Peds & OB HESI
A nurse makes the following obsevations when admitting a full term, breastfeeding baby, into the neonatal nursery: 9lb 2 oz, 21 inches long, TPR: 96.6 F, 158,62, jittery, pink body with bluish hands and feet, crying. Which of the following actions is of highest probability? 1. Swaddle the baby to provide warmth 2. Assess the glucose level of the baby 3. Take the baby to the mother for feeding 4. Administer the neonatal medications
2. The glucose level should be assessed to determine whether or not this baby is hypoglycemic
A woman who states she smokes 2 pack of cigarettes each day is admitted to the labor and delivery suite in labor. The nurse should monitor this labor for which of the following? 1. Delayed placental seperation 2. Late decelerations 3. Shoulder dystocia 4. Precipitous fetal descent
2. The nurse should carefully monitor the labor for late decelerations
The nurse is caring for a client in labor and delivery with the following history: G2 P1000, 39 weeks gestation in transition phase, FH 135 with the early decelerations. The client states, I'm so scared. Please make sure the baby is OK!" Which of the following responses by the nurse is appropriate? 1. There is absolutely nothing to worry about 2. The fetal heart rate is within normal limits 3. How did your first baby die 4. Was your first baby preterm
2. This is the best reponse for the nurse to make. The nurse is providing the client with accurate, reassuring information without guaranteeing that there wil definitely be a positive outcome
The umbilical cord is being clamped by the obstetrician.. Which of the following physiological changes is taking place at this time? 1. The babys' blood bypasses its pulmonary system 2. The babys oxygen level begins to drop 3. Bacteria begin to invade the babys bowel 4. Bilirubin rises in the babys bloodstream
2. This is the correct answer. When the cord is clamped, the blood is no longer being oxygenated through the placenta. The babys oxygen levels, therefore, begin to drop
A nurse caring for a 7lb 8oz baby feeds him with 18.75 ounces of infant formual needed per day. If every infant formula contains 20 calories/ounce, which is the total amunt of calories a baby needs per day? A. 175 calories per day B. 375 calories per day C. 575 calories per day D. 275 calories per day
B. A 7lb 8oz baby would need 50 calories x 7lbs = 350 calories plus 25 calories = 375 calories per day. Most infant formulas contain 20 calories /ounce. Dividing 375 by 20 = 18.75 ounces of formula needed per day
The umbilical cord in a newborn should contain 3 vessels, 1 vein which carries oxygenated blood to the fetus and 2 arteries which carry unoxygenated blood back to the placenta. What do cord abnormalities usually indicate? A. Neurologic anomalies B. Renal anomalies C. Congenital vertebral anomaly D. Chromosome anomaly
B. Cord abnormalities usually indicate cardiovascular or renal anomalies.
The early decelerations in fetal heart rate monitoring are the transient decrease in heart rate which coincides with the onset of the uterine contraction. Between what cm do the early decelerations caused by head compression and fetal descent usually occur in the 2nd stage? A. 2 and 6 cm B. 4 and 7 cm C. 3 and 8 cm D. 7 and 10 cm
B. Early decelerations, caused by head compression and fetal descent, usually occur between 4 and 7 cm in the 2nd stage. Check for labor progress if early decelerations are noted
In the first 12 hours after delivery, the 22 year old client shows signs of hemorrhage. What is one of the common reasons for uterine atony and/or hemorrhage in the first 24 hours after delivery? A. Empty bladder B. Full bladder C. Hypoglycemia D. Low blood pressure
B. FULL BLADDER is one of the most common reasons for uterine atony and/or hemorrhage in the first 24 hours after delivery
When examining a client after delivery, the nurse finds the fundus soft, boggy, and displaced above and to the right of the umbilicus. What action should the nurse take first in this case? A. Have the client empy her bladder B. Perform fundal massage C. Administer narcotic analgesics D. Administer codeine and meperidine
B. First the nurse should perform fundal massage; then have the client empt her bladder
The menstrual phase varies in length for most women. How many days usually are from ovulation to the beginning of the next menstrual cycle? A. 12 days B. 14 days C. 16 days D. 18 days
B. From ovulation to the beginning of the next menstrual cycle is usually exactly 14 days. In other words, ovulation occurs 14 days before the next menstrual period
Approximately 20 prior to nerve block anesthesia, the client should be hydrated with 500-1000 cc of lactated ringers IV. What should the nurse do if hypotension offurs? A. Administer Stadol B. Administer O2 at 10 L/min by face mask C. Administer CO2 at 10 L/min by face mask D. Administer Nubain
B. If hypotension occurs- turn client to her side, administer O2 at 10 L/min by face mask, and increase IV rate
The first day of a womans last normal menstrual period was October 17. By using Nagele's rule, what is the EDB? A. July 10 B. July 24 C. June 10 D. June 24
B. If the first day of a womans last normal menstrual period was October 17, her EDB using Nagele's rule is July 24. Count back 3 months and add 7 days ( Always give February 28 days)
Regardless of who performs the physical assessment , the nurse must know normal versus abnormal variations of the newborn. What is the difference between caput succedaneum and cephalhematoma? A. cephalhematoma crosses suture lines and is usually present at birth B. Cephalhematoma does NOT cross suture lines and manifests a few hours after birth C. Cephalhematoma: edema under scalp D. Caput succedaneum : blood under teh periosteum
B. It is difficult to differentiate between caput succedaneum (edema under the scalp) and cephalhematoma (blood under the peristeum). The caput crosses suture lines and is usually present at birth, while cephalhematoma does not cross suture lines and manifests a few hours after birth.
A nurse consults a pregnant mother and detects late decelerations which indicate uteroplacental insufficiency. What conditions are late decelerations associated with? A. Down Syndrome, AIDS, abruptio placentae B. Postmaturity, preeclampsia, diabetes mellitus, cardiac disease, and abruptio placentae C. Autism, renal insufficiency and cardiac disease D. Kidney failure, cardiac disease, Digialis toxicity
B. Late decelerations indicate unteroplacental insufficiency and are associated with conditions such as postmaturity, preeclampsia, diabetes mellitus, cardiac disease, and abruptio placentae
Physiologic jaundice is the normal inability of the immature liver to keep up with normal RBC destruction. When does jaundice occur in newborns? A. 5-6 days of life B . 2-3 days of life C. 7-8 days of life D. 9-10 days of life
B. Physiologic jaundice (normal inability of the immature liver to keep up with normal RBC destruction) occurs at 2-3 days of life
Postpartum blues are usually normal, especially 5 - 7 days after deliverry. In what case is RhoGAM given to a mother after delivery? A. If mother is Rh positive B. If mother is Rh negative C. If the mother has a positive Coombs D. If the mother has a Rh negative fetus
B. Remember RhoGRAM is given to a Rh negative mother who delivers a Rh positive fetus and has a negative direct Coombs. If the mother has a positive Coombs, there is no need to give RhoGRAM since the mother is already sensitized
if the structures of the foramen ovale, ductus arteriosus and ductus venosus don't close postnatally, cardiac and pulmonary compromise will develop. What should be suctioned by the nurse firstly? A. Nose B. Mouth C. Lungs D. Kidney
B. Suctioning the mouth first and then the nose. Stimulating the nares can initiate inspiration which could cause aspiration of mucus in oral pharynx
Nerve lock anesthesia (spinal or epidural) during labor bloks motor as well as nerve fibers. What does result from vasodilation below the level of the block? A> Maternal hypertension B. Maternal hypotension C. Low BP D. High BP
B. Vasodialation below the level of the block results in blood pooling in the lower extremities and maternal hypotension.
In a 24 year old pregnant woman, the amniocentesis is done in early pregnancy. How should the bladder be to help support the uterus and to help push the uterus up in the abdomen for easy access? A. Empty B. Full C. 1/4 empty D. 1/2 full
B. When an amniocentesis is done in early pregnancy, the bladder must be full to help support the urerus and to help push the uterus up in the abdomen for easy access.
Fetal well being is determined by assessing fundal height, fetal heart tones/rate, fetal movement and uterine activity (contractions). What do changes in fetal heart rate indicate? A. Leukorrhea B. Compromised blood flow to the fetus C. Fluid discharge from vagina D. Change in fetal movement
B. Changes in fetal heart rate are the first and most important indicator of compromised blood flow to the fetus, and these changes require action
Diabetis mellitus (DM) in children was typically diagnosed as insulin dependent diabetes until recently. What diabetes type has been discovered to occur more often in Native Americans, African Americans, and Hispanic children and adolescents? A. Type 1 B. Type 2 C. Type 3 D. Type 4
B. DM in children was typicall diagnosed as insulin dependent until recently. A marked increase in Type 2 DM has occurred recently in the US.
An infant with hypothyroidism is often described as a "good, quite baby" by the parents. What early disease detection is essential in preventing mental retardation in infants? A. Hyperthyroidism B. Phenylketonuria C. Diabetes Mellitus D. Ketoacidosis
B. Early detection of hypothyroidism and phenylketonuria is essential in preventing mental retardation in infants. Knowledge of normal groth and development is important, sin a lack of attaintment can be used to detect the existence of these metabolic/endocrine disorders and attainment can be used for evaluating the treatments effecct
Skin traction for fracture reduction should not be removed unless prescribed by healthcare provider. What fractures have serious consequences interms of growth of the affected limb? A. Greenstick fracture B. Plate fracture C. Torus fracture D. Spiral fracture
B. Fractures involving the epiphyseal plate ( growth plate) can have serious consequences in terms of growth of the affected limb
The screening for neural tube defects is highly associated woth both false positives and false negatives. Through what does the screening for neural tube defects in some states? A. Spinal Bifida B. Maternal serum AFP levels C. MSAFP D. distribution curves of maternal serum APP
B. In some states, the screening for neural tube defects through either maternal seru AFP levels or amniotic fluid AFP leves is mandated by state law. This screening test is highly associated with both false positives and false negatives
As pregnancy advances, the uterus presses on the abdominal vessels ( vena cava and aorta). What position is best for increasing perfucion according to the latest research? A. Left side lying position B. Knee chest position C. Side lying position D. Right side lying position
B. Recent research indicated that the knee chest position is best for increasing perfusion and that the sid lying position (either left or right side lying) is the second most disirable position to increase perfusion. Prior to this research, the left side lying position was usually encouraged
Physiologic jaundice which occurs 2-3 days after birth due to the liver's inability to keep up with RBC destruction. Who is the culprit in this case? A. Conjugated bilirubin B. Unconjugated bilirubin C. Unconjugated penile D. Conjugated penile
B. Typically, NCLEX-RN questions ask about normal problem physiologic jaundice which occurs 2-3 days afte birth due to the livers inability to keep up with RBC destruction and bind bilirubin. Remember, unconjugated bilirubin is the culprit.
A 22 year old primigravida at 12 weeks gestation has a high Hgb of 9.6 g/dl and a Hct of 31% and she has gained 3 pounds during the first trimester, even if the gain of 3.5 to 5 pounds during the first trimester is recommended. Taking into consideration that the client is anemic, what supplements should be recommended to her? A. Potassium B. Magnesium C. Iron D. Calcium
C. For the anemic pregnant client, supplemental iron and a diet high in iron is needed
At approximately 28 - 32 weeks gestation, the maximum plasma volume increase of 25 - 40% occurs, resulting in normal hemodilution of pregnancy and Hct values of 32 - 42%. What does Hct in reality represent, even if its values may look "good"? A. Pregnancy induced hyperglycemia B. Pregnancy induced hypoglycemia C. Pregnancy induced hypertension D. pregnancy induced hypotension
C. High Hct values may look "good" but in reality represent pregnancy induced hypertension and depleted vascular space
Oxytocin should be administered after the placenta is delivered because the drug will cause the uterus to contract. What can happen if the drug is administered before the placenta is delivered? A. Will predispose the client to nausea B. Will predispose the client to amnesia C. Will predispose the client to hemorrhage D. Will predispose the client to hypocalcemia
C. If the oxytocic durg is administered before the placenta is delivered, it may result in a retained placenta, which predisposed the client to hemorrhage and infection
If a child is on oral iron medication, the family should be taught by the nurse how it should be administered. Out of the following options, what oral iron administration advise is inappropriate? A. Oral iron should be given on empty stomach B. Oral iron should be given with citrus juices C. Oral iron shoule be given with dairy products D. A dropper or straw should be used to avoid discoloring teeth
C. Iron can be fatal in severe overdose and as a result, it should be kept away from children. Also, do not give with dairy products.
Skin traction for fracture reduction should not be removed unless prescribed by healthcare provider. What do the pin sites usually cause in an infant client? A. Hypoglycemia B. Hypocalcemia C. Infection D. Low vitamin K concentration
C. Pin sites can be sources of infection. The nurse should monitor signs of infection and cleanse and dress sites as prescribed.
There has been an increase in the number of children diagnosed with Type 2 diabetes with the increasing rate of obesity in children thought to be a contributing factor. What other factors are thought to be contributing in the increase of Type 2 cases? A. Hypotension B. Hypokalemia C. Lack of physical activity D. Hyperkalemia
C. There has been an increase in the number of children diagnosed with Type 2 diabetes. The increasing rate of obesity is children is thought to be a contributing factor. Other contributing factors include lack of physical activity, and a family history of Type 2 diabetes.
When it comes to X-linked recessive linked recessive trait, the trait is carried on the x chromosome, therefore, usually affects male offspring. What is the chance for a pregnant woman carrier her offspring to get the disease? A. Male child: 75% of having the disease B. Female child: 50% of having the disease C. Male child: 50% of having the disease D. Female child: 25% of having disease
C. With each pregnancy of a woman who is a carrier there is a 25% chance of having a child with hemophilia. If the child is male, he has a 50% chance of having hemophilia. If the child is female, she has a 50% chance of being a carrier.
A woman who is 6 weeks pregnant has the following maternal history: a 2 yr old healthey daughter, a miscarriage at 10 weeks, 3 years ago and an elective abortion at 6 weeks, 5 years ago. Describe gravidity and parity in this case. A. gravida 1, para 4 B. gravida 2, para 4 C. gravida 4, para 1 D. gravida 4, para 2
C. With this pregnancy, the woman is a gravida 4, para 1 ( only 1 delivery after 20 weeks geatation)
Vasodialation below the nerve blok results in pooling in the lower extremities and maternal hypotension. Which is the quanity of IV lactated ringers the client should be hydrated with 20 minutes prior to operation? A. 100-200 cc B. 300-500 cc C. 500-1000 cc D. 600-800 cc
C. Approximately 20 minutes prior to nerve block anesthesia, the client should be hydrated with 500-1000 cc of lactated ringers IV
Changes in fetal heart rate are the first and most important indicator of compromised blood flow to the fetus, and these changes require action! What is the normal FHR in a pregnant woman? A. 150 - 180 bpm B. 160 - 190 bpm C. 110 - 160 bpm D. 120 - 150 bpm
C. Changes in fetal heart rate are the first and most important indicator of compromised blood flow to the fetus, and these changes require action! Remember, the normal FHR is 110 to 160 bpm.
Sperm lives approximately 3 days and eggs live abut 24 hours. Which is the time interval a coulple should avoid unprotected intecourse after the ovulation? A. 24 hours B. 48 hours C. 72 hours D. 128 hours
C. From ovulation to the begging of the next menstrual cycle is usually exactly 14 days. In other words, ovulation occurs 14 days before the next menstrual period
Supplemental iron is not givento clients with sickle cell anemia because the anemia is not caused by iron deficiency. What aspect is very important in treatment of sickle cell disease because it promotes hemodilution and circulation of red cells through the blood vessels? A. HgbAS B. HGBS C. Hydration D. Hydrotherapy
C. Hydration is very important in treatment of sickle cell disease because it promotes hemodilution and curculation of red cells through blood vessels
A pregnant client has a temperature over 100.4 F, Dysuria and fluid discharge from vagina. What could these signs most probable indicate? A. Preeclampsia B. Eclampsia C. Infection D. Change in fetal movement
C. Temperature ofve 100.4 F, Dysuria, and fluid discharge from vagina are signs of infection.
At the examination of a expecting woman, the deceleration patterns are associated with decreased or absent variability and tachycardia. What should be done immediately in this case? A. Position the mother in High Fowlers position B. Position the mother in knee chest position C. Immediate intervention and fetal assessment D. Spontaneous abortion
C. When deceleration patterns (late or variable) are associated with decreased or absent variability and tachycardia, the situation is OMINOUS (potentially disastrous) and requires immediate intervention and fetal assessment
In autosomal recessive disease, both parents must be hererozygous, or carriers of the recessive trait, for the disease to be expressed in their offspring. If both parents are heterozygous, what is the chance the baby to have the disease as well? A. 1:2 B. 1:3 C. 1:4 D. 1:1
C. With each pregnancy, there is a 1:4 chance of the infant having the disease.
The umbilical cord should always be checked at birth. What should the umbilical card contain in a newborn? A. 3 vessels, 2 veins which carry oxygenated blood to the fetus and 1 artery whic carries unoxygenated blood back to placenta B. 4 vessels, 2 veins which carry oxygenated blood to the fetus and 2 arteries which carries unoxygenated blood back to placenta C. 3 vessels, 1 veins which carries oxygenated blood to the fetus and 2 arteries which carries unoxygenated blood back to placenta D. 3 vessels, 1 artery which carries oxygenated blood to the fetus and 2 veins which carries unoxygenated blood back to placenta
C. It should contain 3 vessels, 1 vein which carries oxygenated blood to the fetus nad 2 arteries whic carry unoxygenated blood back to the placenta. This is opposite of normal circulation.
Early detection of rheumatoid arthritis can decrease the amount of bone and joint destruction and often the disease will go into remission. What activity recommendations should the nurse provide a client with rheumatoid arthritis? A. Exercise of painful, swollen joints to strengthen them B. Exercise joint to the point of pain so that the pain lessens C. Make Jerky movements during the exercise so that the pain lessens D. Perform exercises slowly and smoothly
D. A nurse should advise the client to perform exercises slowly and smoothly so that no extra pain occurs
Pitocin should be given with caution to clients with hypertension. What drug shouldn't be given to clients with hypertension due to its vasoconstrictive action? A. Analgesics B. Meperidine C. Codeine D. Methergine
D. Methergine is NOT given to clients with hypertension due to its vasoconstrictive action. Pitocinis given with caution to those with hypertension
A nurse must use knowledge base to differentiate between abruptio placentae from plaventa previa. What assessments should be done in case of a patient suspected of abruptio placentae or placenta previa. A. abdominal or vaginal manipulation B. Leopold's maneuvers C. internal monitoring D. Monitor for bleeding at IV sites and gums due to increased risk of DIC
D. Patients with abruptio placentae or placventa previa should have No abdominal or vaginal manipulation. No Leopold's maneuvers. No vaginal exams. No rectal exams, enemas, or suppositories. No internal monitoring
A nurse should teach newbie parents to take both axillary and rectal temperature of the child. How long should the thermometer be held in place if it is done recatally? A. 2 minutes B. 3 minutes C. 4 minutes D. 5 minutes
D. Rectal temperature: the thermometer should be used with blunt end. Insert thermometer 1/4 to 1/2 inch and hold in place for 5 minutes. Hold feet and legs firmly
Monitoring for fetal position is important because the mother cannot tell you she has back pain, which is the cardinal sign of persistant posterior fetal position. Why do the regional blocks, especially epidural and caudal, often result in assisted delivery? A. inability to push effectively in 3rd stage B. inability to push effectively in 4th stage C. inability to push effectively in 1st stage D. inability to push effectively in 2nd stage
D. Regional blocks, especially epidural and caudal, often result in assisted delivery due to inability to push effectively in the 2nd stage.
Fractures in older children are common as they fall during play and are involved in motor vehicle accidents. What fractures in children are related to child abuse? A. Greenstick Fracture B. Growth plate Fracture C. Torus Fracture D. Spiral fracture
D. Spiral fractures (caused by twisting) anf fractures in infants may be related to child abuse
A patient who is 32 weeks gestation has the following symptoms: dark, red vaginal bleeding, 100 bpm FHR, rigid abdomen and severe pain. What is the difference between abruptio placentae and placenta previa? A. Aruptio placentae: painless bright red bleeding occurring in the third trimester B. Abruptio placentae: occurs in the second trimester C. Placenta previa: occurs in the second trimester D. Placenta previa: painless bright red bleeding occurring in the third trimester
D. The nurse must use knowledge base to diffferentiate betewwn abruptia placentae from placenta previa.
A baby, admitted to the nursery, was diagnosed with galactosemia from an anmiocentesis. Which of the following actions must the nurse take? 1. Feed the baby a specialty formula 2. Monitor the baby for central cyanosis 3. Do hemoccult testing on every stool 4. Monitor the baby for signs of abdominal pain
1. Galactosemia is one of the few diseases that is a contraindication for the intake of breast milk or any milk based formula
A client who is 18 weeks gestation has been diagnosed with hydatiform mole (gestational trophoblastic disease). In addition to vaginal loss, which of the following signs/symtoms would the nurse expect to see? 1. Hyperemesis and hypertension 2. Diarrhea nd hyperthermia 3. Polycythemia 4. Polydipsia
1. Hyperemesis and hypertension are often seen in clients with hydatiform mole
Four babies are in the newborn nursery. The nurse pages the neonatologist to see the baby who exhibits which of the following? 1. Intracostal retraction 2. Erythema toxicum 3. Pseudostrabismus 4. Vernix caseosa
1. Intracostal retractions are symptomatic of respiratory distress syndrome
Which of the following laboratory findings would the nurse expect to see in a baby diagnosed with erythroblastosis fetalis? 1. Hemacrit 24% 2. Leukocyte count 45,000 cells/mm 3. Sodium 125 mEq/L 4. Potassium 5.5 mEq/L
1. The baby with erythroblastosis fetalis would exhibit signs of severe anemia, which a hematocrit of 24% reflects
A nurse who has just performed a vaginal examination notes that the fetus is in the LOP position. Which of the following clinical assessments would the nurse expect to note at this time? 1. Complaints of severe back pain 2. Rapid descent and effacement 3. Irregular and hypotonic contractions 4. Rectal pressure with blood show
1. The nurse would expect the client to complain of severe back pain.
A client has just recieved syntheric prostaglandins for the induction of labor. The nurse plans to monitor the client for which of the following side effects? 1. Nausea and uterine tetany 2. Hypertension and vaginal bleeding 3. Urinary retention and severe headache 4. Bradycardia and hypothermia
1. Two side effects of prostaglandin administration are nausea and uterine tetany
A baby exhibits weak rooting and sudking reflexes. Which of the following nursing diagnoses would be appropriate? 1. Risk for deficient fluid volume 2. Activity intolerance 3. Risk for aspiration 4. Feeding self care deficit
1. When a boby roots and sucks poorly, the baby is unable to trasnsfer milk effectively. Because milk intake is the baby's source of fluid, the baby is high risk for fluid volume deficit
A nurse working with a 24 hour old neonate is the well baby nursery has made the following nursing diagnosis: Risk for altered growth. Which of the following assessments would warrant this diagnosis? 1. The baby has lost 8% of weight since birth 2. The baby has not urinated since birth 3. The baby weighed 3,000 grams at birth 4. The baby exhibited signs of torticollis
1. A baby who has lost 8% of his or her weight after only 24 hours of life is very high risk for altered growth
The macrosomic baby in the nursery is suspected of having a fractured clavicle from a traumatic delivery. Which of the following signs/symptoms would the nurse expect to see? ( Select all the apply) 1. Pain with movement 2. Hard lump at the fracture site 3. Malpositioning of the arm 4. Asymmetrical Moro reflex 5. Marked localized ecchymosis
1,2,3,4 1.The baby will complain of pain at the site. 2.If not in the immediate period after the injury, within a few days there will be a palpable lump on the bone at the site of the break 3.Because of the break, the baby is likely to position the arm in an aytpical posture 4.Because of the injury to the bone, the baby is unable to respond with symmetrical arm movement
A woman is being interviewed by a triage nurse at a medical doctor's office. Which of the following signs/symptoms by the client would warrant the nurse to suggest that a pregnancy test be done? (Select all that apply) 1. Amenorrhea 2. Fever 3. Fatigue 4. Nausea 5. Dysuria
1,3,4 1.Pregnancy is the most common cause of amenorrhea 3. A common complaint of women in early pregnancy is fatigue 4. A common complaint of women is early pregnancy is nausea
The triage nurse in an obstetric clinic received the following forur messages during the lunch hour. Which of the woman should the nurse telephone first? 1. " My section incision from last week is leaking a whitish yellow discharge and I have a fever. What should I do?" 2. " I am 39 weeks pregnant with my first baby. I am having contractions about every 10 minutes." 3. " My boyfriend and I had intercourse this morning and our condom broke. What should we do?" 4. " I started my period yesterday. I need some medicine for these terrible menstrual cramps."
1. The nurse should call the postaperative cesarean client back first. It sounds, from her description, that she has a wound infection
A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O negative 2. Type A negative 3. Type B positive 4. Type AB positive
1. ABO incompatibility can arise when the mother is type O and the baby is either type A or B
During cardiopulmonary resuscitation, which of the following actions should be performed? 1. Provide assested ventilation at 40 to 60 breaths per minute 2. Begin chest compressions when heart rate is 0 to 20 bpm 3. Compress the chest using the three finger technique 4 Administer compressions and breaths in a 5:1 ratio
1. Assisted ventilations should be administered at a rate of 40 to 60 per minute
A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform? 1. Cover the baby's eyes with eye pads 2. Turn the lights on for ten minutes every hour 3. Clothe the baby in a shirt and diaper only 4. Tightly swaddle the baby in a baby blanket
1. When phototherapy is administered, the baby's eyes must be protected from the light source
A baby, born at 3,199 grams, now weighs 2,746 grams. The baby is being monitored for dehydration because of the following percent weight loss? (calculate to the nearest hundreth) ____________________________%
14.16% The formula for percentage of weight loss is : Original weight minus current weight divided by original weight. The value is then multiplies by 100 to convert the number to percentage: 3199-2746=453 453/3199=0.1416*100=14.16%
A nurse has just recieved report on 4 neonates in the newborn nursery. Which of the babies should the nurse assess first? 1. Neonate whose mother is HIV positive 2. Neonates whose mother is group B streptococcus positive 3. Neonates whose mother's labor was 12 hours long 4. Neonates whose mother gained 45 pounds during her pregnancy
2. This is the correct response. Babies who are born to mothers who are GBS positive are at high risk for sepsis. The incidence of sepsis is reduced, however, when the mother receives IV antibiotics during labor
A woman is admitted to the labor and delivery unit with active TB. She has not been under a physician's care and is not on medication. Which of the following actions should the nursery nurse perform when the neonate is delivered? 1. Isolate the baby from the other babies is a special care nursery 2. Keep the baby in the regular care nursery but separated from the mother 3. Isolate the baby with the mother in the mother's room 4. Obtain an order from the doctor for antituberculosis medications for the baby
2. This response is accurate. The baby can be cared for in the well baby nursery, but must be kept separated from its mother
Four babies in the well baby nursery were born with congenital defects. Which of the babies' complications developed as a result of the delivery method? 1. Clubfoot 2. Brachial palsy 3. Gastroschisis 4. Hydrocele
2. Brachial palsy can result from either a traumatic vertex or breech delivery
The nurse is caring for an infant with congenital cardiac defect is monitoring the child for which of the following early signs of congestive heart failure? (Select all that apply) 1. Palpitation 2. Tachypnea 3. Tachcardia 4. Diaphoresis 5. Irritability
2,3,4 2. No matter whether a baby or an adult were developing CHF, the patient would be tachpneic 3. No matter whether a baby or an adult were developing CHF, the patient would be tachycardic 4. No matter whether a baby or an adult were developing CHF, the patient would be diaphoretic
A baby is suspected of having esophageal atresia. The nurse would expect to see which of the following signs/symptoms? ( Select all that apply) 1. Frequent vomiting 2. Excessive mucus 3. Ruddy complexion 4. Abdominal distention 5. Pigeon chest
2,4 2. Babies with esophageal atresia would be expected to expel large amounts of mucus from the mouth 4. Abdominal distention can be seen with esophageal atresia as air enters the stomach via the trachea
A baby is born with erythroblastosis fetalis. Which of the following signs/symptoms would the nurse expect to see? 1. Ruddy complexion 2. Anasarca 3. Alopecia 4. Erythema toxicum
2. Babies born with erythroblastosis fetalis often ore in severe congestive heart failure and, therfore, exhibit anasarca
A full term infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. The nurse should monitor this baby carefully for which of the following? 1. Jaundice 2. Jitters 3. Erythema toxicum 4. Subconcunctival hemorrhages
2. Babies who are hypoglycemic will often develop jitters
An 18 hour old baby is placed under the bili lights with an elevated bilirubin level. Which of the following is an expected nursing action in these circumstances? 1. Give the baby oral rehydration therapy after all feedings 2. Rotate the baby from side to back to side to front every two hours 3. Apply restraints to keep the baby under the light source 4. Administer intravenous fluids via pump per doctor orders
2. Rotating the baby's position maximizes the therapeutic response because the more skin surface that is exposed to the light source, the better the results are
Which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 96.5 F? 1. Blood glucose of 50 mg/dL 2. Acrocyanosis 3. Tachypnea 4. Oxygen saturation of 96%
3. Babies who have cold stress syndrome will develop respiratory distress. One symptom of the distress is tachypnea
A client with type 1 diabetes mellitus is 6 weeks pregnant. Her fasting glucose and hemoglobin A1c are noted to be 168 mg/dL and 12%, respectively. Which of the following nursing diagnoses is appropriate for the nurse to make at this time? 1. Altered matenal skin integrity 2. Deficient maternal fluid volume 3. Risk for fetal injury 4. Fetal urinary retention
3. A nursing diagnosis of risk for fetal injury is an appropriate nursing diagnosis.
A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure? 1. Cover the foot with an iced wrap for one minute prior to the procedure 2. Avoid puncturing the lateral heel to prevent damageing sensitive structures 3. Blot the site with a dry gauze after rubbing it with an alcohol swab 4. Firmly grasp the calf of the baby during the procedure to prevent injury
3. Alcohol can irritate the punctured skin and cause hemolysis
A baby has been admitted to the neonatal nursery whose mother is hepatitis B surface antigen positive. Which of the following actions by the nurse should be taken at this time? 1 Monitor the baby for signs of hepatitis B 2. Place the baby on contact isolation 3. Obtain an order for the hepatitis B vaccine and the immune globulin 4. Advise the mother that breast feeding is absolutely contraindicated
3. Babies exposed to hepatitis B in utero should recieve the first dose of hepatitis B vaccine as well as hepatitis B immune globulin (HBIG) within 12 hours of delivery to reduce transmission of the virus
A 6 month old child developed kernicterus immediatedly after birth. Which of the following test should be done to determine whether or not this child has developed andy sequelae to the illness? 1. Blood urea nitrogen and serum creatinine 2. Alkaline phosphatase and bilirubin 3. Hearing testing and vision assessment 4. Peak expiratory flow and blood gass assessments
3. Because the central nervous system may have been damaged by the high bilirubin levels, testing of the senses as well as motor and cognitive assessment are aappropriate
A 1 day old neonate, 32 weeks gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9 F. Which of the following could explain this assessment finding? 1. This is a normal temperature for a preterm neonate 2. Axillary temperatures are not valid for preterm babies 3. The supply of brown adipose tissue is incomplete 4. Conduction heat loss is pronounced in the baby
3. Preterm babies are born with an insufficient supply of brown adipose tissue that is needed for thermogenesis, or heat generation
A neonate is in the warming crib for poor thermoregulation. Which of the following sites is appropriate for the placement of the skin thermal sensor? 1. Xiphoid process 2. Forehead 3. Abdominal Wall 4. Great toe
3. The abdominal wall is the appropriate placement for the skin thermal sensor
Which of the following neonates is at highest risk for cold stress syndrome? 1. Infant of diabetic mother 2. Infant with Rh incompatibility 3. Postdates neonate 4. Down syndrome neonate
3. Postdate babies are at high risk for cold stress syndrome because while still in utero they often metabolize the brown adipose tissue for nourishment when the placental function deteriorates
A fetus is in the LOA position in utero. Which of the following findings would the nurse observe when doing Leopold's maneuvers? 1. Hard, round object in the fundal region 2. Flat object above the symphysis pubis 3. Soft, round object on the left side of the uterus 4. Small objects on the right side of the uterus
4. A nurse could conclude that a fetus is in the LOA when feeling small objects- the fetal arms and legs- on the right side of the uterus
A baby has been admitted to the neonatal intensive care unit with a diagnosis of post maturity. The nurse expects to find which of the following during the initial newborn assessment? 1. Abundant lanugo 2. Flat breast tissue 3. Prominent clitoris 4. Wrinkled skin
4. The post term baby does have dry, wrinkled , and often dequamating skin. The baby's dehydration is secondary to a placenta that progressively deteriorates after 40 weeks gestation.
A woman is seeking counseling regarding tubal ligation. Which of the following should the nurse include in her discussion? 1. The woman wil no longer mensrtuate 2. The surgery shuld be done when the woman is ovulating 3. The surgery is easily reversible 4. The woman will be under anesthesia during the procedure
4. This response is correct. BTL surgery, usually performed laparoscopically, is done under general anesthesia
The nurse is caring for a client, 37 weeks gestaton, who was just told that she is group B strep positive. The client states, "How could that happen? I only have sex with my husband. Will my baby be OK?" Based on this information, which of the following should the nurse communicate to the client? 1. The client's partner must have acquired the bacteria during a sexual encounter 2. The bacteria do not injure babies, but they could cause the client to have a bad sore throat 3. The client is high risk for developing pelvic inflammatory disease from the bacteria 4. Antibiotics will be administered during labor to prevent vertical transmission of the bacteria
4. This statement is accurate. Antibiotics will be administered to the mother during labor and delivery to prevent verticle transmission.
A newborn admitted to the nursery has a positive direct Coombs' test. Which of the following is an appropriate action by the nurse? 1. Monitor the baby for jitters 2. Assess the blood glucose level 3. Assess the rectal temperature 4. Monitor the baby for jaundice
4. When the neonatal blood stream contains antibodies, hemolysis of the red blood cells occurs and jaundice develops
A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate? 1. Place pacifier in the baby's mouth 2. Check the babies diaper 3. Have the mother feed the baby 4. Assess the respiratory rate
4. Grunting is often accompanied by tachypnea, another sign of respiratory distress
Corticosteroids are used shor term in low doses suring exacerbations. What side effect do corticosteroids have on long term? A. Adverse effects on growth B. Adverse effects on bone structure C. Hypoglycemia D. Hypocalcemia
A. Corticosteroids are used short term in low doses during exacerbations. Long term use is avoided due to side effects and their adverse effect on growth
Cord abnormalities usually indicate cardivascular or renal anomalies. What happens if fetal structures of foramen ovale, ductus arteriosus and ductus venous do no close postnatal? A. Cardia pulmonary compromise B. Renal compromise C. Gastro intestinal compromise D. Neurological compromise
A. Postnatally, the fetal structures of foramen ovale, ductus arteriosus and ductus venosus shoul close. If they do not, cardiac and pulmonary compromise will develop
A patient who is 32 weeks gestation is experiencing dark red vaginal bleeding and the nurse determines the FHR to be 100 bpm and her abdomen is rigid and board like. What action should the nurse take first? A. Administer O2 per face mask B. Abdominal manipulation C. vaginal manipulation D. Abdominal exam
A. The nurse should immediately notify the healthcare provider and no abdominal or vaginal manipulation or exams should be done. Administer O2 per face mask and monitor for bleeding at IV sites and gums due to the increased risk of DIC
When examining a client after delivery, the nurse finds the fundus soft, boggy, and displaced above and to the right of the umbilicus. After perfoming fundal massage and having the client empy her bladder when should the nurse recheck fundus? A. q 15 minutes *4 (1 hour) B. q 45 minutes *2 (1.5 hour) C. q 30 minutes *4 (2 hours) D. q 30 minutes *2 (1 hour)
A. The nurse should recheck fundus q 15 minutes *4 (1 hour); q 30 minutes *2 hours
A 28 year old porgnant woman has the following symptoms: visual disturbance, persistant vomiting, swelling of face, fingers or sacrum and severe continuous headache. What do these symptoms most probably indicate? A. Preeclampsia/eclampsia B. Dysuria C. Chills D. Fluid discharge from the vagina
A. Visual distubance, persistant vomiting, swelling of face, fingers or sacrum and severe continuous headache in pregnant woman possible indications of preeclampsia/ eclampsia
A client with prior traumatic delivery and history fo D&C may experience miscarriage or preterm. What is the most common cause of miscarriages? A. Incompetent cervix B. Incompetent pelvis C. Incompetent uterus D. Incompetent vagina
A. Clients with prior traumatic delivery, history of D&C, multiple abortions, or daughters of DES motheres may experience miscarriage or preterm labor related to incompetent cervix. The cervix may be surgically repaired prior to pregnancy, or during gestation
A patient suspected of abruptio placentae or placenta previa should be monitorized for bleeding at IV sites and gums due to increased risk of DIC. What isn't DIC related to? A. cervical carcinoma B. fetal demise C. infection/sepsis D. pregnancy-induced hypertension
A. DIC is related to fetal demise, infection/sepis, pregnancy-induced hypertension ( Preeclampsia) and abruptio placentae. Cervical carcinoma is related to podophyllin
A 7lb 8oz baby would need 50 calories x7lbs=350 calories plus 25 calories= 375 calories per day. Taking into consideration that most infant formulas contain 20 calories/ounce, how many ounces of formula are needed per day? A. 18.75 B. 14.75 C. 13.75 D. 16.75
A. Dividing 375 by 20 =18.75 ounces of formula needed per day for a 7lb 8oz baby
Physiologic jaundice (normal inability of the immature liver to keep up with normal RBC destruction) occurs 2-3 days of life.When does jaundice become pathologic? A. When it occurs before 24 hurs or persists beyond 7 days B. When it occurs before 14 hours or persists beyond 8 day C. When it occurs before 12 hours or persists beyond 3 days D. When it occurs before 10 hours or persists beyond 2 days
A. Physiologic jaundice (normal inability of the immature live to keep up with normal RBC destruction) occurs at 2-3 days of life. It occurs before 24 hours or persists beyond 7 days, it becomes pathologic
In a 24 year old pregnant woman, the amniocenteses is done in late pregnancy. How should the bladder be to avoid puncturing the bladder? A. Empty B. Full C. 1/4 empty D. 1/2 full
A. When an amniocentesis is done in late pregnancy, the bladder must be empty to avoid puncturing the bladder
A nurse should teach the pregnant clients to immediately report any of the following danger signs because early intervention can optimize maternal and fetal outcome. Which are the signs of infection in a pregnant woman? A. FHR 110 - 160 bpm B. Chills C. Persistant vomition D. Visual disturbances
B. Signs of infection in a pregnant woman are Chills, Dysuria, pain in abdomen, fluid discharge from vagina, and increased FHR
A woman of childbearing age present at an emergency room with unilateral and bilateral abdominal pain. What should the nurse correctly suspect in this case? A. Appendicitis B. Ectopic pregnancy C. Entopic pregnancy D. Etiopic pregnancy
B. Suspect ectopic pregnancy in any woman of childbearing age who presents at an emergency room, clinic, or office with unilateral or bilateral abdominal pain. Most are misdiagnosed with appendicitis.
A nurse consults a mother and detects cord prolaspe. How should the examiner position the pregnant woman to relieve pressure on the cord? A. Side lying position B. Right side lying position C. High Fowlers position D. Knee chest position
D. If cord prolaspe is detected, the examiner should position the mother to relieve pressure on the cord, Knee chest position, or push the presenting part off the cord until Immediate cesarean delivery can be accomplished
Most providers prescribe prenatal vitamins to ensure that the client receives and adequate intake of vitamins. However, only the healthcare provider can prescribe prenatal vitamins. Whis is the quanity of milk a pregnant woman should drink per day for ensuring that the daily calcium needs are met? A. 1/2 quart B. 1/3 quart C. 1/4 quart D. 1 quart
D. It is recommended that pregnant woman drink one quart of milk a day. This will ensure that the daily calcium needs are met and help to alleviate the occurrence of leg cramps
Internal rotation is harder to achieve when the pelvic floor is relaxed by anesthesia resulting in persistent occiput posterior of fetus. What regional blocks often result in assissted delivery due to the inability to push effectively in the 2nd stage? A. Epidermis B. Anal Spincter C. Rectal mucosa D. Caudal
D. Regional blocks, especially epidural and caudal, often result in assissted delivery due to the inability to push effectively in 2nd stage
A patient is placed on bed rest at home for mild preeclampsia at 38 weeks gestation. Which of the following must the nurse teach the patient regarding her condition? 1. Eat a sodium restricted diet 2. Check her temperature 4 times daily 3. Report swollen hand and face 4. Limit fluids to 1 liter per day
The client should call her primary caregiver to report swollen hand and face.