Ch 17-19, Ch 15-16

An infant was born weighing 6 lb (2.72 kg). At the end of 30 days, approximately how much should this infant weigh to demonstrate effective breastfeeding?

6 lb, 4 oz to 7 lb (2.83-3.17 kg)

A student nurse asks the newborn nursery nurse why so many babies prefer to be in a flexed position. What answer by the nurse is best?

"It's very familiar to them from being in utero."

The clinical nurse assesses kidney function in a newborn. Which of the following statements accurately describes the development of normally functioning kidneys in the newborn? (Select all that apply.)

-The glomerular filtration rate rapidly increases during the first 4 months of life. -The kidneys are not mature and fully functional until after birth. -Urine specific gravity in a neonate ranges from 1.002 to 1.010.

A perinatal nurse has orders to administer betamethasone (Celestone) to the following women in preterm labor. For which patient should the nurse question this order?

Severe preeclampsia/eclampsia

A nurse takes a newborn's initial set of vital signs and records the following: Temperature: 97.9°F (36.6C), pulse: 198 beats/minute, respirations: 78 breaths/minute, blood pressure: 64/44 mm Hg. What does the nurse conclude about this infant?

Tachypneic: suction if needed, administer oxygen per protocol

The perinatal nurse explains the cardiopulmonary adaptations that occur in the neonate to a student nurse. Which of the following statements accurately describes the sequence of these changes?

"Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs."

An infant who was stable for a day after birth now demonstrates pallor, tachycardia, tachypnea, and circumoral cyanosis. The parent asks how the child might have a heart problem when he was stable yesterday. What information by the nurse is most accurate?

"Symptoms may not appear until fetal circulation routes begin to close after birth."

A student nurse is verbalizing disappointment in a new mother's seeming lack of interest in her newborn baby. The student complains to the registered nurse that the mother just wants to sleep and have someone else care for the infant. What response by the registered nurse is best?

"The mother may be completely exhausted from the childbirth experience."

A perinatal clinic nurse is working with a pregnant woman who wishes a home birth. What information about newborn screening for metabolic disorders does the nurse provide?

"You will have to arrange screening before the end of the baby's first week of life."

A nurse is teaching new and very young parents about safe sleeping practices for their newborn son and asks to hear them describe their nursery and their plans for the baby's sleeping arrangements. What information from the parents would indicate that they did not understand the discharge teaching? (Select all that apply.)

-"A friend bought an air purifier that prevents SIDS." -"He can have a pacifier when he takes a nap." -"Our bed is big enough for all three of us." -"The crib is soft with lots of snuggly blankets."

A birthing unit has a new manager who plans to implement policies to facilitate family bonding after birth. Which of the following possible policies would be most helpful? (Select all that apply.)

-Allow 3-4 hours of uninterrupted family time after birth. Delay noncritical procedures during the initial family time. -Encourage and support breastfeeding practices. -Initiate primary nursing to provide continuity of care.

The perinatal nurse notes that a newborn's respiratory rate is 68 breaths/minute. What actions by the nurse are appropriate? (Select all that apply.)

-Auscultating all lung fields (anterior and posterior) -Inspecting chest for skin color and retractions -Notifying the physician of the assessment findings -Withholding oral feedings while the infant is tachypnei

A nurse is teaching a class of nursing students about the anterior and posterior fontanels. What information should the nurse include? (Select all that apply.)

-Bulging, tense fontanels can indicate increased intracranial pressure. -Fontanel presence allows for cranial molding during the birthing process. -Normal measurements for the anterior fontanel range from 0.4-2.8 in (1-7 cm).

The perinatal nurse is called to assess an infant 4 hours post-birth. The nurse notes a blue tinge to the lips, gums, and tongue of this infant. The nurse prepares for which of the following interventions? (Select all that apply.)

-Cardiac catheterization -Echocardiogram -Oxygen therapy -Vital sign monitoring

A new nurse is preparing to administer a vaccination for hepatitis B to an infant. What actions by the new nurse would lead the nurse's preceptor to intervene? (Select all that apply.)

-Chooses the ventral gluteal site for injection -Informs parents of the need for one more shot -Obtains informed consent from the parents Plans to give the vaccination within 1 hour of birth -Prepares the vastus lateralis for the injection

The nursing instructor is explaining passive acquired immunity to a class of nursing students. What information does the professor include? (Select all that apply.)

-Colostrum and breast milk are important sources of IgA. -IgG passes through the placenta before birth. -Passive acquired immunity generally lasts 6 months

A nurse is preparing an infant for circumcision. The parents ask about pain control. The nurse should inform the parents about what options? (Select all that apply.)

-Concentrated oral glucose solution -Nonnutritive sucking -Swaddling and containment -Topical anesthetics or anesthetic blocks

A pregnant woman at 25 weeks of gestation visits the prenatal clinic for a checkup. She asks the nurse how the baby is able to breathe on his own following childbirth. The nurse plans to explain the factors that influence the initiation of the newborn's first breath, including which of the following?

-Drastic change in temperature -Hypoxia -Recoil of the chest wall after delivery of the trun

The perinatal nurse teaches the student nurse about conditions that may require immediate investigation during the transitional period. These conditions include which of the following? (Select all that apply.)

-Grunting and sternal retractions -Heart rate of 112 beats/minute -Infant born at 36 + 2 weeks' gestation -The presence of nasal flaring

A perinatal nurse suspects that a newborn may be experiencing polycythemia. What further assessments should be made to confirm this condition? (Select all that apply.)

-Hematocrit level -Hemoglobin level -Respiratory rate

The perinatal nurse teaches new parents about the stages of infant behavior. What information does the nurse provide? (Select all that apply.)

-Irregular respirations are common in REM sleep. -Jerking movements may accompany crying. -When stimuli are removed, the baby falls asleep.

The perinatal nurse carefully assesses an infant for evidence of maternal alcohol use. Characteristics the nurse assesses for include which of the following? (Select all that apply.)

-Irritability -Smooth philtrum -Thin upper li

The perinatal nurse completes the Ballard Gestational Age by Maturity rating tool. The nurse assesses which components as part of this tool? (Select all that apply.)

-Neuromuscular -Physical

The perinatal nurse teaches the student nurse about appropriate body surfaces to inspect when assessing the infant's "true color." Which areas does the nurse include in the explanation? (Select all that apply.)

-Palms of the hands -Skin over the sternum -Soles of the feet

A nurse is preparing to discharge an infant with Erb's palsy. Which of the following discharge instructions does the nurse provide the parents? (Select all that apply.)

-Perform passive flexion and extension to the affected arm. -Position the infant with the affected arm flexed gently. -Support the affected arm when holding the baby.

The clinical nurse recalls that the newborn has mechanisms by which heat is lost following birth. Which of the following are examples of heat lost via convection? (Select all that apply.)

-Placed near an open window -Placed under a ceiling fan

The perinatal nurse explains the primary goals of nursing care in the transitional period of newborn life to the nursing student. Which goals does the nurse include? (Select all that apply.)

-Promote bonding within the new family. -Support the infant's physical well-being.

The perinatal nurse wants to contact the pediatrician about a heart murmur that was auscultated during a newborn assessment. During what time frame would hearing the murmur lead the nurse to contact the health-care provider?

48 to 72 hours

The nurse completes an initial newborn examination. The nurse's findings include the following: heart rate, 136 beats/minute; respiratory rate, 64 breaths/minute; temperature, 98.2°F (36.8°C). The nurse also documents a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which finding requires immediate consultation with the health-care provider?

Absent bowel sounds

An infant who is possibly infected with herpes simplex infection is being dismissed. What medication should the nurse anticipate instructing the parents on giving?

Acyclovir (Avirax)

A faculty member explains to a nursing student that the best way to prevent hemorrhage from injuries in a neonate is which of the following?

Administer vitamin K1 phytonadione (AquaMEPHYTON).

What action by the nurse is most important to prevent hemorrhagic disease of the newborn?

Administer vitamin K1 phytonadione (AquaMEPHYTON).

A neonate's 5-minute Apgar assessment reveals the following: active motion; pulse, 126 beats/minute; grimace and coughing during suctioning; appearance, good color all over; and respirations slightly irregular with weak cry. What action by the nurse is most appropriate?

Assess oxygen saturation and administer oxygen if needed.

The perinatal nurse notes that a newborn does not seem to have an opening inside the anal ring. Which action by the nurse takes priority?

Assess the abdomen and notify the physician.

The nursery nurse notes the presence of diffuse edema on a newborn baby's head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. What action by the nurse is best?

Document the findings in the infant's chart.

When assessing a newborn baby, which action should the nurse perform first?

Don clean gloves before taking the baby.

A faculty member is supervising a student who is preparing to administer vitamin K1 phytonadione (AquaMEPHYTON) to an infant. What action by the student prompts the faculty member to intervene?

Draws up 0.5 mg/kg

What action by the nurse is most important to prevent respiratory depression in a newly born infant?

Dry the infant and place on the mother's bare chest.

A nurse is assessing an infant who has a large bruise around his neck and face from a nuchal cord. What other assessment finding correlates with this condition?

Elevated serum bilirubin

A mother worries about her infant feeling pain during a heel stick for a blood test. What action by the nurse is best?

Encourage breastfeeding during the heel stick.

What action by the nurse takes priority in safeguarding a neonate's safety and well-being?

Ensuring that the baby wears an abduction alarm

A mother brings her 1-week-old baby to the clinic with complaints that the baby is not eating well. The mother is attempting to bottle feed about 120 mL every 2 hours. What action by the nurse is best?

Explain that this is too much volume at one time.

The pediatric nurse prepares a newborn for phototherapy. The nurse explains to the parents that certain organs need to be protected during treatment. Which organs are these?

Eyes and genitals

A nurse notes that an infant has a drooping tongue, which causes difficulty with feeding. What cranial nerve should the nurse assess further?

Facial

In preparing a family for discharge from the perinatal unit, which method of nail care does the nurse teach as the preferred method?

Filing the nails with a fine emery board

A neonatal nurse who is caring for newborns suggests the best time for a mother to first attempt breastfeeding is during which of the following stages of activity?

First period of reactivity

A nurse observes a student nurse examining a newborn baby boy's scrotum and testicles. The student softly palpates the scrotum with all five digits of the dominant hand and states that there is only one testicle present. What action by the nurse is best?

Have the student repeat the exam using the proper technique.

A nurse suspects that an infant in the intensive care unit has had intrauterine exposure to one of the TORCH infections. What finding is indicative of in utero exposure to a TORCH infection?

Increased IgM

A postterm baby is born, and the nurse notes that the baby has dirty-looking skin and nails. The baby has moderate respiratory distress with rales and rhonchi noted. What nursing care does the nurse anticipate providing for this infant?

Increasing oxygenation by using CPAP

An infant in the NICU has persistent pulmonary hypertension. The nurse places highest priority on which of the following nursing diagnoses?

Ineffective tissue perfusion: cardiopulmonary

A nursing student asks the registered nurse why babies get dehydrated so easily. What response by the nurse is most accurate?

Infants' long intestines have more surface area from which to lose water.

The perinatal nurse teaches the new mother and her family about appropriate infant care to prevent omphalitis. Information given would include which of the following instructions?

Keep the base of the umbilical cord clean and dry.

A nurse is preparing to admit a newborn to the NICU who weighs 1,750 g. What classification does the nurse use to describe this infant?

Low birth weight

A preterm infant in the NICU is receiving oxygen, and the nurse notes that the oxygen saturation is 98%. Which action by the nurse is most appropriate?

Lower the infant's oxygen concentration and reassess.

The nurse holds an infant upright and allows his feet to brush the surface of the examination table. Which of the following is the normal reflex response to this stimulation?

Makes stepping actions with both feet

The nurse caring for a woman about to deliver a baby at 33 weeks' gestation knows that what factor might have accelerated surfactant production?

Maternal hypertension

A mother-baby nurse assesses newborns for their risk of developing hypoglycemia. Which infant would the nurse assess as being at highest risk?

Maternal use of terbutaline (Brethine)

A new mother with a 6-hour-old infant calls the nursing station complaining that her baby is so cold he is shivering. What action by the nurse is most appropriate?

Perform a thorough head-to-toe assessment.

A baby with brachial plexus injury is being discharged home. What information should the nurse include on the teaching plan?

Perform passive range-of-motion exercises to affected extremity.

An infant was born with anencephaly and was taken immediately to the NICU. The parents are about to visit for the first time. What action by the nurse is most appropriate?

Prepare the parents for how the infant will look.

A nurse in the high-risk obstetrical unit monitors a student nurse preparing to give a patient a dose of betamethasone (Celestone). Which action by the student warrants intervention by the nurse?

Prepares to administer medication in the deltoid muscle

A new nurse is preparing to administer erythromycin (Eyemycin) to an infant. What action by the new nurse would lead the precepting nurse to intervene?

Prepares to administer the medication 4 hours after birth

A term infant is 22 hours old, has a total serum bilirubin level of 13 mg/dL, and has visible jaundice. What action by the nurse is most appropriate?

Review the chart for history of a traumatic birth.

A nurse explains to a student that which of the following is the mechanism by which circulation of oxygen is increased to the organs of a newborn?

Tachycardia

A nurse has been caring for a neonate with the nursing diagnosis of imbalanced body temperature. What assessment finding indicates to the nurse that goals for this diagnosis have been met?

Temperature of 99.2°F (37.3°C)

A nurse is providing discharge teaching to parents of a newborn. The baby had no medical problems and is healthy other than having failed an automated auditory brainstem response (AABR) hearing test conducted in the nursery. What information does the nurse provide?

The baby's hearing should be retested within 1 month.

The nurse teaching a family about bonding with their infant describes touch as an important facet of this process. What does the nurse understand is most important about touch and bonding?

The neonate learns exclusively through touch.

A baby has just been born with anencephaly. Which action by the labor and delivery charge nurse takes priority?

Consult the palliative care team.

A mother brings her 3-month-old baby to the clinic for a well-baby check. She appears exhausted and when the nurse questions her, the mother explains that she feels that she is the only person who can look after and care for her infant properly, so all of her time is devoted to this task. The nurse should document which of the following?

Difficulty with letting-go, as evidenced by excluding her partner from infant care

A pediatric nurse sees a baby with microcephaly. What action is most important for this nurse to do?

Document head circumference at each visit.

A woman with postpartum depression is being treated with a selective serotonin reuptake inhibitor (SSRI). What statement by the patient requires further action by the nurse?

"Adding St. John's wort has really helped my depression."

A woman has painful hemorrhoids after a vaginal birth. Her husband brings her a donut pillow to sit on. What response by the nurse is best?

"Donut pillows actually increase hemorrhoid pain."

A woman with postpartum depression resists treatment, saying: "Who cares if I'm depressed? It only affects me." What response by the nurse is best?

"Infants of depressed mothers have delayed development."

A husband calls the perinatal clinic because he is worried about his wife's emotional state after giving birth 2 weeks ago. Which question by the nurse would be most helpful?

"Is your wife still able to care for herself and the baby?"

The perinatal nurse teaches the student nurse that deep breathing exercises following cesarean birth are critical to the prevention of what complications? (Select all that apply.)

-Atelectasis -Pneumonia

The perinatal nurse teaches the postpartum woman about the normal process of diuresis that she can expect to occur approximately 6 to 8 hours after childbirth. Which hormones are responsible for the diuresis? (Select all that apply.)

-Estrogen -Oxytocin

A perinatal nurse is teaching a woman who is in a violent relationship about safety-promoting behaviors. Which of the following does the nurse include in teaching? (Select all that apply.)

-Begin hiding money and an extra set of keys. -Find and safely store important documents. -Photocopy and save utility and rent receipts. -Remove weapons or bullets from the home.

A perinatal nurse assesses a term newborn for respiratory functioning. The nurse will document which of the following findings as normal for a neonate? (Select all that apply.)

-Breathing pattern that can be shallow, diaphragmatic, and irregular -The neonate's lung sounds are moist during early auscultation

The nursing faculty member explains to a class of nursing students the risk factors for developing postpartum depression (PPD). Which of the following does the faculty include? (Select all that apply.)

-Financial stress -Isolation -Low self-esteem -Unplanned pregnancy

A postpartum woman who had a prolonged labor presents to the clinic complaining of abdominal pain, high fevers with chills, and back pain. The nurse notes the patient's heart rate is 142 beats/minute, and her abdomen is tender with hypoactive bowel sounds. The patient will be admitted, and when giving report to the hospital nurse, the clinic nurse advises that the patient will probably receive what initial treatment? (Select all that apply.)

-Antibiotics -Forced fluids -Heparin -Ibuprofen (Motrin)

A nurse monitors all newborns in the NICU for hypoglycemia. Which manifestations could indicate hypoglycemia in one of the babies? (Select all that apply.)

-Apneic episodes -None (asymptomatic) -Eye rolling -Lethargy

A nurse is caring for a woman who just experienced a cesarean birth under epidural anesthesia. What interventions are important to include on this woman's care plan? (Select all that apply.)

-Apply compression stockings or sequential compression devices. -Encourage ankle exercises while the woman remains in bed. -Maintain bedrest until sensation returns to the woman's legs.

A nurse uses the acronym REEDA to perform a perineal assessment on a postpartum woman. What are the components of this exam? (Select all that apply.)

-Approximation of the episiotomy -Drainage or discharge -Ecchymosis -Redness

A nursing student who once lived in the southwest was overheard making disparaging comments about Hispanic immigrants, stating: "They only come here for free medical care." What response by the nursing faculty member is best?

"Research actually shows that most immigrants come to find work."

The clinic nurse sees a patient and her infant in the clinic for their 2-week follow-up visit. The woman appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. Which question would be most appropriate for the nurse to ask?

"Tell me about the first few days at home."

The nurse is assessing a woman in the immediate postpartum period. The patient's respiratory rate is 22 breaths/minute. The most important aspects of nursing care would be to do which of the following? (Select all that apply.)

-Assess and provide pain management. -Assess the patient's blood pressure and pulse. -Notify the provider for continued tachypnea. -Provide ongoing physical assessment.

A baby was born 4 days ago at 34 weeks' gestation and is receiving phototherapy for neonatal jaundice. The baby has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability. What are the nurse's priority nursing interventions? (Select all that apply.)

-Assess the baby's temperature to check for hypothermia. -Verify laboratory results to check for hypoglycemia.

A diabetic patient is 1 day postpartum after an uncomplicated vaginal birth. She wants to know why her blood sugar levels are so much lower than usual. What explanation by the nurse is best?

"The levels of hormones that cause an anti-insulin effect are decreased."

A premature infant is born and admitted to the NICU. A student nurse questions why the primary nurse is starting to plan discharge teaching so early. Which response by the nurse is best?

"The parents have so much to learn we have to start planning discharge on admission."

A nurse is documenting the types of high-risk newborns on the unit. Which infants would be classified as preterm? (Select all that apply).

-37 weeks -34 weeks

As a member of the health-care team, the perinatal nurse finds it helpful following a maternal emergency, such as a postpartum hemorrhage, to engage in which of the following activities? (Select all that apply.)

-A family meeting to encourage communication and understanding -Debriefing with the other staff members involved in the patient's care -Health-promoting behaviors such as adequate sleep and exercise

The perinatal nurse knows that breastfeeding is contraindicated if a mother has which of the following conditions? (Select all that apply.)

-Active herpes lesion on her nipple -Active tuberculosis

A woman is considering abandoning breastfeeding attempts because of severe afterpains. What actions by the nurse are most helpful? (Select all that apply.)

-Administer pain medication 30 minutes prior to breastfeeding. -Encourage ambulation. -Have the woman lie prone with a pillow under her stomach. -Prepare a sitz bath for the woman after she has breastfed.

The perinatal nurse explains to students that certain groups of women are less likely to breastfeed. Which of the following women would the nurse identify as needing extra education, support, or encouragement to breastfeed? (Select all that apply.)

-African American -Those who participate in federal nutrition programs

A woman presents to the emergency department in labor and states that she is homeless and has not had prenatal care. The emergency department nurse explains to the nursing student that homeless women face many challenges to getting prenatal care, including which of the following?

-Caring for other children -Lack of insurance -Mistrust of health-care providers -Transportation difficulties

A visiting nurse is concerned that a mother has not properly bonded with her infant. The nurse should assess for what factors that could impact this process? (Select all that apply.)

-Chaotic home life -Lack of family support -Poverty -Substance abuse

A woman is hospitalized after an incision and drainage of a large breast abscess that cultured methicillin-resistant Staphylococcus aureus. What dietary choices indicate that she has understood teaching regarding nutrition and wound healing? (Select all that apply.)

-Chicken breast -Hard-boiled egg -Orange slices -Spinach

A nurse is caring for a baby with neonatal abstinence syndrome. Which of the following medications should the nurse be prepared to give? (Select all that apply.)

-Chlorpromazine (Thorazine) -Clonidine (Catapres) -Diazepam (Valium) -Phenobarbital (Luminal)

A nurse preceptor of a student nurse explains that although a high-risk newborn can have complications in any body system, the systems most often impacted include which of the following? (Select all that apply.)

-Circulatory -Neurological -Respiratory

A nurse is observing a student nurse prepare a sitz bath. Which actions should be performed by the student? (Select all that apply.)

-Confirm that the patient can ambulate to the bathroom. -Help the patient remove the peri-pad from front to back. -Ensure that the patient is covered enough to prevent chilling.

A nurse is caring for a premature newborn. What interventions does the nurse include on the baby's care plan? (Select all that apply.)

-Cradle baby in a linen nest in flexed position. -Monitor response to warming measures. -Reposition the baby every 4 hours.

The perinatal nurse includes a pain assessment as part of the postpartum care provided to each patient. This action helps to do which of the following? (Select all that apply.)

-Decrease the recovery time -Decrease the risk of depression -Help identify complications -Improve the patient's coping ability

A nursing faculty member is explaining to a class of students that women experiencing cesarean birth have more challenges than do women who give birth vaginally. The faculty member is referring to what challenges? (Select all that apply.)

-Delayed mother-infant bonding -Increased risk of deep vein thrombosis -Pain from the surgical incision and intestinal gas -Slower initiation and pace of ambulation

The perinatal nurse is teaching the new mother who has chosen to formula-feed her infant. Which of the following are appropriate instructions to give the parents? (Select all that apply.)

-Discard any unused formula in the bottle following use. -Periodically check the nipple for slow flow.

The postpartum nurse is aware that following childbirth there is an increased risk of maternal perineal infection related to which of the following factors? (Select all that apply.)

-Drainage of blood and lochia -Impaired tissue integrity -The anatomical proximity to the anus -Urinary retention

A baby is admitted with a long-bone fracture. What nursing actions are appropriate in the care of this baby? (Select all that apply.)

-Elevation of the extremity -Frequent neurovascular checks -Immobilization while healin

The perinatal nurse explains risk factors for hematoma formation to a group of nursing students. What risk factors does the nurse include in the teaching? (Select all that apply.)

-Episiotomy -Genital tract laceration -Prolonged second stage of labor

The nursing faculty member who is explaining uterine atony to nursing students informs them of risk factors contributing to this condition. Which factors would place a woman at higher risk of uterine atony? (Select all that apply.)

-Forceps-assisted birth -Multi-fetal gestation -Oxytocin labor induction -Use of magnesium sulfate

A perinatal nurse explains to the nursing student that pregnant women have risk factors for deep vein thrombosis (DVT) as a result of their pregnancy. To which components of Virchow's triad is the nurse referring? (Select all that apply.)

-Hypercoagulability -Venous stasis

A woman in labor takes high-dose steroids for a connective tissue disorder. She takes no other medications. The nurse educates her that her baby could be at risk for which of the following conditions? (Select all that apply.)

-Hypoglycemia -Large for gestational age

A postpartum woman has a suspected deep vein thrombosis (DVT). Which diagnostic studies does the nurse prepare the woman to possibly have? (Select all that apply.)

-Laboratory draw for D-dimer -Magnetic resonance imaging (MRI) -Venous duplex ultrasound

A woman is hospitalized emergently for postpartum psychosis. For which of the following does the nurse prepare the patient as initial treatment? (Select all that apply.)

-Lithium (Lithobid) -Chlorpromazine (Thorazine) -Diazepam (Valium)

A nurse manager in the perinatal clinic wants to begin screening male partners for risk factors for committing intimate partner abuse. What risk factors does the manager include on the new screening form? (Select all that apply.)

-Low income -Male-dominant family structure -Unemployment -Young age

The perinatal nurse describes infant feeding cues to a new mother. These feeding cues include which of the following behaviors? (Select all that apply.)

-Mouth movements -Moving the hand to the mouth -Vocalizations

An infant has been admitted to the neonatal intensive care unit because of meconium-aspiration syndrome and related complications. The pediatric nurse assesses the patient frequently for which complication? (Select all that apply.)

-Pneumomediastinum -Pneumothorax

An experienced NICU nurse is explaining to a new nurse why premature infants have such great nutritional needs. What information should the experienced nurse include? (Select all that apply.)

-They haven't built up stores in utero like term babies. -They have complications that increase their metabolic rate. -They lose 10% of their already-low weight at birth.

The perinatal nurse accurately defines postpartum hemorrhage to a group of nursing students by including a decrease in hematocrit levels from prebirth to postbirth by which percentage?

10%

A preterm infant has been started on IV fluids. When assessing the patient, which findings would indicate to the nurse that goals for this therapy are being met? (Select all that apply.)

-Urine output of mL/kg/hour -Urine specific gravity of < 1.012

A postpartum woman is Rho(D)-negative and needs an injection of Rho(D) immune globulin. Which of the following doses would the perinatal nurse expect to be ordered?

300 µg

An infant weighing 3 lb, 7 oz has apnea of prematurity. The nurse needs to administer the loading dose of caffeine citrate (Cafcit). The dose for this is____________________ mg.

31 mg

An infant is born at 35 weeks and 3 days. How would the nurse document this gestational age? ____________________

35 3/7

An infant is born weighing 6 lb, 1 oz and has gastroschisis. The nurse anticipates running this infant's IV fluids at a rate of ____________________ mL/hour.

412.5 mL/hr

A nurse is assessing a woman who had a postpartum hemorrhage treated with fundal massage and oxytocin (Pitocin). Which assessment finding would require the nurse to intervene immediately?

Mean arterial pressure of 58 mm Hg

The perinatal nurse is aware that a key factor contributing to suboptimal outcomes for pregnant women and their families is which of the following?

Delayed communication between health-care provider call groups

The perinatal nurse routinely screens pregnant women for postpartum depression. Which woman does the nurse screen as the priority?

Adolescent

A new nurse is suctioning a neonate. What action by the new nurse would cause the preceptor to intervene?

Positions the suction bulb at the back of the throat

A patient has been transferred to an intensive care unit (ICU) after experiencing a pulmonary embolus. The patient is stable 24 hours later, but will remain in the unit for another day or two. At this time, the priority for the perinatal nurse is to provide the family with information about infant care and what other action?

Advocate for infant visitation and breast pumping in the ICU if desired by the patient.

A postpartum patient is ready for discharge from the hospital with her baby. She describes having some "sad feelings" after her last baby. The perinatal nurse explains that she should seek help in which situation?

After 2 weeks of continuous sad feelings

A nurse assesses an infant using the Premature Infant Pain Profile and gives the baby a score of 19. What action by the nurse is most appropriate?

Administer morphine (Astramorph).

A patient is being dismissed after giving birth and having a hematoma drained in the operating room. What action by the patient best indicates to the nurse that outcomes for the diagnosis of risk for altered attachment have been met?

Administer oxygen

A perinatal clinic nurse develops concerns about a postpartum woman and her infant at the first well-baby checkup. The nurse has assessed several risk factors for depression. Which action by the nurse is most appropriate?

Administer the Edinburgh Postnatal Depression Scale.

A woman gave birth 12 hours ago. The patient complains of severe abdominal cramping when she breastfeeds her infant. The perinatal nurse should document this condition as which of the following?

Afterpains

A woman is being taken to the operating room later in the day for incision and drainage of a large perineal hematoma. What action by the nurse is most important to meet the patient's psychosocial needs?

Allow the woman to make choices when possible.

The perinatal nurse and student nurse are conducting an assessment on a postpartal woman. The nurse demonstrates percussion of the bladder. They hear a dull, thudding sound. How should the nurse document this information?

An empty bladder

A postpartum woman presents to the perinatal clinic complaining of extreme breast tenderness and an inability to express milk on the left side when breastfeeding. What nonpharmacological comfort measure does the nurse teach this patient?

Application of either warm or cold packs

Approximately 8 hours ago, a woman gave birth after 2.5 hours of pushing. She required an episiotomy and an assisted birth (forceps). The perinatal nurse assesses a slight bulge in the perineum and the presence of ecchymosis to the right of the episiotomy. The area feels "full" and is approximately 4 cm in diameter. The patient describes this area as "tender." What intervention does the nurse anticipate for this situation?

Application of ice

A woman complains of perineal pain. The nurse assesses swelling, but sees no other abnormalities. The woman does not wish pharmacological treatment. What suggestion by the nurse is most appropriate?

Applying a covered ice pack to the perineum every 2 to 4 hours for 20 minutes

A nurse is seeing a baby with a diagnosed cleft lip. What assessment finding indicates to the nurse that a priority outcome has been met?

Appropriate weight gain

An adolescent has vaginally given birth to a healthy baby. What action by the nurse would be most important in developing a plan to help this mother bond successfully?

Ask the mother about her expectations of the baby and their relationship.

A new mother is accompanied by her mother during her hospital stay on the postpartum unit. The patient's mother has made specific various requests of the nurses, including asking for a bottle so she can feed the baby after the new mother attempts to breastfeed for the first time. How would the perinatal nurse best respond to the patient's mother in a culturally sensitive way?

Ask the patient what she knows about breastfeeding and provide information to both women to support the patient's decision.

A postpartum woman is in the perinatal clinic for a routine follow-up visit with her new infant. The patient seems agitated by the questions the nurse is asking and often looks up at the ceiling apprehensively. What action by the nurse is best?

Ask the woman if she is hearing voices.

A woman had a cesarean birth 2 hours ago. She now complains of being hungry and wants something to eat. What action by the nurse is best?

Assess for bowel sounds and ask if she is passing gas.

A postpartum woman is complaining of a headache that is worsening despite having taken Tylenol (acetaminophen) an hour ago. She delivered yesterday with epidural anesthesia. What action by the nurse is best?

Assess if the pain is worse when she sits upright.

A nurse is caring for a woman after a cesarean birth. Prior to ambulating her for the first time, which action by the nurse takes priority?

Assess sensation in the lower extremities.

A nurse assesses a premature infant and finds shearing injuries to the infant's arms and legs. What action by the nurse is best?

Assess the baby for pain.

Prior to giving a newborn the first bath, what action by the nurse is most appropriate?

Assess the infant's temperature.

A nurse assessing a postpartum woman 12 hours after uncomplicated vaginal birth finds her pulse to be 110 beats/minute. What action by the nurse is best?

Assess the patient for causes of tachycardia.

A woman with a history of mild heart failure has just vaginally given birth to a healthy baby. What action by the nurse is most important?

Assess the woman for signs of heart failure.

A small-for-gestational-age (SGA) newborn is admitted to the NICU. The nurse notes that the baby's head circumference is in the 68th percentile for gestational age, but the baby's weight is under the 10th percentile. The baby also has a scaphoid abdomen and long fingernails. How does the nurse classify this baby in the handoff report?

Asymmetrical intrauterine growth restriction

What assessment finding indicates to the nurse that goals for the diagnosis of ineffective thermoregulation related to newborn's immature temperature regulatory system have been met?

Axillary temperature is 98.1°F (36.7°C).

The perinatal nurse listens as the patient describes her labor and emergency cesarean birth. Providing an opportunity to review this experience may assist the patient in doing which of the following?

Developing more positive feelings about her labor and birth

The perinatal nurse recognizes that which common organism is responsible for postpartum infection manifesting with scant, odorless lochia?

Beta-hemolytic streptococcus

A postpartum woman who had a cesarean birth complains of warmth and pain in one of her calves. Which assessment should the nurse perform as the priority?

Bilateral calf circumference

A nurse has given a premature hypoglycemic infant an IV glucose solution. How would the nurse best determine if the goals for this treatment have been met?

Blood glucose is 58 mg/dL.

A nurse is assessing a newborn who is jittery, diaphoretic, and hypothermic, and has poor feeding. What laboratory value would the nurse correlate with this condition?

Blood glucose: 32 mg/dL

The pediatric nurse is receiving a morning report via phone call on an infant who will be arriving in the neonatal intensive care unit. The report indicates that shoulder dystocia may have occurred during the birth process. The nurse assesses the neonate as at risk for which additional condition?

Brachial plexus injury

A nurse sees a baby whose left arm is in a flexed position and is held in place by pinning the cuff of the baby's T-shirt sleeve to the opposite shoulder. What can the nurse conclude about this baby?

Broken clavicle

A woman gave birth to an infant weighing 390 g. Which action by the NICU charge nurse is most appropriate?

Consult the palliative care team and admit the infant for comfort care.

The nurse is assessing the cardiovascular status of a newborn. Which of the following findings indicates adequate systemic circulation?

Capillary refill 2 seconds

The nursing professor is explaining to a class of students that which chemical factor in the blood directly leads to the initiation of respirations in the newborn?

Carbon dioxide

As part of a research study on deep vein thrombosis (DVT), a perinatal nurse is collecting blood samples in women at highest risk for factor V Leiden mutation. Which woman would the nurse approach as the priority?

Caucasian American

A newborn has a blood glucose level of 188 mg/dL. What further assessment on this baby takes priority?

Circulatory status

A nurse is assessing a newborn and hears bowel sounds in the infant's chest area. What other finding should the nurse specifically assess for?

Cyanosis

A nurse is beginning a newborn's physical assessment and notes that the infant is jumpy and seems irritable when being handled and when the nurse or parents speak. What action by the nurse is best?

Postpone the assessment until the infant has calmed.

A premature infant has apnea of prematurity accompanied by bradycardia and desaturation. The infant was started on caffeine citrate (Cafcit), and the results from a blood level have just now returned. The infant's blood level of Cafcit is 2.3 mg/mL. What action by the nurse is most appropriate?

Document results; maintain cardiorespiratory monitor.

A nurse assesses a 2-hour-old infant's temperature and notes it to be 97.7°F (36.5°C). What action by the nurse is most appropriate?

Document the findings and continue to monitor.

The nurse notes swelling in the scrotum of a newborn infant. Transillumination reveals a reddish-yellow reflection. What action by the nurse is best?

Document the findings and reassure the parents.

A term infant's initial blood glucose level is 42 mg/dL. What action by the nurse is most appropriate?

Document the findings in the infant's chart.

A nurse assesses a woman's temperature 6 hours after a vaginal birth and finds it to be 100.4°F (38°C). What action by the nurse is best?

Encourage the woman to drink plenty of fluids.

A postpartum woman is about to be dismissed with her baby when she reveals to the nurse that she is homeless and has nowhere to go. What action by the nurse is most appropriate?

Enlist social work to find a shelter that will take them.

A diabetic woman had a cesarean delivery and her baby is noted to have a respiratory rate of 82 breaths/minute with retractions. The baby's blood gas analyses are as follows: pH, 7.20; PCO2, 52 mm Hg; PaO2, 80 mm Hg; PHCO3-, 21 mEq/L. What is an important safety measure the nurse should plan to implement when caring for this infant?

Ensure the CPAP pressures do not exceed 6 cm H2O.

A premature newborn has a pulse pressure of 33 mm Hg. What action by the nurse takes priority?

Ensure the blood pressure cuff is the right size.

A baby is being discharged home to await surgery to correct a cleft palate. What information do the parents need as the priority?

Feeding techniques and special nipples

The nurse caring for small-for-gestational-age (SGA) infants assesses them for attainment of outcomes related to nursing diagnoses. Which assessment finding best demonstrates attainment of priority outcomes?

Gains weight regularly

A new mother is concerned that her 3-year-old child is not adapting well to the birth of a new sibling 1 month ago. What suggestion can the nurse provide to best help this mother?

Give the 3-year-old a special chore that only she does to help her mom.

A woman is 1 day post-cesarean birth. The nurse auscultates crackles in her lung bases. Which action by the nurse is best?

Have the woman use her incentive spirometer.

A 2-hour-old infant has ruddy skin and delayed capillary refill. What laboratory value best correlates with this condition?

Hematocrit is 72%.

A patient is being dismissed after giving birth and having a hematoma drained in the operating room. What action by the patient best indicates to the nurse that outcomes for the diagnosis of risk for altered attachment have been met?

Holds and comforts the infant when fussy

The perinatal nurse describes the need for an assessment for deep vein thrombosis (DVT) in the postpartum patient. Which of the following is one test that can be used as a screening measure for DVT?

Homans' sign

A nurse is preparing to discharge an infant who has developmental dysplasia of the hip (DDH). What discharge instruction would be most important?

How to properly use the Pavlik harness

A nursing student is preparing to give a pregnant woman heparin for a deep vein thrombosis (DVT). The student questions the dose, as it is higher than what the student has given to other patients. What response by the perinatal nurse is most appropriate?

Inform the student that physiological changes in pregnancy require higher doses.

A nurse is assisting a postpartum woman to get up for the first time after an unmedicated vaginal birth. What action by the nurse is best?

Instruct the woman to sit on the edge of the bed prior to standing.

A perinatal nurse is conducting an initial interview and assessment on a new patient in her first trimester of an unplanned pregnancy. The nurse discovers the patient was a victim of child abuse and her husband has left her and returned several times. The nurse should assess this patient for what other issue as the priority?

Intimate partner abuse

A nurse is caring for a patient on heparin for a deep vein thrombosis (DVT) and realizes that the patient has received an overdose of the medication. When contacting the physician, what orders does the nurse anticipate?

Laboratory draw for aPTT; administer protamine sulfate.

A nurse manager has many at-risk mothers in the labor and birth unit. What policy can the manager adapt that would best facilitate mother-baby bonding?

Limit separation of mother and baby to exceptional circumstances only.

A G2 TPAL 2002 patient experienced a precipitous birth 90 minutes ago. Her infant weighed 4,200 g, and a repair of a second-degree laceration was needed following the birth. The nurse assesses that the patient's uterus is boggy and deviated to the right. The patient's vaginal bleeding has increased. Which action by the nurse takes priority?

Massage the uterine fundus with continual lower-segment support.

A nurse has brought a newborn to his mother's room. What action by the nurse takes priority?

Matching the information on the mother's and baby's wristbands

The nurse working in labor and delivery knows that which infant is at highest risk of having a long-bone fracture?

Multiples with one breech presentation

A student nurse is caring for an infant who was just circumcised. What assessment finding should the student report to the registered nurse?

No voiding for 8 hours

The nurse is assessing the neonate's skin and notes the presence of small irregular red patches on the cheeks that turn into single yellow pimples on the baby's chest. What treatment and care does the nurse recommend to the parents to help resolve this rash?

None; it will disappear within about a month.

Two days after an uncomplicated vaginal birth, the nurse notes that the patient's hemoglobin is 13 mg/dL and the hematocrit is 48%. What does the nurse conclude about these values?

Normal for this situation

A nurse is assessing a newborn infant and notes cool skin, poor feeding attempts, and bradycardia. Which action by the nurse is best?

Obtain a rectal temperature.

A postpartum patient is hemorrhaging despite receiving several medications and fundal massage. What action by the nurse takes priority?

Obtain informed consent for surgery.

A postterm newborn is being treated for persistent pulmonary hypertension. Which assessment finding best indicates that a priority outcome has been met?

Oxygen saturation 95%

A nurse is caring for a patient who has excessive blood loss post-delivery from uterine atony. The perinatal nurse notifies the health-care provider while another nurse performs uterine massage. Which medication does the nurse anticipate to be given as the priority?

Oxytocin (Pitocin)

A preterm infant was born at 31 weeks and has been admitted to the NICU. The nurse notes expiratory grunting, nasal flaring, and cyanosis on room air. Which laboratory findings would correlate with this condition?

PaCO2: 56 mm Hg

A woman is 10 hours postpartum after an uncomplicated vaginal birth. She has voided four times, and each time the volume is less than 100 mL. What action by the nurse is best?

Palpate the fundus and assess the amount of lochia present.

A postpartum patient complains of severe perineal pain and a sensation of needing to defecate but cannot pass stool. What action by the nurse is best?

Palpate the perineal area.

A patient is receiving methylergonovine (Methergine) after a vaginal birth. What assessment finding by the nurse warrants immediate intervention?

Palpitations

A woman with postpartum depression is in the perinatal clinic for follow-up. The health-care provider tells the nurse that the patient will be prescribed a tricyclic antidepressant. The nurse will instruct the patient about which medication?

Pamelor (Nortriptyline)

A patient was discharged from the hospital on warfarin sodium (Coumadin) and is now in the perinatal clinic for follow-up. Which of the following would best indicate to the nurse that goals for discharge teaching have been met?

Patient INR of 2.5

A nurse is providing care to several neonates. In giving the infants prophylactic medication to prevent ophthalmia neonatorum, which ordered medication should the nurse question giving?

Penicillin

A postpartum woman who experienced a spontaneous vaginal birth 12 hours ago describes a headache that is worsening. The patient was given two regular-strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. The most appropriate nursing action at this time is to do which of the following?

Perform a comprehensive pain assessment.

A premature infant in the NICU has a sudden increase in head circumference. Which drug does the nurse anticipate administering?

Phenobarbital (Luminal Sodium)

In order to promote thermal stabilization in a neonate, which action by the nurse is best?

Place the infant in skin-to-skin contact with the mom.

A premature infant has not had a bowel movement, and the nurse assesses abdominal distention after the last feeding. What action by the nurse takes priority?

Place the infant on NPO status.

A nurse reads in the chart that a baby has a positive crossed extension reflex and asks a more experienced nurse to demonstrate this assessment. How does the nurse perform the assessment?

Place the infant supine, stimulate one foot, and watch for reaction of the other leg.

A nurse is assessing a patient for a perineal hematoma. Which action by the nurse is most appropriate?

Place the patient in a side-lying position and lift the upper buttock.

An infant is born with an encephalocele. Which action by the nurse takes priority?

Place warm sterile gauze on the defect.

An infant with gastroesophageal reflux disease (GERD) is being discharged home. Which of the following is the priority topic the nurse plans to include in the teaching plan?

Positioning the infant during feeding and sleeping

The perinatal nurse administers heparin as ordered to the postpartum woman with newly diagnosed deep vein thrombosis. The patient asks about the purpose of the medication. Which response by the nurse is best?

Prevents extension of the clot and new clot formation

A postpartum woman has a deep vein thrombosis. The patient states, "I feel anxious and have some pain in my chest." The patient's respiratory rate is 28 breaths per minute. The perinatal nurse should prepare to respond to which of the following conditions?

Pulmonary embolus

New parents are concerned that after initially breastfeeding their baby 2 hours after being born, she is sleeping soundly and will not awaken. What action by the nurse is most appropriate?

Reassure the parents that this is normal.

A nursing student is measuring a newborn baby's head circumference. Which action by the student demonstrates good understanding of this procedure?

Records the largest of three measurements

A nurse is teaching a postpartum patient about preventing infection after discharge. What action by the patient indicates that she needs additional teaching?

Removes her peri-pad from back to front

The nursing faculty member explains to a class of nursing students the correct way to assist with perineal care (peri-care) after childbirth. Which action by a student nurse would warrant intervention by the faculty member?

Removes the peri-pad from back to front and appropriately disposes of it

A nurse assessing an infant notes that the baby is jittery, has muscle twitches, and has jittery movement of the arms and legs. What action by the nurse is most appropriate?

Request laboratory work to detect substances of abuse.

The newborn nursery nurse knows that infant behavior is best assessed by which of the following?

Response to stimulation

A nurse is asked to record preductal and postductal oxygen saturations on an infant with possible persistent pulmonary hypertension. Where does the nurse assess the preductal saturation?

Right finger

A woman with a deep vein thrombosis (DVT) is receiving IV heparin therapy. Which nursing diagnosis does the nurse address as the priority?

Risk for injury

A premature infant was delivered after a prolonged labor with rupture of the maternal membranes >18 hours. The infant's weight is 6 lb, 1 oz (2.75 kg). What assessment finding would require the nurse to intervene immediately?

Skin temperature reading of 96.8°F (36°C)

A nurse has administered an analgesic to a premature infant in pain. What assessment would indicate to the nurse that the baby's pain is improving?

Sleeps after feeding

The pediatric nurse is providing care to an infant diagnosed with phenylketonuria. What education is vital for this nurse to provide the parents?

Special phenylalanine-free infant formula and diet restriction

The perinatal nurse teaches new parents that the best sleeping position for infants is which of the following?

Supine

The pediatric nurse explains to the nursing student that respiratory distress syndrome results from a developmental lack of which substance?

Surfactant

A woman gives birth to a healthy baby boy at 35 weeks' gestation. What factor regarding the development of the normal respiratory system should the nurse consider when performing an assessment of the neonate?

Surfactant production is sufficient to maintain alveolar stability by about 34 weeks.

A perinatal nurse receives reports from the nurse aide on four patients who all gave birth within the last 4 hours. Which patient should the nurse assess first?

Systolic blood pressure change from 132 to 110 mm Hg

A woman had a cesarean birth after a prolonged trial of labor. When assessing the patient, the nurse notes the patient is lethargic, has a pulse of 130 beats/minute, and states: "I'm glad I have so little lochia; I'm too tired to change my pad." What action by the nurse is most appropriate?

Take a full set of vital signs and call the provider.

The perinatal nurse observes the new mother watching her baby daughter closely, touching her face, and asking many questions about infant feeding. This is best described as which stage of mothering?

Taking charge

A woman is being treated for endometritis after a cesarean birth. To prevent a possible complication, what action by the nurse is best?

Teach her to splint her abdominal incision when coughing.

An NICU nurse is caring for several infants who are being treated for hypothermia. Which baby can be dressed and taken out of the warmer?

Temperature 98.2°F (36.7°C)

A nurse is explaining to a student that sudden infant death syndrome (SIDS) has been reduced due mostly to what trend?

The "Back to Sleep" campaign

A nurse is discharging parents and their new infant. When assisting the family to place the infant in a car seat, which observation leads the nurse to reinforce teaching?

The baby is wearing a sack-type sleeper.

A child diagnosed with congenital hypothyroidism is being dismissed from the NICU. What information should the nurse plan to teach the parents?

The correct dose of levothyroxine (Synthroid) is 10-15 mg/kg/day.

A newborn baby has a calcium level of 7.1 mg/dL. What information should the nurse provide the parents?

The level will be rechecked at 72 hours.

The nurse is assessing an infant's extrusion reflex. To perform this correctly, what steps does the nurse take?

Touch the tip of the infant's tongue.

The nurse is watching new parents suction their newborn. The baby begins gagging. What action should the nurse demonstrate to the parents?

Turn the baby's head to the side.

A nurse is caring for a premature infant on oxygen. What action is critical for the infant's safety?

Use the lowest amount of oxygen possible.

A neonatal nurse is demonstrating the proper technique for assessing a newborn's pulse. What technique does the nurse demonstrate?

Use two fingers and the thumb to feel the pulse at the base of the umbilical cord.

The perinatal nurse demonstrates the correct technique of postpartum uterine palpation for a student nurse. The nurse explains that support for the lower uterine segment is critical, because without it there is an increased risk of which complication?

Uterine inversion

The perinatal nurse teaches the postpartum woman about warning signs regarding the development of postpartum infection. The nurse teaches that fever and which of the following symptoms need to be assessed by a health-care provider?

Uterine tenderness

New parents wish to include their extended family in welcoming their new baby. What suggestion does the nurse offer this couple?

Welcome family in small groups for short visits.

The perinatal nurse is teaching the patient about breastfeeding and explains that which of the following is the most appropriate time to breastfeed?

When her infant is in a quiet alert state

A healthy term infant is being discharged at 48 hours of age. When should the nurse instruct the mother to follow up with a bilirubin assessment?

Within 5 days

A neonate has difficulty maintaining a normal temperature. A student nurse prepares to place the infant under a radiant warmer. What action by the student leads the faculty member to intervene?

Wraps the baby in a warmed blanket