replace Rh-negative blood with Rh-positive blood. b) to replenish the neonate's leukocytes. c) to restore the fluid and electrolyte balance. d) to correct the neonate's anemia.

to correct the neonate's anemia. Correct Explanation: An exchange transfusion is done to reduce the blood concentration of bilirubin and correct the anemia. The exchange transfusion does not replenish the white blood cells or restore the fluid and electrolyte balance. The neonate's Rh-positive blood is replaced by Rh-negative blood

After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which agent? a) antibacterial soap b) warm water c) diluted hydrogen peroxide d) pvidone-iodine solution

warm water Correct Explanation: After circumcision with a Plastibell, the most commonly recommended procedure is to clean the circumcision site with warm water with each diaper change. Other treatments are necessary only if complications, such as an infection, develop. Antibacterial soap or diluted hydrogen peroxide may cause pain and is not recommended. Povidone-iodine solution may cause stinging and burning, and therefore its use is not recommended.

The charge nurse in the newborn nursery has an unlicensed assistive personnel (UAP) with her for the shift. Under their care are 8 babies rooming in with their mothers, and 1 infant in the nursery for the night on tube feedings. There is a new client whose infant will be brought to the nursery in 15 minutes. Which tasks would the nurse assign to the UAP? Select all that apply. a) tube feeding b) vital signs on all stable infants c) document feedings of infants d) bath and initial feeding for new admission e) newborn admission f) record voids/stools

• record voids/stools • vital signs on all stable infants • document feedings of infants Correct Explanation: The role of the UAP allows this member of the health care team to take vital signs on clients, record feedings, and voids and stools of infants according to hospital guidelines. The newborn assessment is completed by a licensed care provider as is the tube feeding. Bathing of the newborn is within the scope of practice for the UAP, but the initial assessment of patency of the gastrointestinal tract, which is initiated by the first feeding, is within the scope of licensed care providers. If there is a trachea esophageal fistula, this is the time when it may become eviden

Discharge planning is being finalized for a neonate who was born at 32 weeks' gestation and was diagnosed with retinopathy of prematurity. What should the nurse tell the parents? a) "You should schedule an appointment with a optometrist when the baby is 6 months old. b) "Contact the local support group for the blind." c) "Before your child enters the public school system, you must arrange for an individualized educational plan with the school nurse." d) "An ophthalmologist will examine the baby before discharge."

"An ophthalmologist will examine the baby before discharge." Correct Explanation: An ophthalmologist commonly examines neonates with retinopathy of prematurity before discharge. Serial eye examinations are then necessary to determine the extent of damage. An optometrist can't provide follow-up treatment for the neonate with retinopathy of prematurity because some neonates require cryotherapy and laser photocoagulation therapy, both of which must be performed by an ophthalmologist. The parents should contact the early intervention program to set up an individualized educational plan for their child before he reaches school age. Because the neonate may have permanent vision loss, intervention before school age is important to the child's growth and development. The school nurse is only involved with individualized educational plans for children of school age. The neonate may not be blind, so suggesting a support group for the blind is inappropriate.

After explaining to a primiparous client about the causes of her neonate's cranial molding, which statement by the mother indicates the need for further instruction? a) "The molding was caused by an overlapping of the baby's cranial bones during my labor." b) "The amount of molding is related to the amount and length of pressure on the head." c) "Brain damage may occur if the molding does not resolve quickly." d) "The molding will usually disappear in a couple of days."

"Brain damage may occur if the molding does not resolve quickly." Correct Explanation: Caput succedaneum is common after the use of a vacuum extractor to assist the client's expulsion efforts. This edema may persist up to 7 days. Vacuum extraction is not associated with cephalohematoma. Maternal lacerations may occur, but they are more common when forceps are used. Neonatal intracranial hemorrhage is a risk with both vacuum extraction and forceps births, but it is not a common finding

A new mother is concerned because her breast-feeding neonate wants to "nurse all the time." Which response best indicates the normal neonate's breast-feeding behavior? a) "Don't worry; your baby is an aggressive feeder and needs a lot of sucking satisfaction." b) "Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings." c) "Let me call the lactation consultant to make sure that your baby is feeding properly." d) "It seems as if your baby is hungry. Why don't you provide your baby with formula after the feeding to make sure he's getting enough nourishment?"

"Breast milk is ideal for your baby, so his stomach will digest it quickly, requiring more feedings." Explanation: Breast milk is the ideal food for a neonate. As a result, the neonate will digest and use all of the nutrients in each feeding quickly. Coaching the mother must include relaying this information to allay maternal concerns about producing an adequate supply of milk. Although a lactation consultant may be helpful, the nurse should be able to provide the mother with adequate information. Telling the client not to worry ignores her concern. Suggesting supplementation with formula indicates that the mother's breast-feeding attempts are unsatisfactory. Nurses shouldn't suggest giving formula to a breast-feeding neonate

After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis of an imperforate anus for surgery the next day. The infant's parents are Catholic and do not want the surgery to take place unless the infant has first been baptized. The nurse asks the parents a) "Do you want me to help arrange the baptism?" b) "Do you want to speak with the social worker?" c) "Would you prefer to wait for the surgery?" d) "Are you worried your baby might die?"

"Do you want me to help arrange the baptism?" Explanation: The nurse should honor the parent's belief system and help arrange to have the infant baptized. This may be done through the hospital's chaplaincy department or by the family's clergy. The parents may indeed be worried that the infant may die during surgery. Having the infant baptized would help address the family's spiritual needs. At this time there is an immediate need for chaplaincy, not social service. While surgery may be postponed briefly, the infant cannot begin feeding until an outlet for stool as been established. Therefore, it is not advisable to postpone the surgery for a prolonged period of time.

A nurse is teaching a breast-feeding client how to care for her engorged breasts. Which statement by the client indicates the need for further teaching? a) "If the baby feeds only on one side, I'll express milk from the other side." b) "I'll use massage to help soften my breasts." c) "I'll use warm packs or a warm shower to ease engorgement." d) "If my breasts are uncomfortable, I'll limit the time I spend breast-feeding."

"If my breasts are uncomfortable, I'll limit the time I spend breast-feeding." Correct Explanation: The client stating that she'll limit the time she spends breast-feeding indicates the need for further teaching. Engorgement results from fullness in breast veins and alveolar engorgement with milk. Limiting the time spent breast-feeding causes insufficient breast milk removal; as a result, milk volume exceeds alveolar storage capacity, causing pain. Breast massage, heat application, and milk expression help minimize engorgement

The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. What is the nurse's best response? a) "When faced with a pain, newborns try to roll away from it." b) "Newborns cry and cannot be distracted to stop crying." c) "Newborns typically move their whole body in response to pain." d) "Pain causes the newborn to withdraw the affected part."

"Newborns typically move their whole body in response to pain." Explanation: After surgical repair for an imperforate anus, the infant should be positioned either supine with the legs suspended at a 90-degree angle or on either side with the hips elevated to prevent pressure on the perineum. A neonate who is placed on the abdomen pulls the legs up under the body, which puts tension on the perineum, as does positioning the neonate on the back with the legs extended straight out.

The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse? a) "The stool results from the gassy food eaten by the mother. Refrain from eating these foods while breastfeeding." b) "This type of stool indicates the infant may have diarrhea and should be seen in the office today." c) "Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding." d) "The stool will transition into a soft, brown, formed stool within a few days and is appropriate for breastfeeding."

"Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding." Correct Explanation: A soft seedy unformed stool is the norm for a 4-day-old infant. It may surprise the mother as it is a change from the meconium the infant had since birth. This stool is not diarrhea even though it has no form. There is no need for the infant to be seen for this. As long as the infant is breastfeeding, the stools will remain of this color and consistency. Brown and formed stool is common for an infant who is bottle-fed or after the breastfeeding infant has begun eating food

While the nurse is conducting a teaching session on breast-feeding, a client asks why she should put her newborn to the breast within the first 30 minutes of birth. The nurse's best response will be: a) "Breast-feeding will prevent the newborn from heat loss." b) "The neonate will be responsive and eager to suck at this time." c) "Breast-feeding will inhibit prolactin production." d) "Your breasts will be firm and filled with colostrum at this time."

"The neonate will be responsive and eager to suck at this time." Explanation: During the first 30 minutes or so after birth, the healthy, full-term neonate is highly responsive and has a strong desire to suck. Many neonates breast-feed shortly after birth; all make licking or nuzzling motions, helping to stimulate the mother's prolactin production and enhance maternal-neonate bonding. Also, the client's breasts may be soft and easily manipulated at this time, promoting proper attachment of the neonate. Although the breasts contain colostrum at this time, they aren't firm. Typically, the neonate falls asleep 2 to 3 hours after birth.

According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate? a) "The presence of vernix affects the newborn's immune system." b) "The vernix should be a thicker coating for a newborn." c) "The vernix is difficult and painful to remove from a newborn." d) "The vernix indicates a different gestational age than expected."

"The vernix indicates a different gestational age than expected." Correct Explanation: Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day post-mature baby to have increased amounts of vernix. A discrepancy between EDC (estimated date of conception) and gestational age by physical examination must have occurred.

The nurse has completed discharge teaching with new parents who will be bottle-feeding their normal term newborn. Which statement by the parents reflects the need for more teaching? a) "We should weigh our baby daily to make sure he is gaining weight." b) "Our baby will require feedings through the night for several weeks or months after birth." c) "Our baby should have 1 to 3 soft, formed stools a day." d) "The baby should burp during and after each feeding with no projective vomiting."

"We should weigh our baby daily to make sure he is gaining weight." Explanation: Healthy infants are weighed during their visits to their health care provider (HCP) , so it is not necessary to monitor weights at home. Infants may require 1 to 3 feedings during the night initially. By 3 months, 90% of babies sleep through the night. Projective vomiting may indicate pyloric stenosis and should not be seen in a normal newborn. Bottle-fed infants may stool 1 to 3 times daily.

A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's mother, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which information? a) "A complete blood count analysis is the primary method for determining whether the neonate is HIV positive." b) "We will test your baby now, but testing will need to be repeated for an accurate diagnosis." c) "More than 50% of neonates born to mothers who are positive for HIV will be positive at 18 months of age." d) "An enlarged liver at birth generally means the neonate is HIV positive."

"We will test your baby now, but testing will need to be repeated for an accurate diagnosis." Correct Explanation: New recommendations state that virologic diagnostic testing at birth should be considered for infants at high risk of HIV infection, but it may take several months before an accurate diagnosis can be made. New guidelines suggest that infants should be tested at 2 to 3 weeks, 1 to 2 months, and again 4 to 6 months. It is estimated that 15% to 30% of all HIV-positive mothers without treatment will give birth to HIV-positive infants. With appropriate drug intervention to the mother during pregnancy, 95% of these neonates can be born unaffected. An enlarged liver at birth is associated with erythroblastosis fetalis, not HIV infection. Virologic testing, such as deoxyribonucleic acid polymerase chain reaction, viral culture, or ribonucleic acid plasma assay, can diagnose HIV infection by 6 months of age and commonly in the first month.

A multiparous client who has a neonate diagnosed with hemolytic disease of the newborn asks the nurse why the neonate has developed this problem. Which response by the nurse would be most appropriate? a) "The baby and you are both Rh-positive." b) "You are Rh-negative and the baby is Rh-positive." c) "You are Rh-positive, and the baby is Rh-negative." d) "You and the baby are both Rh-negative."

"You are Rh-negative and the baby is Rh-positive." Correct Explanation: Hemolytic disease of the newborn is associated with Rh problems. Hemolytic disease of the newborn occurs most commonly when the mother is Rh-negative the infant is Rh-positive. About 13% of Caucasians, 7% to 8% of people of African descent, and 1% of people of Asian descent are Rh-negative. Rh-positive cells enter the mother's Rh-negative bloodstream, and antibodies to the Rh-positive cells are produced. In a subsequent pregnancy, the antibodies cross the placenta to the Rh-positive fetus and begin the destruction of Rh-positive cells through hemolysis. This results in severe fetal anemia

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate? a) Adduction and flexion of the extremities with gently rounded shoulders b) Hyperabduction and extension of the arms with external rotation of the hips c) Abduction and flexion of the arms with flattened shoulders d) Neck extension and back arching with flattened shoulders

Adduction and flexion of the extremities with gently rounded shoulders Correct Explanation: The goal of neonatal positioning is to gently round shoulders and flex elbows and to avoid abduction of the shoulders and hips. This positioning enhances physiologic stability and developmental progress. Hyperabduction and external rotation in a preterm neonate may result in contractures. Neck extension, back arching, flattened shoulders, and abduction should be avoided in neonates.

What would the nurse do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? a) Secure the diaper tightly to apply pressure on the site. b) Notify the neonate's health care provider immediately. c) Apply gentle pressure to the site with a sterile gauze pad. d) Check the diaper and circumcision again in 30 minutes.

Apply gentle pressure to the site with a sterile gauze pad. Explanation: If bleeding occurs after circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs. The primary care provider needs to be notified when bleeding cannot be stopped by conservative measures because this may signal a clotting disorder. Typically the neonate's circumcision site, including the diaper, is examined every 15 minutes for 1 hour to assess bleeding. Rechecking in 30 minutes may be too late if the neonate is actively bleeding. Securing the diaper tightly to apply pressure does not allow the nurse to observe whether bleeding has stopped.

An infant needs a one time gavage feeding. After inserting a the nasogastric tube what should the nurse do next? a) Aspirate stomach contents through the catheter. b) Instill about 10 mL of sterile water into the catheter. c) Obtain a prescription for a chest radiograph. d) Clamp the catheter for 1 minute.

Aspirate stomach contents through the catheter. Correct Explanation: After inserting a gavage feeding catheter, the nurse should next check that the catheter is in the stomach before instilling nourishment. One way is to aspirate stomach contents. Another method is to inject a few millimeters of air into the catheter while auscultating over the stomach with a stethoscope to listen for the sound of air entering the stomach. Clamping the catheter momentarily is unnecessary and does not indicate the proper placement of the catheter. Routine chest radiograph to check for placement of the feeding tube usually is not done if the feeding tube will not be left in for a long-term basis because of the increased cost and exposure of the neonate to radiation. Instilling 10 mL of sterile water is to be avoided because the feeding tube could be in the lungs, causing aspiration or pneumonia.

A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes heart rate 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and his body is pink. He also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next? a) Assign an Apgar score of 10, place in the neonate in modified Trendelenburg's position, and suction the neonate's nose. b) Assign an Apgar score of 7, place the neonate in modified Trendelenburg's position, and begin artificial respirations. c) Assign an Apgar score of 6, place the neonate in modified Trendelenburg's position, and initiate a code to gain assistance from the code team. d) Assign an Apgar score of 9, place the neonate in modified Trendelenburg's position, and suction the neonate's nose and oropharynx.

Assign an Apgar score of 9, place the neonate in modified Trendelenburg's position, and suction the neonate's nose and oropharynx. Correct Explanation: The neonate should be assigned an Apgar score of 9 because the neonate is pink, is crying vigorously, is moving all extremities, has a heart rate of 110 beats/minute, and has an irregular respiratory effort. The irregular respiratory effort and the presence of mucus in the nasal and oral cavities signify that the neonate requires suctioning. The neonate doesn't require resuscitation.

While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer a prescribed vitamin K intramuscular injection at 1 hour after birth. Which action should the nurse do first? a) Wait until the first dose of antiretroviral medication is given. b) Wash the injection site with povidone-iodine solution. c) Place the neonate under a radiant warmer. d) Bathe the neonate.

Bathe the neonate. Explanation: Newborns are typically bathed 2 to 4 hours after birth when their temperatures have had time to stabilize, but early/immediate bathing is recommended for the infants of HIV-positive mothers to decrease blood exposure. Placing the neonate under the radiant warmer for the vitamin K injection is not necessary unless the neonate's temperature is subnormal. Washing the injection site with povidone-iodine is not recommended and may increase the risk for possible allergy to iodine preparations. The first dose of zidovudine is given when the newborn is 6 to 12 hours old, but vitamin K is recommended to be given within an hour of birth to be most effective. Therefore the vitamin K should not be delayed.

During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What should the nurse do first? a) Start mouth-to-mouth resuscitation. b) Contact the neonatal resuscitation team. c) Clear the neonate's airway with suction or gravity. d) Raise the neonate's head and pat the back gently.

Clear the neonate's airway with suction or gravity. Explanation: If a neonate gags on mucus and becomes cyanotic during the first feeding, the airway is most likely closed. The nurse should clear the airway by gravity (by lowering the infant's head) or suction. Starting mouth-to-mouth resuscitation is not indicated unless the neonate remains cyanotic, and lowering the head or suctioning does not clear the airway. Contacting the neonatal resuscitation team is not warranted unless the infant remains cyanotic even after measures to clear the airway. Raising the neonate's head and patting the back are not appropriate actions for removing mucus. Doing so allows the mucus to remain lodged causing further breathing difficulties.

An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the parents removed the identification bands from the neonate. Which action should the nurse take next? a) Reprimand the parents for allowing the identification bands to come off. b) Obtain the neonate's footprints and compare them with the footprints obtained at birth. c) Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to one of the neonate's extremities. d) Replace the identification bands.

Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to one of the neonate's extremities. Correct Explanation: The nurse should immediately compare the information on the mother's identification band with that of the neonate's and then reattach the neonate's bands. This safety practice prevents infant abduction. Replacing the bands without first verifying identification is irresponsible. Reprimanding the parents will be detrimental to the nurse-parent relationship. The nurse isn't qualified to compare footprints.

A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents? a) Deficient knowledge related to ventilatory support. b) Risk for aspiration related to nil orally status. c) Deficient knowledge related to inability to cope. d) Deficient knowledge related to lack of exposure to apnea monitor.

Deficient knowledge related to lack of exposure to apnea monitor. Correct Explanation: For the parents of a neonate who needs a home apnea monitor, the nursing diagnosis of Deficient knowledge related to lack of exposure to apnea monitor is most appropriate. Although the premature neonate may be at risk for aspiration, the question asks about the most appropriate nursing diagnosis for the parents, not the neonate. No ventilatory support is being used, so a diagnosis of Deficient knowledge related to ventilatory support isn't warranted. A diagnosis of Deficient knowledge related to prematurity would be appropriate just after birth but would probably be resolved by the time the neonate is ready for discharge.

The parents of a neonate born with congenital clubfoot express feelings of helplessness and guilt and are exhibiting anxiety about how the neonate will be treated. Which action by the nurse would be most appropriate initially? a) Ask them to share these concerns with the health care provider (HCP). b) Discuss the problem with the parents and the current feelings that they are experiencing. c) Arrange a meeting with other parents whose infants have had successful clubfoot treatment. d) Suggest that they make an appointment to talk things over with a counselor.

Discuss the problem with the parents and the current feelings that they are experiencing. Correct Explanation: When an infant is born with an unexpected anomaly, parents are faced with questions, uncertainties, and possible disappointments. They may feel inadequate, helpless, and anxious. The nurse can help the parents initially by assessing their concerns and providing appropriate information to help them clarify or resolve the immediate problems. Referring the parents to the health care provider (HCP) is not necessary at this time. The nurse can assist the parents by listening to their concerns. Having them talk with other parents would be helpful a little bit later, once the nurse assesses their concerns and discusses the problem and the parents' current feelings. If the parents continue to have difficulties expressing and working through their feelings, referral to a counselor would be appropriate.

The client who is breastfeeding asks the nurse if she should supplement breastfeeding with formula feeding. The nurse bases the response on which principle? a) Formula supplements can provide nutrients not found in breast milk. b) More vigorous sucking is needed for a bottle feeding, so supplements should be avoided. c) Formula feeding should be avoided to prevent interfering with the breast milk supply. d) Primarily, water supplements should be used to prevent jaundice.

Formula feeding should be avoided to prevent interfering with the breast milk supply. Correct Explanation: Bottle supplements tend to cause a decrease in the breast milk supply and demand for breastfeeding. Unless medically necessary, bottle supplements should be avoided until breastfeeding is well established. Bottle supplements are not appropriate to prevent jaundice, although if neonatal bilirubin level is excessive, some pediatricians recommend temporary discontinuation of breastfeeding, while others recommend increasing the frequency of breastfeeding. Breastfeeding is considered the best nutritional source for infants. Although formula supplements should be avoided, neonates suck less vigorously on a bottle than on the breast.

A nursery nurse just received the shift report. Which neonate should the nurse assess first? a) Twelve-hour-old term neonate who is small for gestational age b) Two-day-old term neonate in an open bassinette c) Six-day-old neonate in an isolette, whose gestational age assessment places him at 36 weeks' gestation d) Four-hour-old term neonate with jaundice

Four-hour-old term neonate with jaundice Correct Explanation: The nurse should assess the four-hour-old neonate with jaundice. When jaundice occurs within the first 24 hours of life, it typically indicates a life-threatening disorder, such as sepsis, hemolytic disease of the neonate, Rh incompatibility, or ABO incompatibility. Physiological jaundice, which commonly occurs later, is a benign condition. A 2-day-old term neonate in an open bassinette doesn't require immediate assessment by the nurse. A 6-day-old neonate whose gestational age is 36 weeks is a normal preterm neonate who doesn't require immediate assessment by the nurse. A 12-hour-old term neonate who is small for gestational age doesn't require immediate assessment by the nurse

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate? a) Breastfeeding is not recommended, because the neonate needs increased fat in the diet. b) Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. c) Breastfeeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. d) Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done.

Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing. Correct Explanation: Many intensive care units that care for high-risk neonates recommend that the mother pump her breasts, store the milk, and bring it to the unit so the neonate can be fed with it, even if the neonate is being fed by gavage. As soon as the neonate has developed a coordinated suck-and-swallow reflex, breastfeeding can begin. Secretory immunoglobulin A, found in breast milk, is an important immunoglobulin that can provide immunity to the mucosal surfaces of the gastrointestinal tract. It can protect the neonate from enteric infections, such as those caused by Escherichia coli and Shigella species. Some studies have also shown that breastfed preterm neonates maintain transcutaneous oxygen pressure and body temperature better than bottle-fed neonates. There is some evidence that breast milk can decrease the incidence of necrotizing enterocolitis. The preterm neonate does not need additional fat in the diet. However, some neonates may need an increased caloric intake. In such cases, breast milk can be fortified with an additive to provide additional calories. Neonates who are receiving oxygen can breastfeed. During feedings, supplemental oxygen can be delivered by nasal cannula.

A 29-week gestation client arrives in the labor and birth suite for an emergency cesarean section. The neonate is born and artificial surfactant is administered. Which action best explains the main function and goal of surfactant use? a) Helps lungs remain expanded after the initiation of breathing improving oxygenation. b) Promotes mucus production lubricating the respiratory tract. c) Helps maintain a rhythmic breathing pattern reducing tachypnea. d) Assists with ciliary body maturation in the upper airways eliminating mucous.

Helps lungs remain expanded after the initiation of breathing improving oxygenation. Explanation: Surfactant works by reducing surface tension in the lung. It allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Improved oxygenation, as determined by arterial blood gases, is noted. Surfactant has not been shown to influence ciliary body maturation, regulate the neonate's breathing pattern, or lubricate the respiratory tract

A nurse is assessing a 1-hour-old neonate in the special care nursery. Which assessment finding indicates a metabolic response to cold stress? a) Hypoglycemia b) Arrhythmia c) Hyperglycemia d) Hypertension

Hypoglycemia Correct Explanation: Hypoglycemia, not hyperglycemia, occurs as a result of cold stress. When a neonate is exposed to a cold environment his metabolic rate increases as his body attempts to warm itself. The increase in metabolic rate causes glucose consumption resulting in hypoglycemia. Arrhythmia and hypertension are associated with cardiopulmonary problems.

The State Health Department notifies a nursery staff nurse of a phenylketonuria (PKU) metabolic screening test result of [7 mg/dl (423.5 mcmol/L)] for a neonate discharged several days ago. What should the nursery nurse do? a) Immediately notify the physician because the test result is critically elevated. b) Notify the physician in the morning of the normal test result. c) Notify the parents and tell them to take the neonate to the closest hospital for charcoal administration. d) Notify the blood bank because the neonate requires a blood transfusion.

Immediately notify the physician because the test result is critically elevated. Explanation: A normal test result for PKU metabolic screening is < [2 mg/dl 121 mcmol/L)]; a level of [7 mg/dl (423.5 mcmol/L)] is critically elevated. The nurse should immediately notify the physician. The physician should then notify the parents and ask them to bring the neonate to the facility for immediate evaluation. The neonate should have a definitive serum test performed and should be evaluated by a pediatrician who specializes in inborn errors of metabolism such as PKU. Early intervention prevents intellectual disability that can occur as a result of PKU. The test result isn't normal and waiting to notify the physician in the morning delays treatment. Charcoal is administered to neutralize poison ingestion, not to treat PKU. Blood transfusions aren't indicated for PKU.

When the infant returns to the unit after imperforate anus repair, the nurse should place the infant in which of the following positions? a) Lying on the side with the hips elevated. b) On the back, with legs extended straight out. c) On the abdomen, with legs pulled up under the body. d) Lying on the back in a position of comfort.

Lying on the side with the hips elevated. Explanation: After surgical repair for an imperforate anus, the infant should be positioned either supine with the legs suspended at a 90-degree angle or on either side with the hips elevated to prevent pressure on the perineum. A neonate who is placed on the abdomen pulls the legs up under the body, which puts tension on the perineum, as does positioning the neonate on the back with the legs extended straight out.

In a small rural facility, a nurse is caring for a neonate born to a mother with diabetes mellitus. The neonate's respiratory rate is 70 breaths/minute, heart rate 162 beats/minute, and oxygen saturation is 92% on room air. The nurse obtains a blood glucose level, which is [50 mg/dl (2.8 mmol/L)]. Realizing the seriousness of the neonate's condition, the pediatrician arranges transfer to a level III nursery. The social worker asks the nurse what transportation arrangements are needed. What type of transportation is required? a) Ambulance with advanced life support capabilities b) Ambulance from the rural facility manned with emergency medical technicians c) Medical helicopter sent to the rural facility from the level III facility d) Ambulance with transport team from the level III facility

Medical helicopter sent to the rural facility from the level III facility Correct Explanation: The neonate is critically ill and requires immediate transport to the level III facility. The quickest way to achieve this transfer is by the medical helicopter sent from the level III facility. The level III facility helicopter is staffed by health care providers who specialize in caring for critically ill neonates; therefore, care can begin as soon as the team arrives. An ambulance doesn't provide safe, effective means of transportation for this critically ill neonate.

While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan? a) Term neonates generally have few creases on the soles of their feet. b) Strawberry hemangiomas—deep, dark red discolorations—require laser therapy for removal. c) If erythema toxicum is present, it will be treated with antibiotic therapy. d) Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.

Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks. Correct Explanation: Milia are white papules resulting from plugged sebaceous ducts that disappear by age 2 to 4 weeks. Parents should be instructed to avoid scratching them to prevent secondary infection. Term neonates generally have many creases on the soles of their feet. Preterm neonates may have only a few creases due to their immaturity. Strawberry hemangiomas are elevated areas formed by immature capillaries that will disappear over time. Port wine stains are deep, dark red discolorations that require laser therapy for removal. Erythema toxicum is a newborn rash or "flea bite" rash that requires no treatment and disappears over time

During the assessment, the nurse observes a gray pigmented nevus on the neonate's buttocks. The nurse documents this as which finding? a) Harlequin's sign b) port wine stain c) cafe au lait spots d) Mongolian spot

Mongolian spot Explanation: Mongolian spots are gray, blue, or black marks that are found most frequently on the sacral area but also may be on the buttocks, arms, shoulders, or other areas. No treatment is necessary because these usually fade or disappear during the first few years of life. Harlequin's sign, manifested as one side of the body turning a deep red color, occurs when blood vessels on one side of the body constrict while those on the other side of the body dilate. The observance of Harlequin's sign should be documented and reported. Port-wine stains, flat purple-red sharply demarcated areas, or hemangiomas, dark red color lesions, or vascular tumors, are nevi flammeus and do not disappear with time. Cafe au lait spots are flat, patchy, light brown areas.

A 19-year-old primigravida gave birth to a newborn weighing 5 pounds, 8 ounces (2,500 g) 1 hour ago. The priority nursing assessments at this time include: a) Taking vital signs and performing a gestational age assessment b) Monitoring feedings and taking vital signs c) Monitoring for jaundice and performing a physical examination d) Scoring the APGAR and performing a gestational age assessment

Monitoring feedings and taking vital signs Explanation: Infants should be monitored for hypoglycemia, temperature stability, and respiratory distress. The answer that best includes these components is monitoring the infant's feedings and taking vital signs. APGAR assessments are done at 1 and 5 minutes of age, not at 1 hour of age. The gestational age assessment is important for this infant, but after completion, does not require additional monitoring. The infant should be regularly assessed for jaundice as part of the physical assessment, but this is not the priority assessment at this time.

The nurse is assigned to care for 4 mothers and their term newborns. Which mother and newborn couplet requires the nurse's attention first? a) Mother: fundus firm 2 cm below umbilicus, minimal lochia rubra. Infant: color is pink on room air, respirations 67 breaths/minute; bilateral crackles on auscultation. b) Mother: fundus firm 3 cm above umbilicus and to the right, moderate rubra lochia. Infant: color pink when active, currently dusky while quiet, respirations 70 breaths/minute. c) Mother: fundus firm at umbilicus, small amount lochia rubra. Infant: pale pink, quiet alert; respiration 65 breaths/minute; periodic breathing noted. d) Mother: fundus firm 1 cm above umbilicus, small amount lochia rubra. Infant: color pink with acrocyanosis, respirations 68 breaths/minute and intermittent expiratory grunting.

Mother: fundus firm 3 cm above umbilicus and to the right, moderate rubra lochia. Infant: color pink when active, currently dusky while quiet, respirations 70 breaths/minute. Correct Explanation: The mother demonstrates signs of full bladder and vaginal bleeding and requires assistance with bladder emptying and uterine massage to assess the origination of the bleeding. The newborn requires further assessment because turning dusky when quiet and respiration rate of 70 breaths/minute indicates the beginning signs of respiratory distress and requires prompt intervention. All other mothers are recovering normally. While bilateral crackles in a newborn could indicate excessive fluid, a pink color indicates the infant is maintaining oxygenation. Normal respiration is 30 to 60 breaths/minute. While a respiratory rate of 67 is slightly elevated, the baby is not demonstrating any other signs of respiratory distress. The newborn with acrocyanosis (bluish hands and feet) is a normal newborn finding and shows the ability to maintain oxygenation. Respirations of 70 breaths/minute and intermittent expiratory grunt would indicate close observation but does not require immediate intervention if the infant is pink. The last newborn is maintaining oxygenation, with respirations just slightly above normal. Periodic breathing, featuring pauses in breathing of less than 15 seconds, is a normal newborn finding

When performing an initial assessment of a postterm male neonate weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery after a vaginal birth with low forceps, the nurse detects Ortolani's sign. Which action should the nurse take next? a) Obtain a blood sample to check for hypoglycemia. b) Keep the neonate under the radiant warmer for 2 hours. c) Notify the health care provider (HCP) immediately. d) Determine the length of the mother's labor.

Notify the health care provider (HCP) immediately. Correct Explanation: Ortolani maneuver involves flexing the neonate's knees and hips at right angles and bringing the sides of the knees down to the surface of the examining table. A characteristic click or "clunk," felt or heard, represents a positive Ortolani sign, suggesting a possible hip dislocation. The nurse should notify the HCP promptly because treatment is needed, while maintaining the dislocated hip in a position of flexion and abduction. It should be noted that many institutions now limit performing the Ortolani's maneuver to APNs or HCPs. Determining the length of the mother's labor provides no useful information related to the nurse's finding. Keeping the infant under the radiant warmer is necessary only if the neonate's temperature is low or unstable. Checking for hypoglycemia is not indicated at this time, unless the neonate is exhibiting jitteriness

Which action would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched? a) Continue to monitor the infant periodically for changes in the cry. b) Stimulate the neonate to cry to obtain information to document. c) Notify the primary care provider because this may indicate a neurologic problem. d) Tell the mother that excessive analgesia in labor can cause this type of cry.

Notify the primary care provider because this may indicate a neurologic problem. Correct Explanation: Typically a neonate's cry is loud and lusty. A weak, shrill, or high-pitched cry is not normal, possibly indicating a neurologic problem, such as increased intracranial pressure, infection, or hypoglycemia. Thus, the nurse should notify the primary care provider, so further evaluation can be done. Telling the mother that the cry is due to excessive analgesia in labor is not warranted. Stimulating the neonate to cry is not helpful because the cry is most likely due to an underlying problem. Continuing to monitor the infant is a routine nursing responsibility that may be helpful if the neonate needs to be treated for a neurologic problem or drug withdrawal. However, the primary care provider needs to be notified first.

A multiparous client gives birth to dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. What is the most appropriate goal to include in the plan of care for the parents while the twins are hospitalized? a) Identify complications that may occur as the twins develop. b) Participate in care of the twins as much as possible. c) Discuss how they will cope with twin infants at home. d) Take turns providing 24-hour observation of the twins.

Participate in care of the twins as much as possible. Correct Explanation: It is important that the parents be allowed to touch, hold, and participate in care of the twins whenever they desire. Ideally, this will be on a daily basis, to promote parent-infant bonding. It is not appropriate to discuss how the couple will cope with twin infants at home until they are ready to take the infants home. They are too overwhelmed at this point and are focused on the well-being of their infants while hospitalized. Having the couple visit the twins to provide care on a 24-hour basis is not warranted. Identifying complications that may occur is not appropriate. If complications arise, the parents should be well informed and given opportunities for discussion related to the care provided

A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the care plan for the neonate during his first 24 hours? a) Avoid oral feedings. b) Administer a bolus of glucose I.V. c) Provide frequent early feedings with formula. d) Administer insulin subcutaneously.

Provide frequent early feedings with formula. Correct Explanation: The neonate of a mother with gestational diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with gestational diabetes is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia.

A client received magnesuim sulfate during labor. Which condition should the nurse anticipate as a potenial problem in the neonate? a) Respiratory depression b) Jitteriness c) Hypoglycemia d) Tachycardia

Respiratory depression Correct Explanation: Magnesium sulfate crosses the placenta. Potenial neonatal effects include respiratory depression, hypotonia, and bradycardia. The serum blood glucose isn't affected by magnesium sulfate. The neonate would likely be floppy, not jittery.

A client returns to the postnatal ward with her 3-week-old infant. Which statement by the client would prompt the nurse to document "Imbalanced nutrition less than body requirements related to inadequate intake"? a) The baby does not exhibit a steady weight gain." b) "The baby wets 10 to 12 diapers in 24 hours." c) "The baby does not burp after a feeding." d) "The baby shows a desire to be fed every 3 to 4 hours."

The baby does not exhibit a steady weight gain." Correct Explanation: Signs that a neonate is not getting adequate intake include lack of weight gain, wetting 10 to 12 diapers in 24 hours, and showing contentedness after a feeding. Wetting 6 to 8 diapers in 24 hours signifies inadequate intake. Wanting to be fed every 1 to 2 hours indicates that the neonate isn't satiated. Burping after a feeding isn't associated with feeding adequacy. (less)

The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which explanation should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision? a) The foreskin is used to repair the deformity surgically. b) The meatus can become stenosed, leading to urinary obstruction. c) The infant is too small to have a circumcision. d) The associated chordee is difficult to remove during circumcision.

The foreskin is used to repair the deformity surgically. Explanation: The condition in which the urethral opening is on the ventral side of the penis or below the glans penis is referred to as hypospadias. Chordee refers to a ventral curvature of the penis that results from a fibrous band of tissue that has replaced normal tissue. Circumcision is delayed because the foreskin, which is removed with a circumcision, often is used to reconstruct the urethra. The chordee is corrected when the hypospadias is repaired. Circumcision is performed at the same time. Urethral meatal stenosis, which can occur in circumcised infants, results from meatal ulceration, possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision. The infant is not too small to have a circumcision, which is commonly performed on the first or the second day of life.

A 15-year-old primipara who gave birth to a term neonate vaginally tells the nurse, "My mother started feeding me rice cereal when I was only 2 weeks old." What would be the most appropriate response to the client? a) "Give the infant iron-fortified rice cereal at 1 year of age." b) "Wait until the infant is at least 4 months of age before using cereal." c) "A small amount of rice cereal given once in a while is okay." d) "Give cereal in a bottle mixed well with the formula."

Wait until the infant is at least 4 months of age before using cereal." Correct Explanation: Breast milk or formula should provide adequate nourishment for a neonate until 4 to 6 months of age. Cereal, regardless of the amount, given before the age of 4 months is not easily digested by the neonate and may lead to food allergies and possibly aspiration. Cereal should not be given in a bottle. Doing so could lead to obesity or aspiration. The infant's iron stores need to be fortified with formula with iron or cereal with iron at 4 to 6 months of age.

After the physician explains the prognosis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condition, the nurse determines that the mother needs further instructions when she says which of the following? a) "As my child grows, she may have increased fatigue and difficulty breathing." b) "About half of the children born with this defect heal spontaneously." c) "This condition occurs more commonly in females than in males." d) "My child may need to have antibiotics if she develops an infection."

You selected: "About half of the children born with this defect heal spontaneously." Correct Explanation: A child with atrial septal defect will be monitored by a cardiologist. Nonsurgical closure may be attempted via cardiac catheterization. Surgical closure, using either a prosthetic patch or sutures, is performed on an elective basis early in childhood. Children diagnosed with this disorder do not have spontaneous healing or closure. About 20% to 60% of children born with a ventricular septal defect, an abnormal opening between the right and left ventricles, have spontaneous closure. Atrial septal defect accounts for approximately 10% of all congenital heart disease and is seen in more female than male neonates. This lesion consists of an abnormal opening between the atria. Ostium secundum, a defect located in the middle of the atrial septum, is the most common type seen. As the child grows, she may experience fatigue and dyspnea on exertion. A large defect may result in congestive heart failure if the lesion is unrepaired. Bacterial endocarditis prophylaxis with antibiotics may be ordered if the child develops an infection

The nurse determines that a newborn is experiencing hypoglycemia based on which findings? Select all that apply. a) irregular respirations, tremors, and hypothermia b) a blood glucose reading of less than 30 mg/dL (1.7 mmol/L) or less at 1 hour c) large for gestational age d) family history of insulin-dependent diabetes e) internal fetal monitor tracing

a blood glucose reading of less than 30 mg/dL (1.7 mmol/L) or less at 1 hour • irregular respirations, tremors, and hypothermia Explanation: A blood glucose reading at or below 30 mg/dL (1.7 mmol/L) within 2 hours of birth and irregular respirations, tremors, and hypothermia are indicative of hypoglycemia. Blood glucose should be 45 mg/dL (2.5 mmol/L) by 24 hours of age. Internal fetal monitors detect the strength of contractions and the fetal heart rate. An infant of an insulin-dependent mother and a large-for-gestational-age infant are at greater risk of developing hypoglycemia and need to be observed carefully, but these findings are not definitive for the diagnosis of hypoglycemia

An infant is born with facial abnormalities, growth retardation, and vision abnormalities. These abnormalities are likely caused by maternal: a) folic acid deficiency. b) alcohol consumption. c) vitamin B6 deficiency. d) vitamin A deficiency.

alcohol consumption. Correct Explanation: Fetal alcohol syndrome is characterized by central nervous system damage, poor growth, and specific facial stigmata. As many as 90% of children with fetal alcohol syndrome have eye abnormalities. Vitamin B6 and vitamin A deficiency can affect growth and development but not with these specific effects. Folic acid deficiency contributes to neural tube defects.

While caring for a just born female term neonate, the nurse observes that the neonate's clitoris is enlarged and there is some fusion of the posterior labia majora. The nurse should notify the health care provider because these findings are associated with which problem? a) renal disorders b) ambiguous genitalia c) Turner's syndrome d) Potter's syndrome

ambiguous genitalia Correct Explanation: An enlarged clitoris with fusion of the posterior labia majora is associated with ambiguous genitalia. Ultrasound examination will reveal whether ovaries are present. Renal disorders are associated with absence of a kidney and oliguria. Potter's syndrome is a fatal condition involving renal agenesis and facial deformities. Turner's syndrome is an autosomal anomaly in which there are 45 chromosomes. This syndrome also involves intellectual disabilities, a long spine, and delayed or absent sexual maturity.

The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the health care provider (HCP) to further assess the baby and request a prescription for: a) a serum blood glucose level. b) a blood gas analysis. c) a lactation consultation. d) an x-ray with orogastric catheter placement.

an x-ray with orogastric catheter placement. Explanation: The drooling and excessive mucus production is highly suggestive of a tracheoesophageal fistula (TEF). The initial diagnosis is made when an orogastric catheter cannot be passed to the stomach. A lactation consult would be warranted only after determining feedings were safe to continue. While cyanosis can be a sign of sepsis and hypoglycemia, the cyanosis is most likely related to the excessive secretions and airway patency. A blood gas may be needed, but only after ruling out a TEF.

After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which information? a) initial bilirubin level b) antibodies coating the neonate's red blood cells c) antigens coating the neonate's red blood cells d) degree of anemia in the neonate

antibodies coating the neonate's red blood cells Explanation: A direct Coombs test is done on umbilical cord blood to detect antibodies coating the neonate's red blood cells. Hematocrit is used to detect anemia. A direct Coombs does not measure bilirubin but may help explain the underlying cause of increased bilirubin levels. Antigens on the neonate's red blood cells are proteins that help determine the neonate's blood type.

The nurse would expect a postpartum woman to demonstrate lochia in which sequence? A Rubra, alba, serosa B Rubra, serosa, alba C Serosa, alba, rubra D Alba, rubra, serosa

b. Lochia discharge from the uterus proceeds in an orderly fashion, regardless of a surgical or vaginal birth. Its color changes from red to pink to whitish cream consistently, unless there is a complication. The correct sequence is rubra (red), then serosa (pink/brownish), and then alba (white, creamy).

After a vaginal birth, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which position? a) back, with the head turned to the left side b) abdomen, with the head down c) left side, with the neck slightly flexed d) back, with the neck slightly extended

back, with the neck slightly extended Correct Explanation: When receiving oxygen by mask, the neonate is placed on the back with the neck slightly extended, in the "sniffing" or neutral position. This position optimizes lung expansion and places the upper respiratory tract in the best position for receiving oxygen. Placing a small rolled towel under the neonate's shoulders helps to extend the neck properly without overextending it. Once stabilized and transferred to an isolette in the intensive care unit, the neonate can be positioned in the prone position, which allows for lung expansion in the oxygenated environment. Placing the neonate on the left side does not allow for maximum lung expansion. Also, slightly flexing the neck interferes with opening the airway. Placing the neonate on the back with the head turned to the left side does not allow for lung expansion. Placing the neonate on the abdomen interferes with proper positioning of the oxygen mask

Which activity would the nurse include in the teaching plan for parents with a newborn and an older child to reduce sibling rivalry when the newborn is brought home? A Punishing the older child for bedwetting behavior B Sending the sibling to the grandparents' house C Planning a daily "special time" for the older sibling D Allowing the sibling to share a room with the infant

c. An older sibling needs to feel he or she is still loved and not upstaged by the newest family member. Allowing special time for that sibling reinforces the parent's love for him or her also. Regression behavior is common when there is stress in that sibling's life, and punishing him brings attention to negative behavior, possibly reinforcing it. The older sibling might feel he or she is being replaced and is not wanted by the parents when he or she is sent away. Including the older sibling in the care of the newborn is a better way to incorporate the newest member into the family unit. Sharing a room with the infant could lead to feelings of displacement in the sibling. In addition, frequent interruptions during the day and night will awaken the sibling and not allow a full night's sleep or undisturbed nap.

After teaching a group of breast-feeding women about nutritional needs, the nurse determines that the teaching was successful when the women state that they need to increase their intake of which nutrients? A Carbohydrates and fiber B Fats and vitamins C Calories and protein D Iron-rich foods and minerals

c. Lactating mothers need an extra 500 calories to sustain breast-feeding. An additional 20 g of protein is also needed to help build and regenerate body cells for the lactating woman. Additional intake of carbohydrates or fiber is not suggested for lactation. An increase in fats is not recommended, nor is it needed for breast-feeding. To obtain adequate amounts of vitamins during lactation, women are encouraged to choose a varied diet that includes enriched and fortified grains and cereals, fresh fruits and vegetables, and lean meats and dairy products. An increase in vitamins via supplements is not recommended. Choosing a variety of foods from the food pyramid will provide the lactating woman with adequate iron and minerals.

Which of the following concepts would the nurse incorporate into the plan of care when assessing pain in a newborn with special needs? A Newborns experience pain primarily with surgical procedures. B Preterm newborns in the NICU are at least risk for pain. C Pain assessment needs to be comprehensive and frequent. D A newborn's facial expression is the primary indicator of pain.

c. Newborns feel pain and require the same level of pain assessment and pain management as adults. Pain assessment, which is comprehensive, involves observations of changes in vital signs, behavior, facial expression, and body movement. It is considered the "fifth vital sign" and should be checked as frequently as the other four signs. All new borns experience pain, not just newborns undergoing surgical procedures. Preterm newborns have an increased risk of pain because they are subjected to repeat procedures and exposed to noxious stimuli.

When assessing a postpartum woman, which of the following would lead the nurse to suspect postpartum blues? A Panic attacks and suicidal thoughts B Anger toward self and infant C Periodic crying and insomnia D Obsessive thoughts and hallucinations

c. Periodic crying and insomnia are characteristic of postpartum blues, in addition to mood changes, irritability, and increased sensitivity. Panic attacks and suicidal thoughts or anger toward self and the infant would be descriptive of postpartum psychosis, when some women turn this anger toward themselves and have committed suicide or infanticide. Women experiencing postpartum blues do not lose touch with reality. Obsessive thoughts and hallucinations would be more descriptive of postpartum psychosis.

The nurse is preparing to administer erythromycin ophthalmic ointment to a neonate soon after birth. The nurse should explain to the parents that this medication, in addition to preventing blindness caused by gonococcal organisms, also prevents neonatal blindness caused by which organism? a) chlamydia trachomatis b) escherichia coli c) beta-hemolytic streptococcus d) staphylococcus aureus

chlamydia trachomatis Correct Explanation: The use of erythromycin ophthalmic ointment prevents blindness from gonococcal organisms and C. trachomatis. This ointment usually is less expensive than tetracycline. Beta-hemolytic streptococcus, E. coli, and S. aureus can cause a generalized infection in the neonate. However, these organisms typically are not responsible for causing neonatal blindness.

What should the nurse expect to find in a premature female neonate born at 30 weeks' gestation who is small for gestational age? a) prominent creases on the soles and heels b) elbows brought to chest midline with resistance past the midline c) firm cartilage to the edge of the ear pinna d) fine, downy hair over the upper arms and back

fine, downy hair over the upper arms and back Explanation: Lanugo (fine, downy hair) covers the entire body until about 20 weeks' gestation, when it begins to disappear from the face, trunk, and extremities, in that order. Lanugo is a consistent finding in preterm neonates. Firm cartilage to the edge of the ear pinna is a physical characteristic found in neonates born at term. The ability to bring elbows to the midline of the chest with resistance past midline, also known as the scarf sign, is a physical characteristic found in neonates born at term. At 30 weeks' gestation, there is no resistance and the elbow can be moved easily past midline. Creases on the soles and heels are physical characteristics found in neonates born at term. A preterm neonate would exhibit few sole creases.

While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to opiate use during pregnancy, which finding would alert the nurse to possible opiate withdrawal? a) high-pitched cry b) sluggishness c) bradycardia d) hypocalcemia

high-pitched cry Explanation: Manifestations of opiate withdrawal in the neonate include an increased central nervous system irritability, such as a shrill, high-pitched cry, gastrointestinal symptoms, and metabolic, vasomotor, and respiratory disturbances. These signs usually appear within 72 hours and persist for several days. These neonates are difficult to console, have poor feeding behaviors, and have diarrhea. Bradycardia is associated with preterm neonates. Sluggishness and lethargy are associated with neonates whose mothers received analgesia shortly before birth. Hypocalcemia occurs most commonly in infants of mothers with diabetes, premature infants, and low-birth weight infants.

A neonate born by cesarean at 42 weeks' gestation, weighing 4.1 kg (9 lb), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. What is the priority problem for this neonate? a) decreased cardiac output b) hyperthermia c) hypoglycemia d) ineffective airway clearance

hypoglycemia Explanation: Increased respiratory rate and tremors are indicative of hypoglycemia, which commonly affects the postterm neonate because of depleted glycogen stores. There is no indication that the neonate has ineffective airway clearance, which would be evidenced by excessive amounts of mucus or visualization of meconium on the vocal cords. Lethargy, not tremors, would suggest infection or hyperthermia. Furthermore, the postterm neonate typically has difficulty maintaining temperature, resulting in hypothermia, not hyperthermia. Decreased cardiac output is not indicated, particularly because the neonate was born by cesarean section, which is not considered a difficult birth.

The nurse is caring for a primiparous client and her neonate immediately after birth. The neonate was born at 41 weeks' gestation and weighs 9 lb (4,082 g). Assessing for signs and symptoms of which signs and symptoms should be a priority in this neonate? a) hypoglycemia b) anemia c) elevated bilirubin d) delayed meconium

hypoglycemia Explanation: Postmature neonates commonly have difficulty maintaining adequate glucose reserves and usually develop hypoglycemia soon after birth. Other common problems include meconium aspiration syndrome, polycythemia, congenital anomalies, seizure activity, and cold stress. These complications result primarily from a combination of advanced gestational age, placental insufficiency, and continued exposure to amniotic fluid. Delayed meconium is not associated with postterm gestation. Hyperbilirubinemia occurs in term neonates as well as postterm neonates, but unless there is an Rh incompatibility it does not develop until after the first 24 hours of life

The nurse is caring for a newborn of a primiparous woman with insulin-dependent diabetes. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglycemia because of which reason? a) increased pancreatic enzyme production caused by decreased glucose stores b) increased use of glucose stores during a difficult labor and birth process c) interrupted supply of maternal glucose and continued high neonatal insulin production d) a normal response that occurs during transition from intrauterine to extrauterine life

interrupted supply of maternal glucose and continued high neonatal insulin production Explanation: Glucose crosses the placenta, but insulin does not. Hence, a high maternal blood glucose level causes a high fetal blood glucose level. This causes the fetal pancreas to secrete more insulin. At birth, the neonate loses the maternal glucose source but continues to produce much insulin, which commonly causes a drop in blood glucose levels (hypoglycemia), usually at 30 to 60 minutes postpartum. Most neonates do not develop hypoglycemia if their mothers are not insulin dependent unless they are preterm. Therefore, hypoglycemia is not a normal response as the neonate transitions to extrauterine life.

The nurse is assessing a neonate born to a mother with type 1 diabetes. Which finding is expected? a) hypertonia b) scaly skin c) large size d) hyperactivity

large size Correct Explanation: Women with diabetes mellitus generally have neonates who are large but physically immature. Other common findings in these infants are hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia, renal thrombosis, and congestive anomalies. The neonates do not exhibit hypertonia, hyperactivity, or scaly skin.

When formulating a plan of care for the postterm neonate at discharge, which outcome would be most appropriate? a) maintenance of a normal bilirubin level b) maintenance of normal body temperature c) establishment of a deep respiratory pattern d) gain of 4 ounces (120 g) by the time of discharge

maintenance of normal body temperature Correct Explanation: Hypothermia and temperature instability are primary problems in the postterm neonate, so maintaining a normal temperature pattern is the most appropriate goal. Postterm neonates have little subcutaneous fat, predisposing them to cold stress. Establishment of a deep respiratory pattern is inappropriate because all neonates tend to breathe in a shallow manner. A weight gain of 4 oz (120 g) may not be feasible because most neonates lose 5% to 15% of their birth weight during the first few days of life. All infants should be assessed for hyperbilirubinemia. Although polycythemia is common in postterm infants and may take a while to resolve, hyperbilirubinemia is not more common in the postterm neonate than it is in neonates born at term.

After giving birth to a viable term male neonate vaginally under epidural anesthesia, a primiparous client asks the nurse, "Why are my baby's breasts so swollen?" The nurse responds to the client stating that slight breast engorgement in term neonates is due to which factor? a) maternal hyperthyroidism b) genetic influences from both parents c) epidural anesthesia d) maternal hormonal influences

maternal hormonal influences Correct Explanation: Slight breast engorgement in term neonates is related to the maternal hormone elevations that occur during pregnancy. Epidural anesthesia and genetic influences have no effect on breast tissue engorgement in the neonate. Hyperthyroidism in the mother is frequently associated with preterm labor and low birthweight infants. It is unlikely that a preterm infant would have breast engorgement.

After birth of a male neonate at 38 weeks' gestation, the nurse dries the neonate and places him skin to skin on his mother's chest to prevent: a) decreased utilization of calorie stores b) increased shivering to keep warm c) metabolism of brown adipose tissue. d) hyperglycemia.

metabolism of brown adipose tissue. Correct Explanation: Neonates burn brown adipose tissue (fat) as a response to cold stress. In addition, there is increased utilization of glycogen and calorie stores. Hypoglycemia may result from becoming stressed by a cold environment. Neonates do not have the ability to shiver.

One hour after receiving nalbuphine for pain during labor, a primigravida gives birth to a full-term neonate with symptoms of respiratory depression. The nurse anticipates that the neonate will require the administration of which drug? a) naloxone b) promethazine c) naltrexone d) betamethasone

naloxone Correct Explanation: The drug of choice to reverse opioid-induced respiratory depression in a neonate is naloxone, which reverses the effects of opioids. Betamethasone is administered to enhance surfactant production in preterm neonates. Naltrexone is used to relieve pruritus from epidural narcotics. Promethazine is used to control nausea and vomiting in the mother.

A viable male neonate born to a 28-year-old multiparous client by cesarean section because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which factor would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome? a) mother's development of placenta previa b) mother receiving analgesia 4 hours before birth c) neonate with sluggish respiratory efforts after birth d) neonate born preterm

neonate born preterm Explanation: RDS is a developmental condition that primarily affects preterm infants before 35 weeks' gestation because of inadequate lung development from deficient surfactant production. The development of placenta previa has little correlation with the development of RDS. Although excessive analgesia can depress the neonate's respiratory condition if it is given shortly before birth, the scenario presents no information that this has occurred. The neonate's sluggish respiratory activity postpartum is not the likely cause of RDS but may be a sign that the neonate has the condition.

The nurse is caring for a 2-hour old, full-term, breastfeeding newborn. The nurse notes the following assessments: apical pulse, 122 bpm; axilla temperature, 96.6° F (35.9° C); jitteriness. Based on this assessment, the nurse should first: a) obtain a blood glucose sample. b) assist the newborn to breastfeed. c) place the newborn under a radiant heater. d) notify the health care provider (HCP).

obtain a blood glucose sample. Explanation: A temperature of 96.6° F (35.9° C) and jitteriness are signs of hypoglycemia in the newborn. The nurse must first obtain a heel stick blood sample for blood glucose. Breastfeeding, preferably skin-to-skin, should be initiated immediately following the heel stick puncture to treat the suspected hypoglycemia. The HCP can be notified once the blood glucose value is known and the baby is successfully breastfeeding. Normal newborn temperature ranges from 97.7° F (36.5° C) to 99.1° F (37.3° C). A temperature of 96.6° F (35.9° C) is low, another sign of hypoglycemia; however, breastfeeding takes precedence over the radiant heater. Also, breastfeeding via skin-to-skin contact has been found as the most effective way to maintain a newborn's temperature.

The nurse is caring for a neonate at 38 weeks' gestation when the nurse observes marked peristaltic waves on the neonate's abdomen. After this observation, the neonate exhibits projectile vomiting. The nurse notifies the health care provider (HCP) because these signs are indicative of which problem? a) esophageal atresia b) pyloric stenosis c) diaphragmatic hernia d) hiatal hernia

pyloric stenosis Explanation: Marked visible peristaltic waves in the abdomen and projectile vomiting are signs of pyloric stenosis. If the condition progresses without surgical intervention, the neonate will become dehydrated and develop metabolic alkalosis. Signs of esophageal atresia include coughing and regurgitation with feedings. Diaphragmatic hernia, a life-threatening event in which the abdominal contents herniate into the thoracic cavity, may be evidenced by breath sounds being heard over the abdomen and significant respiratory distress with cyanosis. Signs of hiatal hernia include vomiting, failure to thrive, and short periods of apnea

While caring for a neonate 2 days after birth, the nurse observes a swelling on the neonate's head that does not cross the cranial suture line. The nurse should explain to the parents that this will: a) resolve without treatment by 6 weeks of age. b) be a normal symptom of a skull fracture that occurred during the birth. c) remain swollen for at least 6 months before receding. d) require several surgeries to repair.

resolve without treatment by 6 weeks of age. Correct Explanation: The neonate has a cephalohematoma, which usually resolves without treatment by 6 weeks of age. It is usually not present at birth and begins about 24 hours after birth. It is caused by pressure on the fetal skull during the birth process. Because of the breakdown of red blood cells within the hematoma, the neonate is at greater risk for hyperbilirubinemia. The neonate does not need repeated surgeries. The condition will resolve in 6 weeks, not 6 months. About 10% to 25% of neonates may have a skull fracture, but the skull fracture is not the cause of the hematoma.

While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as what finding? a) meningocele b) spina bifida cystica c) spina bifida occulta d) myelomeningocele

spina bifida occulta Explanation: A small tuft of hair and an indentation at the base of the neonate's spine is termed spina bifida occulta. This condition usually occurs between the L5 and S1 vertebrae with failure of the vertebrae to completely fuse. There are usually no sensory or motor deficits with this condition. Spina bifida cystica includes meningocele, myelomeningocele, and lipomeningocele. Meningocele is characterized by a saclike protrusion filled with spinal fluid and meninges. Usually, this condition is associated with sensory and motor deficits. Myelomeningocele is characterized by a saclike protrusion filled with spinal fluid, meninges, nerve roots, and spinal cord. With myelomeningocele, there are usually sensory and motor deficits

The nurse is teaching the mother of a newborn to develop her baby's sensory system. To further improve the infant's most developed sense, the nurse should instruct the mother to: a) place the newborn about 12 inches (30.5 cm) from maternal face for best sight. b) stroke the newborn's cheek with her nipple to direct the baby's mouth to nipple. c) speak in a high-pitched voice to get the newborn's attention. d) give infant formula with a sweetened taste to stimulate feeding.

stroke the newborn's cheek with her nipple to direct the baby's mouth to nipple. Correct Explanation: Currently, touch is believed to be the most highly developed sense at birth. It is probably why neonates respond well to touch. Auditory sense typically is relatively immature in the neonate, as evidenced by the neonate's selective response to the human voice. By 4 months, the neonate should turn his eyes and head toward a sound coming from behind. Visual sense tends to be relatively immature. At birth, visual acuity is estimated at 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Taste is well developed, with a preference toward glucose; however, touch is more developed at birth

Two hours ago, a neonate at 38 weeks' gestation and weighing 3,175 g (7 lb) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which finding would alert the nurse to notify the health care provider (HCP)? a) positive Babinski's reflex b) increased muscle tone c) temperature instability d) alkalosis

temperature instability Explanation: The neonate is at high risk for sepsis due to exposure to the mother's infection. Temperature instability in a neonate at 38 weeks' gestation is an early sign of sepsis. Other signs include tachycardia, decreased muscle tone, acidosis, apnea, respiratory distress, hypotension, poor feeding behaviors, vomiting, and diarrhea. Late signs of infection include jaundice, seizures, enlarged liver and spleen, respiratory failure, and shock. Alkalosis is not typically seen in neonates who develop sepsis. Acidosis and respiratory distress may develop unless treatment such as antibiotics is started. A positive Babinski reflex is a normal finding and does not need to be reported.

A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if: a) the neonate loses 10% to 15% of the birth weight within the first 2 days after birth. b) the neonate voids once or twice every 24 hours. c) the neonate latches onto the areola and swallows audibly. d) the neonate breast-feeds four times in 24 hours.

the neonate latches onto the areola and swallows audibly. Correct Explanation: Breast-feeding is effective if the infant latches onto the mother's areola properly and if swallowing is audible. A breast-feeding neonate should void at least 6 to 8 times per day and should breast-feed every 2 to 3 hours. Over the first few days after birth, an acceptable weight loss is 5% to 10% of the birth weight

When teaching a primiparous client who used cocaine during pregnancy how to comfort her fussy neonate, the nurse can advise the mother to: a) tightly swaddle the neonate. b) touch the baby only when he is crying. c) feed the neonate extra, high-calorie formula. d) keep the neonate in a brightly lit environment.

tightly swaddle the neonate. Correct Explanation: A neonate undergoing cocaine withdrawal is irritable, often restless, difficult to console, and often in need of increased activity. It is commonly helpful to swaddle the neonate tightly with a blanket, offer a pacifier, and cuddle and rock the neonate. Offering extra nourishment is not advised because overfeeding tends to increase gastrointestinal problems such as vomiting, regurgitation, and diarrhea. Environmental stimuli such as bright lights and loud noises should be kept to a minimum to decrease agitation. Minimizing touching of the neonate to only when he or she is crying will not aid the bonding process between mother and neonate. Frequent holding and touching are permissible

After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck reflex as occurring when the neonate displays which behavior? a) extends and abducts the arms and legs with the toes fanning open b) steps briskly when held upright near a firm, hard surface c) pulls both arms and does not move the chin beyond the point of the elbows d) turns head to the left, extends left extremities, and flexes right extremities

turns head to the left, extends left extremities, and flexes right extremities Correct Explanation: The tonic neck reflex, also called the fencing position, is present when the neonate turns the head to the left side, extends the left extremities, and flexes the right extremities. This reflex disappears in a matter of months as the neonatal nervous system matures. The stepping reflex is demonstrated when the infant is held upright near a hard, firm surface. The prone crawl reflex is demonstrated when the infant pulls both arms but does not move the chin beyond the elbows. When the infant extends and abducts the arms and legs with the toes fanning open, this is a normal Babinski reflex

When assessing a neonate's temperature with a disposable digital thermometer, in which location should the nurse place the thermometer? a) into the neonate's ear b) under the neonate's tongue c) into the neonate's rectum d) under the neonate's arm

under the neonate's arm Correct Explanation: The correct method of assessing a neonate's temperature is to place the thermometer under the neonate's arm for an axillary reading. The oral route is not appropriate for obtaining the temperature in a neonate because the neonate is unable to close the mouth around the thermometer, thus leading to an inaccurate reading. Additionally, inserting a thermometer into a neonate's mouth may cause trauma to delicate tissues. Rectal temperatures are to be avoided in neonates because of the risk of injury to or perforation of the delicate rectal mucosa. Only a specialized tympanic membrane device should be used to obtain a temperature reading via the ear. Inserting a disposable digital thermometer into the neonate's ear may cause trauma to the delicate tissues.

What assessment findings in a term neonate would cause the nurse to notify the health care provider (HCP)? a) absence of tears b) pupillary constriction to bright light c) unequally sized corneas d) red circle on pupils seen with a penlight

unequally sized corneas Correct Explanation: Corneas of unequal size should be reported because this may indicate congenital glaucoma. An absence of tears is common because the neonate's lacrimal glands are not yet functioning. The neonate's pupils normally constrict when a bright light is focused on them. The finding implies that light perception and visual acuity are present, as they should be after birth. A red circle on the pupils is seen when a penlight or ophthalmoscope's light shines onto the retina and is a normal finding. Called the red reflex, this indicates that the light is shining onto the retina

When feeding a neonate with a cleft lip, the nurse should expect to: a) use a bulb syringe with a rubber tip. b) perform gastric gavage. c) administer I.V. fluids. d) provide thickened formula.

use a bulb syringe with a rubber tip. Explanation: The nurse should expect to use a bulb syringe with a rubber tip because it is a safe, effective feeding device for a neonate with a cleft lip. I.V. fluids are required only during the immediate postoperative period, until the neonate can tolerate oral fluids. Thickened formula and gastric gavage rarely are necessary for a neonate with a cleft lip.

A full-term neonate is diagnosed with hydrocephalus. Nursing assessment is most likely to reveal: a) heightened alertness. b) wide or bulging fontanels. c) a decreased occipitofrontal circumference. d) upward-slanting eyes.

wide or bulging fontanels. Correct Explanation: Hydrocephalus typically causes an enlarged head with wide or bulging fontanels, an excessive diameter (increased occipitofrontal diameter), a shiny scalp with prominent veins, separation of the suture lines, and downward-slanting eyes. Other findings in hydrocephalus include bradycardia, apneic episodes, vomiting, irritability, excessive crying, and reduced alertness

A 24-hour-old, full-term neonate is showing signs of possible sepsis. The nurse is assisting the health care provider (HCP) with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure? Select all that apply. a) Hold the neonate steady in the correct position. b) Obtain a serum glucose level. c) Maintain a sterile field. d) Administer the IV antibiotic. e) Ensure a patent airway.

• Maintain a sterile field. • Hold the neonate steady in the correct position. • Ensure a patent airway. Correct Explanation: Holding the neonate steady and in the proper position will help ensure a safe and accurate lumbar puncture. The neonate is usually held in a "C" position to open the spaces between the vertebral column. This position puts the neonate at risk for airway obstruction. Thus, ensuring the patency of the airway is the first priority, and the nurse should observe the neonate for adequate ventilation. Maintaining a sterile field is important to avoid infection in the neonate. It is not necessary to administer antibiotics or obtain a serum glucose level during the procedure

A nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering the eyes and gonads for protection. The parents asked the nurse to tell them how their baby will benefit from having phototherapy done. Which statement by the nurse is the most appropriate response about phototherapy? a) "Phototherapy decreases the serum unconjugated bilirubin level." b) "Phototherapy increases the baby's iron level." c) "Phototherapy promotes respiratory stability." d) "Phototherapy prevents hypothermia."

"Phototherapy decreases the serum unconjugated bilirubin level." Correct Explanation: The goal of phototherapy is to decrease the serum unconjugated bilirubin level because a high level may lead to bilirubin encephalopathy (kernicterus). Phototherapy does not prevent hypothermia or increase iron level or promote respiratory stability.

When teaching a primaparous client about neonatal reflexes the nurse determines that teaching about the rooting reflex has been effective when the mother identifies what as the age at which the rooting reflex disappears? a) 3 to 4 months b) 2 weeks to 1 month c) 6 weeks to 2 months d) 5 to 6 months

3 to 4 months Explanation: The rooting reflex, stimulated by touching the upper lip or cheek before a feeding, disappears by the age of 3 to 4 months. A rooting reflex that disappears before 2 months of age or persists beyond 4 months of age requires further evaluation of neurologic capabilities

A 6-lb, 8-oz (2,948 g) neonate was born vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, and overall pale white in color. The Apgar score is: a) 2. b) 6. c) 3. d) 4.

4. Explanation: The neonate has a heart rate greater than 100, which earns him 2 points. His respiratory rate of 70 is equivalent to a 2 on the scale. His flaccid muscle tone is equal to 0 on the scale. The lack of response to stimulus also equals 0, as does his overall pale white color. Thus, the total score equals 4.

A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho(D) immune globulin (RhoGAM). The nurse should administer the medication within which time frame after birth? a) 24 hours b) 8 hours c) 72 hours d) 96 hours

72 hours Correct Explanation: For maximum effectiveness, RhoGAM should be administered within 72 hours postpartum. Most Rh-negative clients also receive RhoGAM during the prenatal period at 28 weeks' gestation and then again after birth. The drug is given to Rh-negative mothers who have a negative Coombs test and give birth to Rh-positive neonates. If there is doubt about the fetus's blood type after pregnancy is terminated, the mother should receive the medication

A 12-hour-old neonate has a continuous grade II cardiac murmur with no thrill. The splitting of the second heart sound (S2) that was heard with inspiration immediately after birth is no longer present. The neonate's heart rate is 150 beats/minute. Based on these assessment findings, how should the neonate be transported to the parents? a) A registered nurse (RN) should transport the neonate in a warmed isolette with a cardiac monitor and oxygen saturation monitor. b) The hospital volunteer assigned to the nursery should transport the neonate in an isolette. c) The licensed practical nurse (LPN) should transport the neonate in a bassinet with an oxygen hood to administer oxygen during transport. d) A nursing assistant should transport the neonate in a bassinet.

A nursing assistant should transport the neonate in a bassinet. Explanation: A splitting of S2 with inspiration commonly occurs during the first few hours of life. If it continues, it's most likely caused by a congenital heart defect. Murmurs commonly occur in the neonate and normal heart rate ranges from 120 to 160 beats/minute. The neonate in this scenario has a heart rate of 150 beats/minute, which falls within the normal range. Because these assessment findings are normal for a 12-hour-old neonate, the nursing assistant can safely transport the neonate in a bassinet to the parents. Transporting the neonate in an isolette isn't necessary. The neonate doesn't require an LPN or RN for transport

The nurse is providing care to several newborns with variations in gestational age and birthweight. When developing the plan of care for these newborns, the nurse focuses on energy conservation to promote growth and development. Which measures would the nurse include in the nursing plans of care? Select all that apply. A Keeping the handling of the newborn to a minimum B Maintaining a neutral thermal environment C Decreasing environmental stimuli D Initiating early oral feedings E Using thermal warmers in all cribs

A, B and C. Minimal handling, maintaining a neutral thermal environment, and decreasing environmental stimulai are important measures to conserve energy in newborns with variations in birth weight and gestational age. Feeding and digestion will increase energy demands. Thermal warmers may produce hypothermia and thus increase energy demands. Preventing parents from visiting their newborn is not a plan to reduce energy expenditure and could increase stress for both parents and newborn.

Which instructions should the nurse give to a client after noting a white, cheese-like substance on the neonate's body creases? a) Clean the area with alcohol. b) Allow it to remain on the skin. c) Brush it off with a dry washcloth. d) Remove it with hand lotion.

Allow it to remain on the skin. Correct Explanation: The white, cheese-like substance on the neonate's body creases is called vernix caseosa. Unless the vernix is stained with meconium or the mother has a bloodborne pathogen, it should be left on the skin because it serves as a protective coating that typically disappears within 24 hours of birth. Attempting to remove vernix caseosa (e.g., with lotion, alcohol, or a washcloth) will remove the protection and may damage the neonate's fragile skin.

A registered nurse is staff-shared to the maternal-neonatal unit where she has never worked before. How can this nurse be best employed? a) Use her as a nursing assistant in the postpartum unit. b) Assign her a client care assignment in the postpartum unit. c) Assign her to the labor and delivery area. d) Assign her to the nursery.

Assign her a client care assignment in the postpartum unit. Explanation: The staff-shared nurse can be best employed in client care in the postpartum unit because such an assignment requires medical-surgical knowledge. In this setting, the nurse can safely use her nursing skills and doesn't need to assume the role of a nursing assistant. The staff-shared nurse isn't qualified to work in the labor and delivery area or the nursery because both require specialized training to safely administer care

While caring for a the postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thromobosis, the nurse should contact the client's health care provider (HCP) immediately if the client exhibited which symptom? a) Dyspnea b) Bradycardia c) Hypertension d) Pain in her calf

Dyspnea Correct Explanation: A major complication of deep vein thrombosis is pulmonary embolism. Signs and symptoms, which may occur suddenly and require immediate treatment, include dyspnea, severe chest pain, apprehension, cough (possibly accompanied by hemoptysis), tachycardia, fever, hypotension, diaphoresis, pallor, shortness of breath, and friction rub. Pain in the calf is common with a diagnosis of deep vein thrombosis. Hypotension, not hypertension, would suggest a possible pulmonary embolism. It also could suggest possible hemorrhage secondary to intravenous heparin therapy. Bradycardia for the first 7 days in the postpartum period is normal.

A nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Physiologic jaundice is caused by which characteristic? a) Large, immature liver b) High hemoglobin (Hb) levels between 14 and 20 g/100 ml of blood c) Poor clotting mechanism d) Persistent fetal circulation

Large, immature liver Explanation: The primary cause of neonatal jaundice is the immaturity of the liver and its inability to break down red cells effectively. Poor clotting mechanisms, elevated Hb, and persistent fetal circulation contribute to the jaundice but aren't causes of it.

An infant received the wrong medication dose. What is the charge nurse's role in following up on the incident? a) Suggest that the nurse who administered the medication speak to the hospital lawyer. b) Objectively assess the circumstances surrounding the error. c) Make sure the nurse has liability insurance. d) Send the nurse to a medication administration course.

Objectively assess the circumstances surrounding the error. Correct Explanation: The charge nurse should objectively assess the circumstances surrounding the medication administration error. After completing her assessment, the charge nurse should develop a plan with the nurse to prevent future errors. The charge nurse doesn't need to suggest that the nurse speak with hospital lawyer or make sure the nurse has liability insurance until the circumstances surrounding the error are investigated. Nothing suggests that the nurse needs to attend a medication administration course

While caring for a mother and her 1-day-old neonate born vaginally at 30 weeks' gestation, the nurse explains about the neonate's need for gavage feeding at this time instead of the mother's plan for bottle feeding. What should the nurse include as the rationale for this feeding plan? a) The neonate has difficulty coordinating sucking, swallowing, and breathing. b) Gavage feedings can minimize the neonate's increased risk of developing hypoglycemia. c) This type of feeding, easily given in the isolette, decreases the neonate's risk of cold stress. d) A high-calorie formula, presently needed at this time, is more easily delivered via gavage.

The neonate has difficulty coordinating sucking, swallowing, and breathing. Correct Explanation: Before 32 weeks' gestation, most neonates have difficulty coordinating sucking and swallowing reflexes along with breathing. Increased respiratory distress may occur with bottle-feeding. Bottle-feedings can be given after the neonate shows sucking and swallowing behaviors. High-calorie formulas can be given by bottle or by gavage feeding. Although frequent feeding prevents hypoglycemia, the feeding does not have to be given via a gavage tube. Although these neonates can be stressed by cold, they can be kept warm with blankets while being bottle-fed or fed while in the warm isolette environment

The father of a neonate diagnosed with gastroschisis tells the nurse that his wife had planned on breastfeeding the neonate. Which information should the nurse include in the preoperative teaching plan about feeding the neonate? a) The neonate will need total parenteral nutrition for nourishment. b) An iron-fortified formula will be given before surgery. c) The neonate will remain on nothing-by-mouth (NPO) status until after surgery. d) The mother may breastfeed the neonate before surgery.

The neonate will remain on nothing-by-mouth (NPO) status until after surgery. Correct Explanation: The parents need to know that the neonate will be kept on NPO status and will receive intravenous therapy before surgery. After surgery, feeding will depend on the neonate's condition. Total parenteral nutrition may be prescribed after surgery, but not before. Breastfeeding may be started after surgery if the neonate's condition is stable. The mother can pump the breasts until that time

A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do? a) Bring in toys for distraction. b) Stroke the neonate's back. c) Place a musical mobile over the crib. d) Use constant, gentle touch.

Use constant, gentle touch. Correct Explanation: Neonates that are sick do not have the physical resources or energy to respond to all elements of the environment. The use of a constant touch provides comfort and only requires one response to a stimulus. To comfort a sick neonate, the care provider applies gentle, constant physical support or touch. Toys for distraction are not developmentally appropriate for a neonate. Sick neonates react to any stimulus; in responding, the sick neonate may have increased energy demands and increased oxygen requirements. A musical mobile may be too much audio stimulation and thus increases energy and oxygen demands. Repetitive touching with a hand going off and on the neonate, as with stroking or patting, requires the neonate to respond to every touch, thus increasing energy and oxygen demands.

A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The health care provider (HCP) has prescribed IV fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4 mEq/L (3.4 mmol/L). What should the nurse do first? a) Verify that the infant has urinated. b) Have the potassium level redrawn. c) Notify the HCP. d) Administer the prescribed fluids.

Verify that the infant has urinated. Explanation: Normal serum potassium levels are 3.5 to 4.5 mEq/L (3.5 to 4.5 mmol/L). Elevated potassium levels can cause life threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potassium through urination before administering the drug. Infants with pyloric stenosis frequently have low potassium levels due to vomiting. A level of 3.4 mEq/L (3.4 mmol/L) is not unexpected and should be corrected with the prescribed fluids. The lab value does not need to be redrawn as the findings are consistent with the infant's condition

At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing? a) a state of deep sleep b) respiratory distress c) drug withdrawal d) first period of reactivity

a state of deep sleep Explanation: At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteriness, a high-pitched cry, and tremors are associated with drug withdrawal. The first period of reactivity occurs in the first 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress because the neonate's respiratory rate of 35 breaths/min is normal.

When caring for a client who has had a cesarean birth, which action by a nurse requires intervention? a) Removing the initial dressing for incision inspection b) Supporting self-esteem concerns about the birth c) Monitoring pain status and providing necessary relief d) Assisting with parent-neonate bonding

Removing the initial dressing for incision inspection Explanation: Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate

A client and her boyfriend of 5 months are celebrating the birth of a healthy baby boy when the client's estranged partner arrives to visit the baby he believes is his son. The nurse caring for the client knows that the estranged partner has the right to: a) decide to circumcise his son. b) see the neonate through the nursery glass window. c) hold the neonate after the mother gives permission. d) ask security to remove the boyfriend from his estranged wife's hospital room.

hold the neonate after the mother gives permission. Correct Explanation: The neonate's mother has legal control over the neonate. Therefore, the mother must grant permission for her estranged partner to hold him. The neonate commonly stays in the mother's room, not in the nursery. Therefore, looking through the nursery window isn't an option. The estranged partner can't ask to have the boyfriend removed because the client wants him to remain. The mother must sign the consent for circumcision.

In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation? a) taking on b) taking hold c) letting go d) taking in

taking hold Explanation: The client is in the taking hold phase with a demonstrated focus on the neonate and learning about and fulfilling infant care and needs. The taking in phase is the first period after birth where there is emphasis on reviewing and reliving the labor and birth process, concern with self, and needing to be mothered. Eating and sleep are high priorities during this phase. Taking on is not a phase of postpartum psychological adaptation. Letting go is the process beginning about 6 weeks postpartum when the mother may be preparing to go back to work. During this time, she can have other individuals assume care of the infant and begin the separation process

A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks only Spanish. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle? a) Foods from home are generally discouraged on the postpartum unit. b) The client's health care provider (HCP) needs to give permission for the foods. c) The mother can bring the daughter any foods that she desires. d) This is permissible as long as the foods are nutritious and high in iron.

The mother can bring the daughter any foods that she desires. Correct Explanation: On most postpartum units, clients on regular diets are allowed to eat whatever kinds of food they desire. Generally, foods from home are not discouraged. The nurse does not need to obtain the HCP's permission. Although it is preferred, the foods do not necessarily have to be high in iron. In some cultures, there is a belief in the "hot-cold" theory of disease; certain foods (hot) are preferred during the postpartum period, and other foods (cold) are avoided. Therefore, the nurse should allow the mother to bring her daughter "special foods from home." Doing so demonstrates cultural sensitivity and aids in developing a trusting relationship

While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should: a) notify the client's health care provider (HCP) about the findings. b) assess the client's lochia for large clots. c) continue to monitor the client's vital signs. d) offer the mother an ice pack for her forehead.

continue to monitor the client's vital signs. Correct Explanation: The nurse needs to continue to monitor the client's vital signs. During the first 24 hours postpartum it is normal for the mother to have a slight temperature elevation because of dehydration. A temperature of 100.4° F (38° C) that persists after the first 24 hours may indicate an infection. Bradycardia during the first week postpartum is normal because of decreased blood volume, diuresis, and diaphoresis. The client's respiratory rate is within normal limits. Large clots are indicative of hemorrhage. However, the client's vital signs are within normal limits and her fundus is firm and midline. Therefore, large clots and possible hemorrhage can be ruled out. The HCP does not need to be notified at this time. An ice pack is not necessary because the client's temperature is within normal limits.

A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age? a) 6 months b) 8 months c) 2 months d) 10 months

6 months Explanation: Pediatricians recommend that infants be given either breast milk or formula until at least 6 months of age because of the neonate's difficulty digesting solid foods. Giving solid foods too early can lead to food allergies. Because chewing movements do not begin until 7 to 9 months of age, foods requiring chewing should be delayed until this time.

A postpartum client has a temperature of 99.8° F (37.7.° C) during the first 24 hours after birth. Which nursing intervention is appropriate? a) Encourage more fluid intake. b) Check for signs of puerperal infection. c) Assess lochia for foul odor. d) Check the client's breasts for red, swollen areas.

Encourage more fluid intake. Explanation: A slight temperature elevation from dehydration is common during the first 24 hours after giving birth. Infection should be suspected if the client's temperature exceeds 100.4° F (38° C) for 2 successive days after giving birth, excluding the first 24 hours. A slightly elevated temperature isn't an indication for the nurse to assess for odor in the lochia, breast-abnormalities, or puerperal infection.

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn? a) Increased amounts of vernix b) Hypoglycemia c) Meconium aspiration d) Absence of lanugo

Increased amounts of vernix Explanation: Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. A discrepancy between the estimated date of conception and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress, but does not coincide with gestation. The presence of lanugo is greatest at 28-30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation, although it is associated with other conditions, including prematurity and small size for gestational age

Which hormone is responsible for the let-down reflex? a) Estrogen b) Prolactin c) Oxytocin d) Progesterone

Oxytocin Explanation: Oxytocin is responsible for milk let-down, the process that brings milk to the nipple. The other hormones mentioned contribute indirectly to the lactation process. Prolactin stimulates lactation. Estrogen stimulates development of the duct in the breast. Progesterone acts to increase the lobes, lobules, and alveoli of the breasts

When assessing the term newborn, the following are observed: newborn is alert, heart and respiratory rates have stabilized, and meconium has been passed. The nurse determines that the newborn is exhibiting behaviors indicating: A Initial period of reactivity B Second period of reactivity C Decreased responsiveness period D Sleep period for newborns

b. The behaviors demonstrated by the newborn, such as alertness, stabilized heart and respiratory rates, and passage of meconium are associated with the second period of reactivity. The first period of reactivity starts with a period of quiet alertness followed by an active alertness with frequent bursts of movement and crying. During the decreased responsiveness period, also called the sleep period, the newborn is relatively unresponsive and difficult to waken.

Which condition would be missed if a newborn were screened before he had tolerated protein feedings for at least 48 hours? A Hypothyroidism B Cystic fibrosis C Phenylketonuria D Sickle cell disease

c. Ingestion of certain amino acids found in breast milk or formula must be accumulated in the newborn to identify a deficiency in an enzyme that cannot metabolize them. If the PKU test is done prior to 24 to 48 hours after feeding, it must be repeated after the infant has tolerated feedings for at least that length of time. Identifying hypothyroidism is not linked to ingesting protein feedings. Cystic fibrosis is a genetic inherited condition not related to protein intake. Sickle cell disease is a genetically inherited condition unrelated to protein ingestion in the newborn.

After teaching a group of nursing students about thermoregulation and appropriate measures to prevent heat loss by evaporation, which of the following student behaviors would indicate successful teaching? A Transporting the newborn in an isolate B Maintaining a warm room temperature C Placing the newborn on a warmed surface D Drying the newborn immediately after birth

d. Evaporation is the loss of heat as water is lost from the skin to the environment. Drying the newborn at birth and after bathing, keeping linens dry, and using plastic wrap blankets and heat shields will all prevent heat loss through evaporation. Placing the newborn on a warmed surface will prevent heat loss via conduction. Maintaining a warm room temperature will prevent heat loss via convection. Transporting the newborn in an isolette will prevent heat loss via radiation.

A breastfeeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which nutrient? a) fat b) iron c) calcium d) sodium

fat Explanation: Breast milk has a higher fat content than cow's milk. Thirty to fifty-five percent of the calories in breast milk are from fat. Breast milk contains less iron than cow's milk does. However, the iron absorption from breast milk is greater in the neonate than with cow's milk. Breast milk contains less sodium and calcium than cow's milk.

On her third postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do next? a) Anticipate that the physician will order laboratory tests and cultures. b) Recheck the client's temperature in 4 hours. c) Call the physician and request an order for antibiotics. d) Assess the client's breasts for engorgement.

Anticipate that the physician will order laboratory tests and cultures. Correct Explanation: Signs and symptoms of localized infection include a morbid temperature, chills, malaise, generalized pain or discomfort, and foul-smelling, yellow lochia. The physician may order laboratory tests, including a complete blood count and cultures, to confirm an infection and the causative organisms. Rechecking the client's temperature in 4 hours isn't appropriate because the client requires intervention now. The client's signs and symptoms don't suggest breast engorgement. Laboratory work should be done before starting antibiotics

A client gives birth to a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the neonate's father seems withdrawn and barely speaks to the staff when visiting his child in the NICU. Which interpretation of his behavior is most appropriate? a) The father has depression because of grieving. b) The father denies the seriousness of his child's condition. c) The father is exhibiting diplaced anger at the nursing staff. d) The father needs antidepressants.

The father has depression because of grieving. Correct Explanation: During the depression stage of grief, hopelessness, powerlessness, and despair are common. Some depressed people put their feelings into words; others withdraw, becoming noncommunicative and indicating a wish to be left alone. A parent in denial would postpone recognizing the child's condition and attempt to ignore its reality or seriousness. A parent in the anger stage would exhibit resentment, bitterness, or rage and might blame the health care team for the child's condition. There is no indication that the neonate's father needs antidepressants.

A nurse on a postpartum unit is teaching a new mother about babies using cues to communicate needs. Which of the following supports that the mother understands about a newborn's cues? Select all that apply. a) The mother states that the cues will be lessened after the first month of life. b) The mother states that she will look for cues around feeding times. c) The mother states that cues could be communicating, "I need something different." d) The mother looks for nonverbal and behavioral cues. e) The mother states she will seek cues when the infant is in an awake state.

The mother looks for nonverbal and behavioral cues. • The mother states that cues could be communicating, "I need something different." Explanation: Cues are nonverbal and behavioral in nature, and are present in the newborn from the first day of life. They provide a means for the baby to interact with his or her caregiver, and include cues to be engaged with the caregiver and cues to be disengaged. Disengagement cues could include infants trying to communicate a need for something else to the caregiver to meet the baby's needs. Cues may occur in many states including when the infant is asleep, at rest, alert, or active--they do not occur only when the newborn is awake or only at feeding times. If the caregiver is looking only for feeding cues, they may be missing many cues from the infant. Cues are both purposeful and meaningful.

A nurse is performing a psychosocial assessment on a first-time mother and her neonate. Which behavior indicates a need for further evaluation? a) The mother speaks to the neonate in a soft tone. b) The mother pays more attention to the neonate than to the nurse. c) The mother makes little eye contact with the neonate. d) The mother holds the neonate close to her.

The mother makes little eye contact with the neonate. Correct Explanation: Behaviors that indicate a positive mother-neonate interaction include making eye contact with the neonate, talking to the neonate in a soothing tone, holding the neonate close, and paying more attention to the neonate than to the observer. Therefore, a client who makes little eye contact with the neonate requires further evaluation.

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further? a) perineal lacerations b) bladder distention c) uterine inversion d) retained placental tissue

perineal lacerations Explanation: A small, constant trickle of blood and a firm fundus are usually indicative of a vaginal tear or cervical laceration. If the client had retained placental tissue, the fundus would fail to contract fully (uterine atony), exhibiting as a soft or boggy fundus. Also, vaginal bleeding would be evident. Uterine inversion occurs when the uterus is displaced outside of the vagina and is obvious on inspection. Bladder distention may result in uterine atony because the pressure of the bladder displaces the fundus, preventing it from fully contracting. In this case the fundus would be soft, possibly boggy, and displaced from midline.

Prophylactic heparin therapy is prescribed to treat thrombophlebitis in a multiparous client who gave birth 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when she states which as the purpose of the drug? a) to prevent further blood clot formation b) to increase the lochial flow c) to increase the perspiration for diuresis d) to thin the blood clots

to prevent further blood clot formation Correct Explanation: Heparin therapy is prescribed to prevent further clot formation by inhibiting further thrombus and clot formation. Heparin, an anticoagulant, does not make blood clots thinner. An adverse effect of heparin therapy during the puerperium is increased lochia flow, so the nurse must be observant for symptoms of hemorrhage, such as heavy lochial flow. Heparin does not increase diaphoresis, which is normal for the postpartum client.

A nurse is teaching a new mother about exercise and injury prevention. Which statement by the client requires further teaching? a) "Pelvic tilts will help my back." b) "I can perform muscle flexing and stretching." c) "I'm allowed to jog in place." d) "I should do Kegel exercises."

"I'm allowed to jog in place." Correct Explanation: The client requires additional teaching if she states that she may jog in place. Jogging can increase the amount of lochia rubra, which indicates new bleeding. Muscle flexing and stretching, Kegel exercises, and pelvic tilts are safe to do during the first 3 weeks postpartum. Stretching and flexing muscles relieves tension. Kegel exercises tone the muscles of the pelvic floor. Pelvic tilts strengthen the muscles of the lower back.

Which information would the nurse include in the primiparous client's discharge teaching plan about measures to provide visual stimulation for the neonate? a) Move a brightly colored rattle in front of the baby's eyes. b) Use brightly colored animals and cartoon figures on the wall. c) Paint the baby's room in bright colors accented with teddy bears. d) Maintain eye contact while talking to the baby.

Maintain eye contact while talking to the baby. Correct Explanation: Neonates like to look at eyes, and eye-to-eye contact is a highly effective way to provide visual stimulation. The parent's eyes are circular, move from side to side, and become larger and smaller. Neonates have been observed to fix on them. In general, neonates prefer circular objects of darkness against a white background. Sharp black and white images of geometric figures are appropriate. Use of bright colors on the walls and moving a colorful rattle do not provide as much visual stimulation as eye-to-eye contact with talking. Brightly colored animals and cartoon figures are more appropriate at approximately 1 year of age.

A new primiparous client asks the nurse, "Can my baby see?" Which statement about neonatal vision should the nurse include in the explanation? a) Neonates primarily distinguish light from dark. b) Usually they see clearly by about 2 days after birth. c) Neonates primarily focus on moving objects. d) They can see objects up to 12 inches (30.5 cm) away.

They can see objects up to 12 inches (30.5 cm) away. Explanation: The neonate has immature oculomotor coordination, an inability to accommodate for distance, and poorly developed eyes, visual nerves, and brain. However, the normal neonate can see objects clearly within a range of 9 to 12 inches (22.9 to 30.5 cm), whether or not they are moving. Visual acuity at birth is 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Newborns can distinguish colors as well as light from dark

A primipara calls the birthing unit 3 days after a vaginal birth. She tells the nurse that she is bottle-feeding and her breasts are swollen and painful. Which instructions would be appropriate? a) Avoid wearing a bra to allow the engorgement to subside. b) Wear a tight breast binder for the next 24 hours. c) Refrain from taking a shower with the water on the breasts. d) Use ice packs for 20 minutes every 3 to 4 hours.

Use ice packs for 20 minutes every 3 to 4 hours. Correct Explanation: Ice packs cause vasoconstriction and can provide temporary relief of breast engorgement for the bottle-feeding mother. Breast engorgement is transitory and usually disappears within a few days. A tight breast binder is not recommended because it can worsen the engorgement and restrict blood flow. A supportive bra should be worn at all times by both bottle-feeding and breastfeeding mothers. Taking a warm shower may help relieve some of the discomfort of the breast engorgement.

A breast-feeding client is diagnosed with mastitis. Which nursing intervention is appropriate? a) Recommending that she wear a special brassiere when breast-feeding b) Advising her to massage the affected area gently while breast-feeding c) Instructing her to breast-feed the neonate at least every 4 hours d) Teaching her to apply a cold compress to the affected breast after each feeding

Advising her to massage the affected area gently while breast-feeding Correct Explanation: To help relieve mastitis, the nurse should advise the client to massage the affected area gently during breast-feeding; breast-feed at least every 2 to 3 hours; apply a warm, wet washcloth to her breast before each feeding; and avoid wearing a brassiere when breast-feeding

Because subcutaneous and brown fat stores were used for survival in utero, the nurse would assess an SGA newborn for which of the following? A Hyperbilirubinemia B Hypothermia C Polycythemia D Hypoglycemia

b. subcutaneous and brown fat stores may be used by the stressed fetus to survive in utero and thus will not be available to provide extrauterine warmth. Excessive red blood cell breakdown is responsible for hyperbilirubinemia, not the breakdown of brown fat stores. Polycythemia is caused by a buildup of red blood cells in response to a hypoxic state in utero; it is not linked to loss of subcutaneous and brown fat stores. Glycogen stores are used for survival in an environment with depleted glycogen and are unrelated to brown fat stores.

Which one of the following immunizations is most commonly received by newborns before hospital discharge? A Pneumococcus B Varicella C Hepatitis A D Hepatitis B

d. Most newborns are started on the hepatitis B series before discharge from the hospital and receive the remaining two immunizations at 1 month and 4 to 6 months of age. The pneumococcal vaccine is given between 2 to 23 months of age, not at birth. Varicella immunization is not given until 12 to 18 months of age. Hepatitis A immunization is recommended for children and adolescents in selected states and regions and for high-risk groups. It is not a universal vaccine for all children.

While the nurse is palpating the breasts of a client who is breastfeeding her 12-hour-old neonate, what is an expected finding? a) slightly firm, filling breasts b) firm breasts that are tender to touch c) soft breasts that are not tender to touch d) firm breasts beginning milk production

soft breasts that are not tender to touch Explanation: Because the client is 12 hours postpartum, the breasts should still be soft and not tender to touch. Breast milk production does not begin until the second or third postpartum day. Therefore, this client's breasts would not be firm with noticeable filling. When production begins, the breasts become larger, firm, and tender to touch

After the nurse counsels a primiparous, breastfeeding client about diet and nutritional needs during the lactation period, which client statement indicates a need for additional teaching? a) "I need to make sure I have enough calcium in my diet." b) "I need to get an extra 500 cal/day." c) "I need to increase my intake of vitamin D." d) "I should drink at least five glasses of fluid daily."

"I should drink at least five glasses of fluid daily." Correct Explanation: For the breastfeeding client, drinking at least 8 to 10 glasses of fluid a day is recommended. Breastfeeding women need an increased intake of vitamin D for calcium absorption. A breastfeeding woman requires an extra 500 cal/day above the recommended nonpregnancy intake to produce quality breast milk. Breastfeeding women need adequate calcium for blood clotting and strong bones and teeth

The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which client should the nurse assess first? a) a multiparous client at 48 hours postpartum who is being discharged b) a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally c) a multiparous client at 24 hours postpartum whose infant is in the special care nursery d) a primiparous client at 48 hours after cesarean birth of a term neonate

a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally Correct Explanation: The primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally should be assessed first because this client is at risk for postpartum hemorrhage. Early postpartum hemorrhage typically occurs during the first 24 hours postpartum. Once the nurse has assessed the client's fundus, lochia, and vital signs, a determination about the stability of the client can be made. After this assessment, the nurse can provide care to the other clients, who are of lesser priority than the newly postpartum primiparous client

A 15-year-old unmarried primiparous client is being cared for in the hospital's birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which response would be most appropriate? a) "I will check with the social worker to see if the adopting parents will permit this." b) "I think we should ask your health care provider if this is a good idea." c) "I will bring the baby to you for feeding." d) "It is not a good idea for you to have any contact with the baby."

"I will bring the baby to you for feeding." Correct Explanation: After birth, the client should make the decision about how much she would like to participate in the neonate's care. Seeing and caring for the neonate commonly facilitates the grief process. The nurse should be nonjudgmental and should allow the client any opportunity to see, hold, and care for the neonate. The health care provider (HCP) does not need to be contacted about the client's desire to see the baby, which is a normal reaction. The social worker and the adoptive parents do not need to give the client permission to feed the baby.

A client gave birth 2 days ago and has been given instructions on breast care for bottle-feeding mothers. Which statement indicates that the nurse should reinforce the instructions to the client? a) "When showering, I will direct water onto my shoulders." b) "I will only use only water to clean my nipples." c) "I will use a breast pump to remove any milk that may appear." d) "I will wear a sports bra or a well-fitting bra for several days."

"I will use a breast pump to remove any milk that may appear." Explanation: The use of a breast pump to remove milk is contraindicated in bottle-feeding mothers. Nipple and breast stimulation and emptying of the breasts produce milk, rather than eliminate milk production. The bottle-feeding client is discouraged from stimulating the breasts in any way. A sports bra that is well fitting provides support and decreases stimulation. (Binders are not suggested.) Having the water in a shower land on the shoulders of the mother rather than the breasts also decreases stimulation. Only water is necessary to clean nipples when breast or bottle-feeding.

A nurse and a nursing student discuss the risk factors associated with a client's postpartum depression. Which of the following statements from the nursing student are accurate about postpartum depression? Select all that apply. a) "Symptoms often begin around 4 weeks postpartum." b) "The incidence is infrequent, happening in less than 5% of pregnancies." c) "Symptoms present for two weeks or more." d) "A risk factor is an unplanned pregnancy." e) "It is more common with primiparas."

"Symptoms often begin around 4 weeks postpartum." • "A risk factor is an unplanned pregnancy." • "Symptoms present for two weeks or more." Correct Explanation: For a diagnosis of postpartum depression (PPD), symptoms are experienced by women for at least 2 weeks postpartum. These symptoms often begin around 4 weeks postpartum, but can begin anytime within the first year after birth. Approximately 13-15% of women experience PPD. PPD can occur with any pregnancy and is often worse with multiparas who have more risk factors for PPD. Risk factors for PPD also include unplanned or unwanted pregnancy, poor maternal support, unsuccessful breastfeeding, and PPD in previous pregnancies

The nurse is providing postpartum teaching to a couple. Which of the following statements indicates to the nurse that the couple understands the teaching about physiologic jaundice? Select all that apply. a) "Often the treatment requires a blood transfusion for the baby." b) "The symptoms disappear between the 7th and 10th day postpartum." c) "It occurs more often in formula-fed babies." d) "The jaundice is caused by normal lessening of red blood cells in the baby's body." e) "The symptoms start after the first 48 hours of life."

"The symptoms start after the first 48 hours of life." • "The symptoms disappear between the 7th and 10th day postpartum." • "The jaundice is caused by normal lessening of red blood cells in the baby's body." Explanation: Physiologic jaundice occurs 48 hours or more after birth, peaks at the 5th to 7th day, and disappears between the 7th and 10th day postpartum. Physiologic jaundice is caused by the normal reduction of red blood cells and occurs for both breast-fed and bottle-fed babies. Physiologic jaundice is treated with phototherapy.

A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breastfeed my baby?" The nurse should tell the client: a) "You can continue to breastfeed as long as you want to do so." b) "You will need to modify your technique by manually pumping your breasts." c) "Alternate your breastfeeding with formula feeding to help you rest." d) "You'll need to discontinue breastfeeding until the antibiotic therapy is stopped."

"You can continue to breastfeed as long as you want to do so." Explanation: The client can continue to breastfeed as often as she desires. Continuation of breastfeeding is limited only by the client's discomfort or malaise. Antibiotics for treatment are chosen carefully so that they avoid affecting the neonate through breast milk. Drugs such as sulfonamides, nitrofurantoin, and cephalosporins usually are not prescribed for breastfeeding mothers. Manual pumping of the breasts is not necessary.

A 24-year-old primipara decides to breastfeed her baby but says, "I am worried that I will not be able to breastfeed my baby because my breasts are so small." What would the nurse include in the explanation to the client? a) Because her breasts are small, she will have to feed the baby more often. b) The woman's motivation to breast-feed is more important than breast size. c) Breast size poses no influence on a woman's ability to breastfeed a baby. d) Breast milk can be enhanced by occasional formula feeding.

Breast size poses no influence on a woman's ability to breastfeed a baby. Correct Explanation: Breast size is not important as long as there is glandular tissue to secrete the milk, although various factors can influence milk supply, such as suckling, emptying of the breasts, diet, exercise, rest, level of contentment, and stress. The fat in breast tissue plays no role in milk production. Breastfeeding and formula feeding at the same time can result in nipple confusion. The client's belief in her ability to breastfeed is important because women who lack motivation are more likely to discontinue breastfeeding. Women with small breasts do not produce less milk. Also, the size of the breast does not influence the neonate's ability to grasp the nipple. The frequency of feeding is determined by the baby's needs, not the size of the mother's breasts.

A nurse is caring for a client with history of a warm, reddened, painful area in the breast diagnosed as mastitis as well as cracked and fissured nipples. The client expresses the desire to continue breast-feeding throughout treatment. Which instructions would the nurse include to prevent a recurrence of this condition? Select all that apply. a) Wash the nipples with soap and water. b) Expose the nipples to air for part of each day. c) Release the neonate's grasp on the nipple before removing him from the breast. d) Wash hands before handling the breast and breast-feeding. e) Change the breast pads frequently. f) Make sure that the neonate grasps the nipple only.

Change the breast pads frequently. • Expose the nipples to air for part of each day. • Wash hands before handling the breast and breast-feeding. • Release the neonate's grasp on the nipple before removing him from the breast. Explanation: Mastitis is an infection of the breast tissue usually caused by Staphylococcus aureus. This infection typically occurs in the second or third postpartum week and is more frequent in primigravidas. To help prevent mastitis, the nurse would suggest measures to prevent cracked and fissured nipples. Changing breast pads frequently and exposing the nipples to air for part of the day help keep the nipples dry and prevent irritation. Washing hands before handling the breast reduces the chance of accidentally introducing organisms into the breast. Releasing the baby's grasp on the nipple before removing the baby from the breast also reduces the chance of irritation. Nipples would be washed with water only; soap tends to remove the natural oils and increases the chance of cracking. The baby would grasp both the nipple and areola

A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action? a) Discuss the unit's policy with the charge nurse. b) Notify security because the neonate's father is demanding to see his baby. c) Teach the grandparents how to scrub and gown before entering the nursery. d) Invite everyone into the large conference room to see the neonate.

Discuss the unit's policy with the charge nurse. Correct Explanation: Because the nurse is new to the hospital, she should check with the charge nurse about the unit's visiting policy. The scenario doesn't provide information about whether the neonate's parents are married or if the mother is an emancipated minor. Therefore, the adolescent mother may not be able to legally make her own decisions about her parents' (the baby's grandparents') presence. She or her parents do have a say as to whether the father's parents can visit. The mother of the neonate does have a say in visitors seeing her baby. Because the family dynamics aren't clear in this scenario, the best answer would be to check with the charge nurse who knows the unit's policy. Although the neonate's father may have demanded to see the baby, the question doesn't indicate violent or threatening behavior; therefore, notifying security isn't necessary. The nurse can instruct the father's parents on how to gown and glove before visiting the neonate if they have permission to visit. Because the family dynamics aren't known, inviting everyone to gather in a conference room isn't advisable.

Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. What should the nurse do next? a) Gently massage the fundus to expel the clots. b) Encourage the client to ambulate to the bathroom and void. c) Contact the health care provider (HCP) for a prescription for oxytocin. d) Document this as a normal finding in the client's record.

Encourage the client to ambulate to the bathroom and void. Explanation: At 12 hours postpartum, the fundus normally should be in the midline and at the level of the umbilicus. When the fundus is firm yet above the umbilicus, and deviated to the right rather than in the midline, the client's bladder is most likely distended. The client should be encouraged to ambulate to the bathroom and attempt to void because a full bladder can prevent normal involution. A firm but deviated fundus above the level of the umbilicus is not a normal finding, and if voiding does not return it to midline, it should be reported to the HCP. Oxytocin is used to treat uterine atony. This client's fundus is firm, not boggy or soft, which would suggest atony. Gentle massage is not necessary because there is no evidence of atony or clots.

A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action? a) Call the nursery to ask which baby is missing. b) Go to the obstetrics unit to determine if they need help with the situation. c) Move to the entrance of the hospital and check each person leaving. d) Observe individuals in the area for large bags or oversized coats.

Observe individuals in the area for large bags or oversized coats. Correct Explanation: The process for infant abduction in a hospital system focuses on utilizing all health care workers to observe for anyone who may possibly be concealing an infant in a large bag or under an oversized coat and is attempting to leave the building. Moving to the entrances and exits and checking each individual would be a responsibility of the doorman or security staff within the hospital system. Going to the obstetrics unit to determine if they need help would not be advised as the doors to the unit will be locked and access will not be available. Calling the nursery to ask about a missing baby wastes time, and the nursery staff should not reveal such information.

The nurse is evaluating the client who gave birth vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a multigravida breastfeeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the prescriptions sheet would be the most appropriate for this client? a) aspirin 1,000 mg PO every 4 to 6 hour PRN b) ducosate 100 mg PO twice a day c) acetaminophen and hydrocodone 10 mg 1 tab PO every 4 to 6 hour PRN d) ibuprofen 800 mg PO every 6 to 8 hour PRN

acetaminophen and hydrocodone 10 mg 1 tab PO every 4 to 6 hour PRN Correct Explanation: Acetaminophen and hydrocodone would be the drug of choice for this situation because the pain level is so high. Aspirin is not usually used because of the bleeding risk associated with its use. Although ibuprofen would typically be a good choice because it inhibits the prostaglandin synthesis associated with a multiparous client breastfeeding, the pain level is too high for this drug to have an acceptable effect. Docusate is used as a stool softener postpartum but does not provide pain relief.

A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which factor? a) moving the infant during the feeding b) a defect in the gastrointestinal system c) burping the infant too frequently d) an immature cardiac sphincter

an immature cardiac sphincter Correct Explanation: Initial regurgitation in the neonate during the first 12 to 24 hours may be caused by excessive mucus and gastric irritation from foreign substances in the stomach. After the first 24 hours, regurgitation is thought to be caused by the neonate's immature cardiac sphincter. It represents an overflow of stomach contents and is probably a result of feeding the neonate too fast or too much. A defect in the gastrointestinal system usually results in more severe symptoms. A small amount of regurgitation is normal, but vomiting or forceful fluid expulsion is not. Burping the infant often during a feeding can decrease the amount of air in the stomach from swallowing. However, burping too often can lead the neonate to become tired or fussy. Moving the infant usually does not result in regurgitation.

While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal birth under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which factor? a) hemorrhage during the birth process b) effects of the anesthetic during labor c) effects of analgesics used during labor d) decreased blood volume in the vascular system

decreased blood volume in the vascular system Explanation: The client's dizziness is most likely caused by orthostatic hypotension secondary to the decreased volume of blood in the vascular system resulting from the physiologic changes occurring in the mother after birth. The client is experiencing dizziness because not enough blood volume is available to perfuse the brain. The nurse should first allow the client to "dangle" on the side of the bed for a few minutes before attempting to ambulate. By 6 hours postpartum, the effects of the anesthesia should be worn off completely. Typically, the effects of epidural anesthesia wear off by 1 to 2 hours postpartum, and the effects of local anesthesia usually disappear by 1 hour. The client scenario provides no information to indicate that the client experienced any postpartum hemorrhage. Normal blood loss during birth should not exceed 500 mL.

A multigravid client gave birth vaginally 2 hours ago. A family member notifies the nurse that the client is pale and shaky. Which are the priority assessments for the nurse to make? a) fundus and lochia b) blood glucose level and vital signs c) uterine infection and pain d) temperature and level of consciousness

fundus and lochia Explanation: A client who is pale and shaking could be experiencing hypovolemic shock likely caused by blood loss. A primary cause of blood loss after the birth of an infant is uterine atony. Therefore, the priority assessments should be the fundus of the uterus for firmness and location. In addition, the amount of vaginal bleeding (lochia) should also be assessed. An immediate intervention for uterine atony is fundal massage that will help the uterus to contract and therefore stop additional bleeding. Assessing the client's level of consciousness does not require additional time and can be done by the nurse while the fundus and lochia are assessed. Obtaining vital signs, blood glucose, and temperature are important but should be done either after the fundus has been assessed and massaged or should be obtained by a second responder. Assessing for uterine infection and pain should be done after treatment for hypovolemic shock has been initiated.

The nurse makes a home visit to a primigravida on the fourth postpartum day after birth of a viable neonate. When the nurse enters the house, the nurse finds the client sitting in a chair, crying inconsolably, while the neonate is crying in another room. The client tells the nurse that she has not been sleeping well and has been hearing voices. The nurse determines that the client is most likely experiencing: a) postpartum psychosis. b) postpartum depression. c) the "baby blues." d) normal reactions to being a new mother.

postpartum psychosis. Correct Explanation: The client's symptoms of insomnia, crying inconsolably, and hearing voices (hallucinations) are all symptoms of postpartum psychosis. The client needs immediate treatment to prevent injury to herself and the neonate. Postpartum psychosis occurs in about 1 in 1,000 pregnancies; thus, it is relatively rare but serious. Hospitalization, social support, and psychotherapy are used to treat postpartum psychosis. Prognosis for recovery is good, but the condition may recur with subsequent pregnancies. Although crying at times may be expected, ignoring a crying newborn and hearing voices are not normal reactions. "Baby blues" is a transient condition; mothers experiencing this do not hear voices. Postpartum depression continues for several weeks or months after birth. Crying, sadness, and lack of appetite may be present, but the client does not hear voices.

The nurse evaluates the mothering skills of an adolescent primigravida changing her baby's diaper for the first time. When caring for this client, the nurse should focus on the client's need for which support? a) detailed written instructions b) acceptance by the client's peers c) praise and encouragement d) family availability for assistance

praise and encouragement Explanation: The adolescent client may have special needs during the postpartum period. Praise and encouragement of her mothering skills are important for building the client's confidence and self-esteem. Although they may be helpful in some instances, detailed written instructions or prolonged verbal instructions are inappropriate. Lengthy explanations, either verbal or in writing, may overwhelm the first-time mother, adding to her fears and feelings of inadequacy. Family availability is important but not essential. For example, it is not essential that the client's mother assist her. However, the nurse can instruct the client while her mother is present. Peer acceptance is a major component of adolescence, but lack of knowledge or experience about infant care is unrelated to peer acceptance. The reality of caring for a neonate may be a crisis for the adolescent.

A woman who has given birth to a healthy baby is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider (HCP) about: a) bleeding that becomes lighter each day. b) lochia that lasts longer than 1 week. c) saturating a pad in an hour. d) clots the size of grapes.

saturating a pad in an hour. Explanation: A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes from red to pink to off-white. It also decreases in amount each day. Passing blood clots the size of a fist or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up to 6 weeks postpartum.

A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which guideline should the nurse include in the teaching plan as evidence of adequate intake? a) six to eight wet diapers by the fifth day b) three to four transitional stools on the fourth day c) ability to fall asleep easily after feeding on the first day d) regain of lost birth weight by the third day

six to eight wet diapers by the fifth day Correct Explanation: The nurse should instruct the client that the baby is getting enough to eat when there are six to eight wet diapers by the fifth day of age. Other signs include good suckling sounds during feeding, dripping breast milk at the mouth, and quiet rest or sleep after the feeding. By the fourth day of age, the infant should have soft yellow stools, not transitional (greenish) stools. Falling asleep easily after feeding on the first day is not a good indicator because most infants are sleepy during the first 24 hours. Most infants regain their lost birth weight in 7 to 10 days after birth. An infant who has gained weight during the first well-baby checkup (usually at 2 weeks) is getting sufficient breast milk at feedings

During a home visit 4 days after delivery, the breast-feeding primiparous client tells the nurse that her breasts are hard and tender. The nurse determines the client has breast engorgement and should instruct the client to: a) apply ice packs to the breasts for 20 minutes just before breastfeeding the newborn. b) take a moderately strong analgesic after the infant breastfeeds on both sides. c) use her hand or a pump to express a small amount of breast milk before breastfeeding. d) discontinue breastfeeding immediately and replace it with bottle-feeding during the night.

use her hand or a pump to express a small amount of breast milk before breastfeeding. Explanation: The client should be instructed to express milk from the nipples either by hand or with a breast pump to stimulate milk flow and relieve the engorgement. As soon as the areola is soft, the client should begin to breastfeed. Frequent feedings with complete emptying of the breasts should alleviate engorgement. There is no reason why the client needs to discontinue breastfeeding. Rather, more frequent breastfeeding is indicated. Ice packs can be used to relieve edema and pain but should be used between feedings not immediately before a feeding. Warm compresses may be used to help stimulate milk flow. Although the client's breasts are tender, this tenderness is a result of the engorgement. A strong analgesic will not alleviate breast engorgement. Expressing the milk and feeding the neonate are most effective in relieving the problem.

The nurse is providing follow-up care with a client 10 days after birth of a newborn. The nurse would anticipate what outcomes for the new mother? Select all that apply. a) The family has adequate support from one another and others. b) The client feeds the baby every 6 to 8 hours without difficulty. c) Lochia is changing from red to pink and is smaller in amount. d) The client feels tired but can care for herself and her new infant. e) The client has positive comments about her new infant.

• The client has positive comments about her new infant. • Lochia is changing from red to pink and is smaller in amount. • The client feels tired but can care for herself and her new infant. • The family has adequate support from one another and others. Correct Explanation: Outcome evaluation for a family about 7 days after childbirth would include a mother who is tired but is able to care for herself and her baby. Having adequate support systems enables the mother to care better for herself and family members, as they can provide the backup for situations that may arise and a resource for new families. The normal progression for lochia is to change from red to pink to off-white while decreasing in amount. This is within the usual time periods for a postpartum mother. The baby should be feeding more frequently than every 6 to 8 hours. It is expected that a 7-day old infant feeds every 3 to 4 hours if bottle-feeding and every 1½ to 3 hours if breastfeeding. Follow-up questions the nurse would ask to further evaluate this situation include, How many wet diapers the infant has daily? How alert the infant is? Did the infant gain any weight at the first checkup? It is expected that the mother has positive comments about the infant, but the nurse will evaluate to determine if there is at least one positive comment.

After the birth of her first neonate, a mother asks the nurse about the reddened areas at the nape of the neonate's neck. How should the nurse respond? a) "They're normal and will disappear as the baby's skin thickens." b) "They're caused by a blockage in the apocrine glands." c) "They commonly result from a traumatic delivery." d) "They're a common congenital abnormality."

"They're normal and will disappear as the baby's skin thickens." Correct Explanation: Capillary hemangioma (also called a "stork bite") may appear on the neonate's upper eyelids, the bridge of the nose, or the nape of the neck. They result from vascular congestion and will disappear as the skin thickens. They aren't associated with congenital abnormalities, traumatic delivery, or blocked apocrine glands

Which client statement indicates effective teaching about burping a breastfed neonate? a) "I will breastfeed my baby every 3 hours so I won't have to burp him." b) "If I supplement the baby with formula, I will rarely have to burp him." c) "Breastfed babies who are burped frequently will take more on each breast." d) "When I switch to the other breast, I'll burp the baby."

"When I switch to the other breast, I'll burp the baby." Correct Explanation: Breastfed neonates do not swallow as much air as bottle-fed neonates, but they still need to be burped. Good times to burp the neonate are when the mother switches from one breast to the other and at the end of the breastfeeding session. Neonates do not eat more if they are burped frequently. Breastfeeding mothers are advised not to supplement the feedings with formula because this may cause nipple confusion and decrease milk production. If supplements are given, the baby still needs to be burped. Neonates who are fed every 3 hours still need to be burped.

After teaching the client about bottle-feeding, which client statement indicates the need for additional teaching? a) "Whole milk is an acceptable alternative to formula once the baby is 4 months old." b) "Bottle-fed babies up to 6 months of age may gain as much as 1 ounce (30 g)/day." c) "Iron-fortified formulas are usually recommended for newborns." d) "Bottle-fed babies will usually regain their birth weight by 10 to 14 days of age."

"Whole milk is an acceptable alternative to formula once the baby is 4 months old." Correct Explanation: Neither unmodified cow's milk nor whole milk is an acceptable alternative for newborn nutrition. The American Academy of Pediatrics and Canadian Pediatric Society recommend that infants be given breast milk or formula until 1 year of age. However, the American Academy of Pediatrics Committee on Nutrition has decreed that cow's milk could be substituted in the second 6 months of life, but only if the amount of milk calories does not exceed 65% of total calories and iron is replaced through solid foods. The protein content in cow's milk is too high, is poorly digested, and may cause gastrointestinal tract bleeding. Bottle-fed infants may gain as much as 1 oz (30 g)/day up to age 6 months.

Prioritize the postpartum mother's needs 4 hours after giving birth by placing a number 1, 2, 3, or 4 in the blank before each need. _________ Learn how to hold and cuddle the infant. _________Watch a baby bath demonstration given by the nurse. _________ Sleep and rest without being disturbed for a few hours. _________ Interaction time (first 30 minutes) with the infant to facilitate bonding.

1 Interaction time with the infant for about 30 minutes to facilitate bonding 2 Sleep and rest without being disturbed for a few hours to restore mother 3 Lessons on holding and cuddling the infant 4 Watching a baby bath demonstration given by the nurse

A new mother asks, "When will the soft spot near the front of my baby's head close?" The nurse should tell the mother the soft spot will close in about: a) 2 to 3 months. b) 6 to 8 months. c) 9 to 10 months. d) 12 to 18 months.

12 to 18 months. Correct Explanation: Normally, the anterior fontanel closes between ages 12 and 18 months. Premature closure (craniostenosis or premature synostosis) prevents proper growth and expansion of the brain, resulting in an intellectual disability. The posterior fontanel typically closes by ages 2 to 3 months

Which complication is common in neonates who receive prolonged mechanical ventilation at birth? a) Bronchopulmonary dysplasia b) Hydrocephalus c) Esophageal atresia d) Renal failure

Bronchopulmonary dysplasia Explanation: Bronchopulmonary dysplasia commonly results from the high pressures that must sometimes be used to maintain adequate oxygenation. Esophageal atresia, a structural defect in which the esophagus and trachea communicate with each other, isn't related to mechanical ventilation. Hydrocephalus and renal failure don't typically occur in neonates who receive mechanical ventilation

A nurse has been teaching a new mother how to feed her infant who was born with a cleft lip and palate. Which action by the mother indicates that the teaching has been successful? a) Placing the baby flat during feedings b) Providing fluids with a small spoon c) Placing the nipple in the cleft palate d) Burping the baby frequently

Burping the baby frequently Correct Explanation: Because an infant with a cleft lip and palate can't grasp a nipple securely, he may swallow a large amount of air during feedings and, therefore, require frequent burping. An infant with a cleft lip and palate should be fed in an upright position to reduce the risk of aspiration. Spoons shouldn't be used. A neonate with a cleft lip and palate may use specially prepared nipples for feeding. Placing the nipple in the cleft palate increases the risk of aspiration

A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation? a) By holding the neonate in the football position b) By positioning the neonate so that the head remains still c) By letting the medication drip onto the surface of the eye d) By avoiding holding the eyelid open during medication instillation

By positioning the neonate so that the head remains still Explanation: After positioning the neonate securely so that the head remains still, the nurse should hold the eyelid open and instill the medication into the conjunctival sac. Holding the neonate in the football position doesn't secure the head.

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which instruction should the nurse give to the mother? a) Contact the health care provider (HCP). b) Switch to a soy-based formula because the current one seems inadequate. c) Continue feeding every 3 to 4 hours since the weight loss is normal. d) Change to a higher-calorie formula to prevent further weight loss.

Continue feeding every 3 to 4 hours since the weight loss is normal. Correct Explanation: This 3-day-old neonate's weight loss falls within a normal range, and therefore no action is needed at this time. Full-term neonates tend to lose 5% to 10% of their birth weight during the first few days after birth, most likely because of minimal nutritional intake. With bottle-feeding, the neonate's intake varies from one feeding to another. Typically, neonates regain any weight loss by 7 to 10 days of life. If the weight loss continues after that time, the HCP should be called

Which action is most appropriate when noting small, shiny white specks on the neonate's gums and hard palate during assessment? a) Continue monitoring because these spots are normal. b) Attempt to obtain a sterile specimen on a swab. c) Try to remove the specks with a wet washcloth. d) Place the neonate in an isolation area.

Continue monitoring because these spots are normal. Explanation: Small, shiny white specks on the neonate's gums and hard palate are known as Epstein's pearls. They have no special significance and often disappear within a few weeks. However, white patches on the inside of the mouth, possibly signaling thrush due to Candida albicans infection, warrant further investigation. Isolation is not necessary because this finding is normal and the neonate is not contagious. Because these specks often disappear within a few weeks, the nurse does not need to remove these with a wet washcloth. Sending a sterile specimen to the laboratory is not necessary because this finding is normal.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following? a) Epispadias. b) Phimosis. c) Hypospadias. d) Hydrocele.

Hypospadias. Explanation: The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy

A client tells a nurse that she's going to breast-feed her neonate, but she isn't sure what she should eat. Which client statement requires further teaching? a) "I will consume 500 more calories each day than if I wasn't breast-feeding." b) "I'll take all the same medications I was taking before my pregnancy." c) "I will drink 10 glasses of fluid every day." d) "I'll include milk products in my diet."

I'll take all the same medications I was taking before my pregnancy." Correct Explanation: The client indicates she needs additional teaching when she states she'll resume taking all the medications she was taking before her pregnancy because most drugs are excreted through breast milk and may affect the neonate. The client should consult with her physician before taking any drugs while breast-feeding. She should increase her daily calories by 500, drink 10 glasses of fluid, and include milk products in her diet to increase her milk production and provide adequate nutrition for her neonate and herself.

Which of the following would the nurse assess as indicating positive bonding between the parents and their newborn? A Holding the infant close to the body B Having visitors hold the infant C Buying expensive infant clothes D Requesting that the nurses care for the infant

a. Desiring to be in close proximity to another human being is all part of the bonding process. Bonding cannot take place with separation of individuals. Closeness is needed by the two people bonding, and not having others hold the infant. Buying or wearing expensive clothes has no emotional effect on a bonding relationship. Requesting that nurses provide care separates the parent from the infant and suggests that the parents lack the desire for closeness with their infant.

Postpartum breast engorgement occurs 48 to 72 hours after giving birth. What physiologic change influences breast engorgement? A An increase in blood and lymph supply to the breasts B An increase in estrogen and progesterone levels C Colostrum production increases dramatically D Fluid retention in the breasts due to the intravenous fluids given during labor

a. Engorgement refers to the swelling of the breast tissue as a result of an increase in blood and lymph supply to produce milk for the newborn. Estrogen and progesterone levels decrease considerably and are not restored until the first menses returns several weeks or months later, depending on the lactation status of the mother. Colostrum can be secreted as early as 16 weeks' gestation. The mother's body is going through profuse diuresis to restore prepregnant fluid levels to her body and therefore would not be retaining fluid in the breasts. Estrogen and progesterone levels decrease, which allows prolactin to stimulate the glands to secrete milk. Their levels are restored when the first menses returns several weeks or months later, depending on the lactation status of the mother. Delete the "colostrum" rationale there and replace with this one instead: Colostrum is a lemon-colored fluid secreted by both breasts immediately at birth and within 4 to 5 days postpartum it gradually changes to transitional milk and finally mature milk by two weeks. Colostrum production reduces within days after childbirth as transitional and mature milk, thereby not contributing to breast engorgement.

The major purpose of the first postpartum homecare visit is to: A Identify complications that require interventions B Obtain a blood specimen for PKU testing C Complete the official birth certificate D Support the new parents in their parenting roles

a. Home visits are usually made within the first week of discharge to assess the mother and newborn. This visit is made primarily to provide the nurse with the opportunity to recognize common biomedical and psychosocial problems or complications. Although not the primary reason, this visit also offers an opportunity to provide support and guidance to the parents in making the adjustment to the change in their lives. The home visit is not the time to complete PKU testing or complete the birth certificate.

SGA and LGA newborns have an excessive number of red blood cells related to: A Hypoxia B Hypoglycemia C Hypocalcemia D Hypothermia

a. the fetus's body, in an attempt to compensate for the low oxygen level, produces more red blood cells to carry the limited amount of oxygen available. Thus, polycythemia will be present at birth in a fetus experiencing hypoxia in utero. Hypoglycemia is typically caused by inadequate stores of glycogen and overuse while living in a hostile environment. Low serum calcium levels are associated with perinatal asphyxia and not an increase in red blood cells. Hypothermia is associated with a decrease in body fat, particularly brown fat stores, and is not linked to increased production of red blood cells.

While caring for a neonate born at 32 weeks' gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)? a) abdominal distention b) jaundice appearing on the face and chest c) an increase in bowel peristalsis d) the presence of 1 mL of gastric residual before a gavage feeding

abdominal distention Explanation: Indications of NEC include abdominal distention with gastric retention and vomiting. Other signs may include lethargy, irritability, positive blood culture in stool, absent or diminished bowel sounds, apnea, diarrhea, metabolic acidosis, and unstable temperature. A gastric residual of 1 mL is not significant. Jaundice of the face and chest is associated with the neonate's immature liver function and increased bilirubin, not NEC. Typically with NEC, the neonate would exhibit absent or diminished bowel sounds, not increased peristalsis

When performing a physical assessment on a postterm neonate, the nurse expects to find: a) abundant subcutaneous fat. b) patchy fine hair distribution. c) absent plantar creases. d) abundant lanugo.

abundant subcutaneous fat. Correct Explanation: Typical assessment findings for a postterm neonate include abundant subcutaneous fat; long, silky hair; absent vernix caseosa; dry, cracked skin; and long nails. Absent plantar creases, abundant lanugo, and patchy fine hair distribution are typical assessment findings for a preterm neonate

The nurse is performing an admission assessment on a neonate and finds the femoral pulses to be weaker than the brachial and radial pulses. The next nursing action should be to: a) note and tell the health care provider (HCP) when rounds are made. b) take the neonate's blood pressure in all four extremities. c) call for a cardiac consult. d) place the neonate in reverse Trendelenburg position.

ake the neonate's blood pressure in all four extremities. Explanation: The next nursing action in this situation would be to assess the blood pressure in all four extremities and compare the findings. A difference of 15 mm Hg in the systolic blood pressure between the arms and legs is an indication of a narrowed aorta. This could be an emergency, and the HCP needs to be notified as soon as the blood pressure data has been collected. Generally, prescribing a HCP consult is not a nursing function. Placing the neonate in reverse Trendelenburg will only decrease the perfusion to the lower extremities

The mother of a newborn is concerned about the number of persons with heart disease in her family. She asks the nurse when she should start her baby on a low-fat, low-cholesterol diet to lower the risk of heart disease. The nurse should tell her to start diet modifications: a) at age 5. b) at birth. c) at age 2. d) at age 10.

at age 2. Explanation: Infants and toddlers younger than age 2 should not be placed on a fat-restricted diet because cholesterol and other fatty acids are required for continued neural growth. After age 2 it is believed that no harm is done by encouraging a child to eat a variety of foods, maintain a desirable body weight, limit saturated fat and cholesterol, and increase fiber.

Which of the following suggestions would be most appropriate to include in the teaching plan for a postpartum woman who needs to lose weight? A Increase fluid intake and acid-producing foods in her diet. B Avoid empty-calorie foods and increase exercise. C Start a high-protein diet and restrict fluids. D Eat no snacks or carbohydrates.

b. Because weight loss is based on the principle of intake of calories and output of energy, instructing this woman to avoid high-calorie foods that yield no nutritive value and expending more energy through active exercise would result in weight loss for her. Acid-producing foods (plums, cranberries, and prunes) are typically recommended for women to prevent urinary tract infections to acidify the urine, not for weight-loss purposes. Increasing fluid intake (water) would be good for weight loss because it fills the stomach and reduces hunger sensations; however, this option does not identify which fluids should be increased. Increasing high-calorie juice and soda drinks would be counterproductive to weight-loss measures. Fluid restriction combined with a high-protein diet would increase the risk of gout and formation of kidney stones. Carbohydrates are needed by the body to make ATP and convert it to energy for cellular processes. Limiting snacks might be a good suggestion depending on which ones are selected. Raw fruits and vegetables are excellent high-fiber snacks that will help in an overall weight-loss program.

Which finding would the nurse most expect to find in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? a) hyperbilirubinemia b) bulging fontanels c) increased muscle tone d) hyperactivity

bulging fontanels Correct Explanation: A common finding of IVH is a bulging fontanel. The most common site of hemorrhage is the periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile. Rapid volume expansion, hypercarbia, and hypoglycemia contribute to the development of IVH. Other common manifestations include neurologic signs such as hypotonia, lethargy, temperature instability, nystagmus, apnea, bradycardia, decreased hematocrit, and increasing hypoxia. Seizures also may occur. Hyperbilirubinemia refers to an increase in bilirubin in the blood and may be seen if bleeding was severe

In the taking-in maternal role phase described by Rubin (1984), the nurse would expect the woman's behavior to be characterized as which of the following? A Gaining self-confidence B Adjusting to her new relationships C Being passive and dependent D Resuming control over her life

c. According to Reba Rubin, the mother is very passive and is dependent on others to care for her for the first 24 to 48 hours after giving birth. Gaining self-confidence would characterize a mother in the taking-hold phase, during which the mother demonstrates mastery over her own body's functioning and feels more confident in caring for her newborn. Adjustment to relationships does not occur until the third phase, letting go, when the mother begins to separate from the symbiotic relationship she and her newborn enjoyed during pregnancy and birth. Resuming control over her life would denote the second phase of taking hold, during which the mother does resume control over her life and gains self-confidence in her newborn care.

The nurse is assessing Ms. Smith, who gave birth to her first child 5 days ago. What findings by the nurse would be expected? A Cream-colored lochia; uterus above the umbilicus B Bright-red lochia with clots; uterus 2 fingerbreadths below umbilicus C Light pink or brown lochia; uterus 4 to 5 fingerbreadths below umbilicus D Yellow, mucousy lochia; uterus at the level of the umbilicus

c. The nurse would expect light pink or brown lochia, and the uterus should be four to five fingerbreadths below the umbilicus. Cream-colored lochia wouldn't be seen for about 10 to 14 days after childbirth, thus it wouldn't be observed this early in the postpartum period. The uterus would be involuting downward into the pelvis, thus it would not be above the umbilicus by this timeframe. Bright-red lochia would be observed for up to three days post birth, not five days later unless there was a problem. The uterus descends into the pelvis at a rate of 1 cm/day, thus the fundus should be 4 to 5 cm (fingerbreadths) below the umbilicus by now.

The nurse documents that a newborn is postterm based on the understanding that he was born after: A 38 weeks' gestation B 40 weeks' gestation C 42 weeks' gestation D 44 weeks' gestation

c. a postterm infant is one born after the 42nd week of gestation. Birth between 38 and 41 weeks is considered within a normal range for a term newborn. A gestation of 44 weeks would be considered extremely long if the dates were calculated correctly.

In dealing with parents experiencing a perinatal loss, which of the following nursing interventions would be most appropriate? A Sheltering the parents from the bad news B Making all the decisions regarding care C Encouraging them to participate in the newborn's care D Leaving them by themselves to allow time to grieve

c. the parents need to validate the experience of loss. The best way to do this is to encourage them to participate in their newborn's care so that the grieving process can take place. Avoiding the experience of loss inhibits the grieving process. Avoidance prolongs the experience of loss and does not allow the parents to vent their feelings so that they can progress through their grief. It is not the nurse's responsibility, nor is it healthy for the family, to take over decisions for a family. Family members need to support each other and need to decide what is best for their situation. Leaving the family alone can be viewed as abandonment; privacy is important, but leaving them totally alone is not therapeutic.

Which of the following would lead the nurse to suspect that a postpartum woman was developing a complication? A Fatigue and irritability B Perineal discomfort and pink discharge C Pulse rate of 60 bpm D Swollen, tender, hot area on breast

d. A swollen, tender area on the breast would indicate mastitis, which would need medical intervention. Fatigue and irritability are not complications of childbearing, but rather the norm during the early postpartum period secondary to infant care demands and lack of sleep on the caretaker's part. Perineal discomfort and lochia serosa are normal physiologic events after childbirth and indicate normal uterine involution. Bradycardia is a normal vital sign for several days after childbirth because of the dramatic circulatory changes that take place with the loss of the placenta at birth and the return of blood back to the central circulation.

Which of these activities would best help the postpartum nurse to provide culturally sensitive care for the childbearing family? A Taking a transcultural course B Caring for only families of his or her cultural origin C Teaching Western beliefs to culturally diverse families D Educating himself or herself about diverse cultural practices

d. Nurses need first to become educated about various cultural practices to incorporate them into their care delivery. By gaining an understanding of diverse cultures different from their own, nurses can become sensitive to these different practices and not violate them. Attending a transcultural course might be beneficial, but this would take several weeks to complete and the information is needed much sooner to provide culturally sensitive care for an admitted client and her family. Caring only for families of the nurse's cultural origin would not be possible or realistic in our global, culturally diverse population within the United States. Nurses need to care for every person regardless of their color, creed, or nationality with respect and competence. Teaching diverse cultural families Western beliefs would demonstrate ethnocentric behavior and would not be professional. Each culture needs to be respected and learned about with tolerance and understanding.

At birth, a newborn's assessment reveals the following: heart rate of 140 bpm, loud crying, some flexion of extremities, crying when bulb syringe is introduced into the nares, and a pink body with blue extremities. The nurse would document the newborn's Apgar score as: A 5 points B 6 points C 7 points D 8 points

d. One point would be subtracted for color (acrocyanosis) and 1 point for fair flexion of extremities. All the assessment parameters should rate 2 points, except for color and flexion. Therefore, any score except 8 points would be incorrect.

The nurse is explaining phototherapy to the parents of a newborn. The nurse would include which of the following as the purpose? A Increase surfactant levels B Stabilize the newborn's temperature C Destroy Rh-negative antibodies D Oxidize bilirubin on the skin

d. Phototherapy reduces the bilirubin on the newborn's skin via oxidation. Phototherapy does not affect surfactant levels in the newborn's lungs, nor does it help to stabilize temperatures in the newborn. In fact, it might cause hyperthermia at times if not monitored closely. Phototherapy cannot destroy Rh antibodies attached to RBCs within the circulation.

The nurse is explaining to a postpartum woman 48 hours after her giving childbirth that the afterpains she is experiencing can be the result of which of the following? A Abdominal cramping is a sign of endometriosis B A small infant weighing less than 8 lb C Pregnancies that were too closely spaced D Contractions of the uterus after birth

d. The direct cause of afterpains is uterine contractions. Mothers experience abdominal pain secondary to contractions, especially when breast-feeding because sucking stimulates the release of oxytocin from the posterior pituitary gland, which causes uterine contractions. There is no association of afterpains with endometriosis. The small size of the newborn wouldn't stretch her uterus, thus would not be a contributing factor to her discomfort now. Pregnancies spaced too close together can contribute to frequent stretching of the uterus, but this is not the cause of afterpains.

A mother who is breastfeeding and has known food sensitivities is asking the nurse what foods she should avoid in her diet. Which foods should the nurse advise the client to avoid? Select all that apply. a) eggs b) lamb c) beef d) shellfish e) peanuts

eggs • shellfish • peanuts Correct Explanation: Some providers recommend that breastfeeding mothers avoid consuming potentially allergic foods. The top 6 foods known to cause allergies in children are shellfish, peanuts, eggs, milk, soy, and tree nuts

While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which stage of grief? a) denial b) bargaining c) anger d) shock

shock Correct Explanation: The physical appearance of the anomaly and the life-threatening nature of the disorder may result in shock to the parents. The parents may hesitate to form a bond with the neonate because of the guarded prognosis. Denial would be evidenced if the parents acted as if nothing were wrong. Bargaining would be evidenced by parental statements involving "if-then" phrasing, such as, "If the surgery is successful, I will go to church every Sunday." Anger would be evidenced if the parents attempted to blame someone, such as health care personnel, for the neonate's condition

When assessing a postterm neonate, what is considered a normal finding? a) small hands and feet b) wrinkled, peeling skin c) flattened nose d) red abdominal rash

wrinkled, peeling skin Correct Explanation: A common finding for postmature neonates is wrinkled, peeling skin. Flattened nose is associated with neonates who have trisomy 21, not with a postmature neonate. Small hands and feet are typically found in preterm and small-for-gestational-age neonates, not in a postterm neonate. There is no relationship between postmaturity and a red abdominal rash. An abdominal rash may be seen in any newborn in the first few days of life.

A nurse is explaining basic principles of asepsis and infection control to a client who has a respiratory tract infection following birth. The nurse determines the client understands principles of infection control to follow when the client says: a) "I must use individual client care equipment." b) "I must wear gloves when I handle my baby." c) "I must practice frequent hand washing." d) "I must use barrier isolation."

"I must practice frequent hand washing." Correct Explanation: Frequent handwashing is the most important aspect of infection control. The nurse can emphasize, monitor, and ensure this strategy for all who come in contact with this client. The use of gloves is not needed for clients caring for their own infants. The best practice is to restrict visitation if the client has a respiratory illness. If visitation is necessary, it is better if the client with the known infection wears the mask. Individual client care equipment is not needed in this situation

After teaching the parents of a neonate born with a cleft lip and cleft palate about appropriate feeding techniques, the nurse determines that the mother needs further instruction when the mother says makes which statement? a) "I should feed her in an upright position." b) "I may need to use a special nipple for feeding." c) "I need to remember to burp her often." d) "I should clean her mouth after each feeding."

"I should clean her mouth after each feeding." Explanation: It is not necessary to clean the mouth of an infant with an unrepaired cleft palate after each feeding. The neonate needs to be fed in an upright position to prevent aspiration. The neonate with a cleft lip and palate commonly swallows large amounts of air during feeding. Therefore, the neonate needs to be burped frequently to help eliminate the air and decrease the risk for regurgitation. The neonate with a cleft lip and palate should be fed with a special soft nipple that fills the cleft and facilitates sucking.

The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which client statement indicates that this teaching has been effective? a) "Any varicosities I had during pregnancy will disappear within 2 weeks." b) "It's normal for me to have reddish lochia until my 6-week checkup." c) "I can expect to have heart palpitations for several weeks." d) "My menstrual flow should resume in approximately 6 to 10 weeks."

"My menstrual flow should resume in approximately 6 to 10 weeks." Explanation: For clients who are bottle-feeding, menstrual flow usually returns in 6 to 10 weeks. Heart palpitations for several weeks are not normal and require further investigation. Reddish lochia at 6 weeks postpartum is not normal and warrants further evaluation. Although varicosities may fade, they rarely disappear completely after childbirth.

After teaching a new mother about the neonate's fontanels and when they close, which age, when cited by the client for closure of the posterior fontanel, would indicate effective teaching? a) 10 to 12 months b) 6 to 8 months c) 14 to 16 months d) 2 to 3 months

2 to 3 months Correct Explanation: Normally, the posterior fontanel closes by age 2 to 3 months. The anterior fotanelle typically closes by 18 months.

A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum? a) Ask the physician for an order to obtain cultures of both of the neonate's eyes. b) Notify the physician immediately. c) Do nothing; discharge is a normal finding in the eyes of a 1-day-old neonate. d) Obtain a nasal viral culture.

Ask the physician for an order to obtain cultures of both of the neonate's eyes. Explanation: Ophthalmia neonatorum, caused by Neisseria gonorrhea, causes neonatal blindness if left untreated. The nurse should ask the physician for an order to obtain cultures of both eyes so antibiotic treatment can be initiated. Eye discharge isn't normal in a 1-day-old neonate. Neisseria gonorrhea is caused by a gram-negative bacteria, not by a virus

A neonate born several hours ago shows signs of a tracheoesophageal fistula (TEF). During the initial assessment, what does the nurse expect to find? a) Continuous drooling b) Passage of frothy meconium c) Diaphragmatic breathing d) A slow response to stimuli

Continuous drooling Correct Explanation: Signs of a TEF include continuous drooling, excessive oral secretions, and choking and coughing, which are especially pronounced during feeding. TEF doesn't cause diaphragmatic breathing, a slow response to stimuli, or passage of frothy meconium

A neonate born 18 hours ago with myelomeningocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal? a) Providing adequate nutrition b) Preventing infection c) Preventing contracture deformity d) Ensuring adequate hydration

Preventing infection Correct Explanation: Preventing infection is the nurse's primary preoperative goal for a neonate with myelomeningocele. Although ensuring adequate hydration, providing adequate nutrition, and preventing contracture deformity are relevant for this neonate, they're secondary to preventing infection.

While caring for a healthy female neonate, the nurse notices red stains on the diaper after the baby voids. Which action should the nurse take next? a) Call the physician to report the problem. b) Check the baby's urine for hematuria. c) Encourage the mother to feed the baby to decrease dehydration. d) Do nothing because this is normal.

Do nothing because this is normal. Explanation: Female neonates may have some vaginal bleeding in the first or second day after birth because they no longer have the high levels of female hormones that they were exposed to while in the uterus. The physician needn't be called. This bleeding is normal and doesn't indicate dehydration or hematuria.

A nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate? a) Soft skin b) Vernix caseosa c) Enlarged breast tissue d) Weak sucking response

Enlarged breast tissue Correct Explanation: It's common to see enlarged breast tissue in both male and female neonates in their first few days of life because of maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and aren't related to estrogen.

A mother is instructed to stimulate the rooting reflex when attempting to breast-feed her baby. Which action shows that the mother understands these instructions? a) Initiating the neonate's startle reflex to make sure the baby is aware b) Turning the neonate's head to the side, causing the neonate to extend the extremities on that side c) Giving the neonate water to check for swallowing d) Stroking the neonate's cheek

Stroking the neonate's cheek Explanation: The rooting reflex is a neonate's response to having his cheek stroked. The neonate will turn his head to the side of the stroked cheek and will open his mouth in anticipation of having a nipple placed in it. The client demonstrates understanding of teaching if she tries to elicit this reflex. The tonic neck reflex is elicited by turning the neonate's head to the side when he's lying on his back. The extremities on the same side extend and those on the other side flex. Moro's reflex is the startle reflex. Water isn't indicated for neonates

Which of the following newborns could be described as breathing normally? A Newborn A is breathing deeply, with a regular rhythm, at a rate of 20 bpm. B Newborn B is breathing diaphragmatically with sternal retractions, at a rate of 70 bpm. C Newborn C is breathing shallowly, with 40-second periods of apnea and cyanosis. D Newborn D is breathing shallowly, at a rate of 36 bpm, with short periods of apnea.

d. Normal breathing can be described as shallow, at a rate of 36 bpm, with short periods of apnea.

In assessing a preterm newborn, which of the following findings would be of greatest concern? A Milia over the bridge of the nose B Thin transparent skin C Poor muscle tone D Heart murmur

d. When a newborn is born too soon, fetal circulation may persist into extra uterine life. The ductus arteriosis and foramen ovale may remain open if pulmonary vascular resistance remains high and oxygen levels remain low. This would be manifested by a heart murmur.

When developing the teaching plan for a primiparous client who is bottle-feeding her term neonate for the first feeding, what information should the nurse include? a) Propping of the bottle results in too much air being taken in by the baby. b) Bubble the baby after 2 oz (60 mL) of formula have been taken. c) All term babies have well-developed sucking skills. d) Fill the entire nipple of the bottle with formula

Fill the entire nipple of the bottle with formula. Explanation: Formula should fill the entire nipple of the bottle while the baby is sucking. This decreases the amount of air taken in by the baby; taking in too much air can lead to regurgitation. Not all babies at term are born with well-developed sucking skills. Some neonates are sleepy and do not suck well. For the first feeding, the baby should be bubbled after taking one-fourth to one-half ounce of formula and then again when the infant has finished the feeding. Bottle propping can lead to aspiration, decreased infant bonding, and aspiration of formula. However, it is not associated with the intake of too much air

Following a precipitous birth, examination of the client's vagina reveals a fourth-degree laceration. Which intervention is appropriate when caring for this client? a) Applying heat to limit edema during the first 12 to 24 hours b) Instructing the client to use two or more perineal pads to cushion the area c) Instructing the client about the importance of perineal (Kegel) exercises d) Instructing the client to avoid using sitz baths if ordered

Instructing the client about the importance of perineal (Kegel) exercises Correct Explanation: Kegel exercises, cold (not heat) applications, and sitz baths are all appropriate interventions for a client with a fourth-degree laceration. Using two or more perineal pads would do little to reduce pain or promote perineal healing.

When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema that is most likely caput succedaneum. What is the most appropriate nursing action based on this finding? a) Call the physician and inform him of the finding. b) Note the finding on the assessment record. c) Keep the neonate on nothing-by-mouth status and observe for seizures. d) Tell the parents this is a normal finding for a neonate who was breech.

Note the finding on the assessment record. Correct Explanation: Caput succedaneum refers to a vaguely outlined area of scalp edema that crosses the suture line and typically clears within a few days after birth. The nurse should note this finding on the assessment record, but no other action is needed. Caput succedaneum isn't found on neonates who were in the breech position.

A nurse is preparing a neonate for circumcision. Which behavior is the best example of nursing advocacy? a) Ensuring that the neonate has had nothing by mouth (NPO) for at least 6 hours before the procedure b) Recommending the use of analgesia for circumcision c) Monitoring the neonate for the excessive bleeding after the procedure d) Promptly returning the neonate to his mother for comfort and bonding after the procedure

Recommending the use of analgesia for circumcision Correct Explanation: Recommending the use of analgesia is an example of advocacy for the neonate. Ensuring that the neonate has been NPO for at least 6 hours before the procedure, monitoring for excessive bleeding after the procedure, and returning the neonate to his mother for comfort and bonding are examples of providing safe care, not of advocacy

Which assessment finding should a nurse interpret as abnormal for a term neonate who's 1 hour old? a) Slight yellowish hue to the skin b) Enlargement of the mammary glands c) Blue hands and feet d) Black and blue spots on the neonate's buttocks

Slight yellowish hue to the skin Correct Explanation: A slight yellowish hue to the skin would be abnormal because it's too early for the neonate to be showing signs of jaundice. The finding should be reported immediately to the neonate's health care provider. All of the remaining responses are normal findings for a 1-hour-old neonate

How should a nurse assess a neonate's rooting reflex? a) Stroke the neonate's cheek. b) Place an object in the neonate's palm. c) Touch the neonate's lips. d) Stroke the sole of the neonate's foot.

Stroke the neonate's cheek. Correct Explanation: The rooting reflex is elicited by stroking the neonate's cheek or stroking near the corner of the neonate's mouth. The neonate turns the head in the direction of the stroking, looking for food. This reflex disappears by 6 weeks. The palmar grasp reflex is elicited by placing an object in the palm of a neonate; the neonate's fingers close around it. This reflex disappears between ages 6 and 9 months. Babinski's reflex is elicited by stroking the neonate's foot, on the side of the sole, from the heel toward the toes. A neonate will fan his toes, producing a positive Babinski's reflex, until about age 3 months. The sucking reflex is seen when the neonate's lips are touched and lasts for about 6 months

A neonate circumcised with a Plastibell 1 hour ago is brought to his mother for feeding. What should the nurse instruct the mother to do? a) Place petroleum jelly over the site every 2 hours. b) Read a pamphlet about circumcision care. c) Remove the petroleum jelly gauze in 24 hours. d) Tell the nurse when the neonate voids.

Tell the nurse when the neonate voids. Explanation: The nurse should instruct the mother to report the first voiding after the circumcision because edema could cause a urinary obstruction. Although reading a pamphlet about circumcision care may be helpful, it may not be appropriate for all mothers. Some mothers could have difficulty reading or understanding the information. Petroleum jelly gauze is used with Gomco clamp circumcisions, not Plastibell. Petroleum jelly should not be used with Plastibell circumcision methods because the bell prevents further bleeding

A primiparous client who is breastfeeding develops endometritis on the third postpartum day. What instructions should the nurse give to the mother? a) The neonate will need to be bottle-fed for the next few days. b) The condition typically is treated with IV antibiotic therapy. c) The client's uterus may become "boggy," requiring frequent massage and oxytocics. d) The client needs to remain in bed in a side-lying position as much as possible.

The condition typically is treated with IV antibiotic therapy. Explanation: Postpartum infection is a leading cause of maternal mortality in the United States. Typical treatment for the condition is IV antibiotic therapy with drugs such as clindamycin, gentamicin, or both. Cultures of the lochia will also be obtained. The neonate can continue to breastfeed as long as the mother desires. A switch to bottle-feeding is not necessary. The uterus tends to be firm, with increased cramping to rid the uterus of the infection. The client should be encouraged to remain in Fowler's position when in bed to allow for drainage of the lochia

Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, which finding should alert the nurse to the development of a possible side effect? a) diarrhea b) urinary frequency c) hypertension d) dizziness

dizziness Correct Explanation: Analgesics with narcotics have numerous side effects, including respiratory depression, dizziness, light-headedness, hypotension, and fainting. Other side effects include constipation, nausea and vomiting, and urinary retention. Hypotension, not hypertension, is a possible adverse effect of narcotic analgesics. Constipation, not diarrhea, is a possible adverse effect of narcotic analgesics. Urinary retention, not urinary frequency, is a possible adverse effect of narcotic analgesics.

A mother with a history of gestational hypertension gives birth to a neonate at 26 weeks' gestation. After the neonate receives surfactant through an endotracheal tube in the delivery room, a nurse takes him to the neonatal intensive care unit (NICU), places him on an overbed warmer, and provides mechanical ventilation. When the mother arrives in the NICU for the first time, the nurse's priority should be to: a) explain the NICU visiting policy for the mother and family. b) enhance bonding by pointing out the neonate's features. c) obtain a family medical history. d) question the mother about her preterm labor.

enhance bonding by pointing out the neonate's features. Correct Explanation: Pointing out neonate's features to the mother enables the mother to begin to bond with him. The nurse should encourage this important activity from the time of the neonate's admission to the NICU. Explaining the NICU visiting policy, obtaining a family medical history, and questioning the mother about her preterm labor don't take priority over enhancing maternal bonding

A nurse is working on the labor and delivery unit, a locked unit. The nurse understands that the purpose of security and video surveillance is to: a) keep solicitors out of the unit. b) ensure the security of the neonates. c) ensure that the health care team won't be disturbed. d) keep family members from disturbing women in labor.

ensure the security of the neonates. Correct Explanation: Labor and delivery units use surveillance to ensure the security of the neonates. The surveillance system isn't intended to keep family members from disturbing clients in labor. The client designates which family members may be at her bedside. Solicitors aren't allowed on hospital premises at all, so keeping them off the unit isn't the primary purpose of the surveillance. The surveillance system isn't used to prevent the healthcare team from being disturbed.

When obtaining a blood sample to screen a neonate for phenylketonuria (PKU), the nurse should obtain the sample from the: a) scalp vein. b) radial artery. c) heel. d) brachial artery.

heel. Explanation: The blood sample for routine screening for phenylketonuria, done after the neonate has been eating for 48 hours, is obtained from a heel stick. The lateral heel is the best site because it prevents damage to the posterior tibial nerve and artery, plantar artery, and the important longitudinally oriented fat pad of the heel. The radial artery is an inappropriate site to obtain the blood sample because of the risk for severe trauma. The scalp vein is used for intravenous infusions, not to obtain a blood sample for PKU. The brachial artery is not an appropriate site for obtaining a PKU blood sample because the artery is too small and severe trauma may result.

While assessing a 4-day-old neonate born at 28 weeks' gestation, the nurse cannot elicit the neonate's Moro reflex, which was present 1 hour after birth. The nurse notifies the health care provider (HCP) because this may indicate which complication? a) facial nerve paralysis b) postnatal asphyxia c) intracranial hemorrhage d) skull fracture

intracranial hemorrhage Correct Explanation: When the nurse cannot elicit the Moro reflex of a 4-day-old preterm infant and the Moro reflex was present at birth, intracranial hemorrhage or cerebral edema should be suspected. Other symptoms include lethargy, bulging fontanels, and seizure activity. Confirmation can be made by ultrasound. Postnatal asphyxia is suggested by respiratory distress, grunting, nasal flaring, and cyanosis. A skull fracture can be confirmed by radiography. However, it is unlikely to occur in a preterm neonate. Rather, it is more common in the large-for-gestational-age neonate. Facial nerve paralysis is indicated when there is no movement on one side of the face. This condition is more common in the large-for-gestational-age neonate.

As part of the respiratory assessment, a nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because: a) a deviated septum will interfere with breathing. b) problems with nasal patency may cause flaring. c) neonates are obligate nose breathers. d) nasal patency is required for adequate feeding.

neonates are obligate nose breathers. Explanation: Neonates are obligate nose breathers and have no ability to breathe through their mouths. Therefore, blocked nares contribute to respiratory distress in the neonate. Nasal patency is unnecessary for neonate feeding. Nasal flaring may indicate respiratory distress. A deviated septum doesn't cause significant breathing difficulties.

A registered nurse on the neonatal unit appropriately uses the chain of command when she: a) discusses unprofessional behavior of laboratory personnel with the laboratory manager. b) asks the unit manager to grant her vacation requests. c) notifies the unit manager of unresolved issues between the nursing unit and housekeeping personnel. d) e-mails the housekeeping supervisor about a problem on the nursing unit.

notifies the unit manager of unresolved issues between the nursing unit and housekeeping personnel. Explanation: The concept of chain of command requires that the nurse contact the nurse-manager for issues related to other departments; the nurse-manager should handle such issues. Contacting the laboratory manager, asking the unit manager to grant her vacation requests, and e-mailing the housekeeping supervisor aren't appropriate uses of the chain of command

Which oral contraceptive is considered safe for use while breastfeeding because it will not affect the breast milk supply once breastfeeding has been well established? a) estrogen b) progestin c) testosterone d) estrogen and progestin

progestin Explanation: Progestin alone has no effect on breast milk or breastfeeding once the milk supply is well established. Estrogen suppresses milk output. Testosterone is not given as an oral contraceptive.

The nurse carefully documents the premature neonate's response to oxygen therapy, delivering only as much oxygen as is necessary to prevent the development of which complication? a) glaucoma b) ophthalmia neonatorum c) retinopathy of prematurity d) cataracts

retinopathy of prematurity Correct Explanation: High levels of oxygen delivered to a preterm neonate can result in retinopathy of prematurity. The immature blood vessels in the eye constrict, then overgrow, resulting in edema and hemorrhage that produce scarring, retinal detachment, and eventual blindness. Cataracts and glaucoma are congenital abnormalities in the neonate unrelated to oxygen therapy. Ophthalmia neonatorum is a gonorrheal infection of the eyes that is likely to occur if a mother has the gonorrheal organism in her birth canal.

While assessing a neonate at age 24 hours, the nurse observes several irregularly shaped, red, flat patches on the back of the neonate's neck. The nurse interprets this as which finding? a) stork bite b) café au lait spot c) port-wine stain d) newborn rash

stork bite Correct Explanation: Several irregularly shaped red patches, common skin variations in neonates, are termed stork bites. They eventually fade away as the neonate grows older. Port-wine stains are disfiguring darkish red or purplish skin discolorations on the scalp and face that may need laser therapy for removal. Newborn rash is typically generalized over the body, not localized to one body area, and is commonly raised. Café au lait spots are brown and typically found anywhere on the body. More than six spots or spots larger than 1.5 cm are associated with neurofibromatosis, a genetic condition of neural tissue

Puerperium is defined as: a) the duration of breast-feeding. b) the 6 weeks following birth. c) the first hour after birth. d) the days spent in the hospital after birth.

the 6 weeks following birth.

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation? a) numerous scrotal rugae b) thin, wasted appearance c) abundance of scalp hair d) descended testicles

thin, wasted appearance Correct Explanation: The premature neonate characteristically exhibits a thin, wasted appearance. The premature neonate commonly exhibits a scarcity of scalp hair. In the premature male neonate, testicles are typically high in the inguinal canal and absence of rugae on the scrotum is typical.

A neonate is receiving an IV infusion of dextrose 10% administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply. a) when the infusion is started b) when the neonate returns from X-ray c) when the neonate moves in the crib d) after the parents have visited e) at the beginning of each shift

• at the beginning of each shift • when the neonate returns from X-ray • when the infusion is started Correct Explanation: The alarm settings on infusion pumps should be verified at the time the infusion is started, at the beginning of each shift, and when the client is moved. The neonate can move in bed, but if the alarm is triggered, the nurse should verify the settings. Unless the neonate has moved or been taken out of the crib, it is not necessary to check alarm settings after the parents visit

The neonate in the nurse's care has a pneumothorax. The nurse knows the signs of early decompensation and to observe carefully for changes in which assessments? Select all that apply. a) color b) urinary output c) heart rate d) blood pressure e) temperature

• heart rate • blood pressure • color Correct Explanation: The pneumothorax may affect cardiac output, thus affecting perfusion causing a decrease in blood pressure and changes in color from pallor to cyanosis. As the neonate attempts to compensate, bradycardia or tachycardia may be exhibited. A change in temperature and urinary output are very late signs of decompensation.

A primiparous client who gave vaginal birth 1 hour ago voices anxiety because she has a nephew with Down syndrome. After teaching the client about Down syndrome, which client statements indicate the need for additional teaching? a) "Down syndrome usually results in some degree of intellectual disability." b) "There are several methods available to determine whether my baby has Down syndrome." c) "Older mothers are more likely to have a baby with chromosomal abnormalities." d) "Down syndrome is an abnormality that can result from a missing chromosome."

"Down syndrome is an abnormality that can result from a missing chromosome." Explanation: Down syndrome is a genetic abnormality that is caused by an extra chromosome that results in intellectual disability. The degree of disability is difficult to predict in a neonate, although most children born with Down syndrome have some degree of intellectual disability. Various methods can be used to determine whether a neonate has Down syndrome, which is commonly manifested by hypotonia, poor Moro reflex, flat facial profile, up-slanting palpebral fissures, epicanthal folds, and hyperflexible joints. Genetic studies can be indicative of this disorder. Mothers older than 35 years are at a higher risk for having a child with Down syndrome. However, chromosomal abnormalities can occur regardless of the mother's age.

A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in her teaching? a) "If you have excessive vaginal bleeding, massage your fundus and call the physician." b) "Don't worry. Women have been having babies for years without postpartum problems." c) "The neonate can sleep in the bed with you." d) "Sleep when the neonate sleeps to avoid exhaustion."

"If you have excessive vaginal bleeding, massage your fundus and call the physician." Explanation: Advising the client to massage the fundus and call the physician if excessive bleeding occurs is the priority because such bleeding can lead to hemorrhage, causing loss of fluid balance and fainting. Although recommending that a new mother sleep when her neonate sleeps can help the mother avoid exhaustion, this teaching point isn't the top priority. Sleeping with the neonate is a potential hazard; rolling over can suffocate the infant. Telling the client not to worry doesn't provide proper instruction and doesn't address concerns the client may have

After giving birth to a viable neonate 12 hours ago, the client's fundus is firm at midline, and her breasts are soft. She has scant lochia and she is voiding sufficiently. The client reports pain in her lower back. What should the nurse do next? a) Contact the primary care provider for a prescription to obtain a urinalysis. b) Administer a prescribed mild analgesic. c) Ask the client how long she was in labor. d) Instruct the client to perform abdominal exercises.

Administer a prescribed mild analgesic. Correct Explanation: After giving birth, it is not unusual for postpartum clients to have backache, which results from stretching of the muscles during the labor and birth process. The nurse can provide the client with a mild analgesic to help alleviate the backache. The client is not demonstrating any evidence of a urinary tract infection at this time, so calling the primary care provider to obtain a prescription for a urinalysis is not necessary. Although asking the client how long she was in labor may encourage her to discuss her labor and birth experience and provide the nurse with additional information, it will not alleviate the client's backache. On the day of childbirth, it is too soon for the client to begin abdominal exercises.

A primiparous client, 20 hours after giving birth, asks the nurse about starting postpartum exercises. What instructions would be most appropriate to include in the plan of care? a) Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles. b) Flex the knees while supine, and then bring chin to chest while exhaling and reach for the knees by lifting the head and shoulders while inhaling. c) Assume a prone position, and then do push-ups by using the arms to lift the upper body. d) Start in a sitting position, then lie back, and return to a sitting position, repeating this five times.

Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles. Explanation: After an uncomplicated birth, postpartum exercises may begin on the first postpartum day with exercises to strengthen the abdominal muscles. These are done in the supine position with the knees flexed, inhaling deeply while allowing the abdomen to expand and then exhaling while contracting the abdominal muscles. Exercises such as sit-ups (sitting, then lying back, and returning to a sitting position) and push-ups or exercises involving reaching for the knees are ordinarily too strenuous for the first postpartum day. Sit-ups may be done later in the postpartum period, after approximately 3 to 6 weeks

When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take? a) Notify the physician. b) Assure the client that such bleeding is normal. c) Apply an ice pack to the perineum. d) Massage the uterus every 15 minutes.

Notify the physician. Correct Explanation: The nurse should notify the physician because a continuous flow of bright red blood from the vagina and a firm, contracted uterus indicate laceration of the birth canal. Ice application doesn't slow bleeding. Massage isn't necessary because the client's fundus is firm. Telling the client that bleeding is normal would be misleading and would give her a false sense of security.

Which measure included in the care plan for a client in the fourth stage of labor requires revision? a) Have the client spend time with the neonate to initiate breast-feeding. b) Obtain an order for catheterization to protect the bladder from trauma. c) Perform perineal assessments for swelling and bleeding. d) Check vital signs and fundal checks every 15 minutes.

Obtain an order for catheterization to protect the bladder from trauma. Correct Explanation: Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the care plan during the fourth stage of labor.

Which factor is the most important in nursing care in the postpartum period? a) Supporting the mother's ability to successfully feed and care for her neonate b) Monitoring the normal progression of lochia c) Providing group discussions on neonatal care d) Involving the family in the teaching

Supporting the mother's ability to successfully feed and care for her neonate Correct Explanation: Most of the nursing interventions during the postpartum period are directed toward helping the mother successfully adapt to the parenting role. Although family involvement in teaching, group discussions on neonatal care, and lochia monitoring are important aspects of care, the mother's ability to feed and care for her neonate takes priority.

A client gave birth to a healthy full-term girl 2 hours ago by cesarean birth. When assessing this client, which finding requires immediate nursing action? a) Gush of vaginal blood when she stands up b) Tachycardia and hypotension c) Complaints of abdominal pain d) Blood stain 2″ (5.1 cm) in diameter on the abdominal dressing

Tachycardia and hypotension Correct Explanation: A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartum woman who has been sitting and may suddenly gush out when she stands up. Immediate nursing action isn't required. A 2″ (5.1 cm) blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. It's normal for a woman who has had a cesarean birth to feel pain at the incision site after her anesthesia has worn off.

A client recently gave birth to a boy. Two minutes before breast-feeding the baby, she administers one nasal spray (40 units/ml) of oxytocin into each nostril. Why is the client using this drug? a) To stimulate lactation b) To treat erythroblastosis c) To treat eclampsia d) To reduce postpartum bleeding

To stimulate lactation Correct Explanation: Oxytocin is administered as a nasal spray before breast-feeding to stimulate lactation. When oxytocin is used to treat eclampsia, reduce postpartum bleeding, or treat erythroblastosis fetalis, the drug is administered parenterally

After birth, the nurse would expect which fetal structure to close as a result of increases in the pressure gradients on the left side of the heart? A Foramen ovale B Ductus arteriosus C Ductus venosus D Umbilical vein

a. The foramen ovale is the fetal structure within the heart that allows blood to cross immediately to the left side and bypass the pulmonary circuit. When left-side pressure gradients increase at birth, this opening closes, thereby establishing an extrauterine circulation pattern. The ductus venosus is not located in the heart; it is located between the umbilical vein and the inferior vena cava, and it shunts blood away from the liver during fetal life. The ductus arteriosus connects the pulmonary artery to the aorta to bypass the pulmonary circuit. It begins to constrict as pulmonary circulation increases and arterial oxygen tension increases. The umbilical vein, along with two umbilical arteries, is part of the umbilical cord that is cut at birth.

The nurse administers a single dose of vitamin K intramuscularly to a newborn after birth to promote: A Conjugation of bilirubin B Blood clotting C Foreman ovale closure D Digestion of complex proteins

b. Vitamin K is needed for blood clotting and is a vital component of the blood-clotting cascade. The newborn's gut is sterile at birth and unable to manufacture vitamin K on its own without an outside source initially. Vitamin K has no impact on bilirubin conjugation, transport, or excretion. It is not involved in closing the foreman ovale; cutting the cord and changing gradient vascular pressures are responsible for this closure. Vitamin K has no influence over the digestive process of complex proteins.

When teaching a primipara who gave birth to a term male neonate 1 hour ago about the characteristics of her neonate, what characteristic should the nurse include? a) kidneys typically nonpalpable b) oozing at the cord insertion site c) testes probably undescended d) obligatory nose breather

obligatory nose breather Explanation: The nurse should instruct the mother that the neonate is an obligatory nose breather. Care must be taken to keep the infant's nares free from obstruction. The testes of a term male neonate should be in the scrotal sac. If they are undescended, further evaluation is required. Both kidneys should be palpable, each approximately the size of a walnut. Oozing at the cord insertion site is not normal and may indicate an infection.

During a home visit with a primipara who gave birth 7 days ago, the client tells the nurse that her lochia serosa has been profuse and foul-smelling and she has had chills. During palpation of the uterus, the client indicates that she is very sore. The nurse should further assess the client for: a) retained placental fragments. b) normal uterine involution. c) puerperal infection. d) uterine atony.

puerperal infection. Correct Explanation: The client is exhibiting signs and symptoms of puerperal infection, which include profuse foul-smelling lochia, chills, fever, and a uterus that is larger than expected for the first postpartum day. Infection may spread through the lymphatic system; antibiotic therapy is necessary. During normal uterine involution, the lochia becomes less profuse and should not be foul smelling. If the client had retained placental fragments, lochia rubra, not foul-smelling lochia serosa, would continue. Uterine atony refers to relaxation of the uterus and subsequent failure to contract properly. It may be a result of retained placental fragments.

Two weeks after a breastfeeding primiparous client is discharged, she calls the birthing center and says that she is afraid she is "losing my breast milk. The baby had been nursing every 4 hours, but now she is crying to be fed every 2 hours." The nurse interprets the neonate's behavior as most likely caused by which factor? a) the mother's fears about the baby's weight gain b) lack of adequate intake to meet maternal nutritional needs c) the neonate's temporary growth spurt, which requires more feedings d) preventing the neonate from sucking long enough with each feeding

the neonate's temporary growth spurt, which requires more feedings Correct Explanation: Neonates normally increase breastfeeding during periods of rapid growth (growth spurts). These can be expected at age 10 to 14 days, 5 to 6 weeks, 2.5 to 3 months, and 4.5 to 6 months. Each growth spurt is usually followed by a regular feeding pattern. Lack of adequate intake to meet maternal nutritional needs is not associated with the neonate's desire for more frequent breastfeeding sessions. However, an intake of adequate calories is necessary to produce quality breast milk. The mother's fears about weight gain and preventing the neonate from sucking long enough are not associated with the desire for more frequent breastfeeding sessions.