Exam 12 Review

Breast-feeding instructions for the postpartum mother should include avoidance of soaps on the nipples, frequent changing of breast pads, intermittent exposure of nipples to air, and hand washing before handling the breast and before breast-feeding. The nurse understands that these measures are specific to the prevention of:

Mastitis

A first time mother is to be discharging from the hospital tomorrow with her baby girl. Which behavior indicates a need for further intervention by the nurse before she can be discharged?

Leaves the baby on her bed while she takes a shower

The mother asks the practical nurse (PN) what her infant may need if the phenylketonuria (PKU) test is positive. What type of treatment should the PN tell the mother will be required?

Lifelong dietary management

The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements immediately postpartum?

Lower than before she became pregnant

Which intervention should the practical nurse (PN) use to facilitate mother-infant attachment in a 15-year-old primigravida who seems to ignore her newborn?

Show the mother how the baby initiates interaction and responds to her

A new mother states that her baby is having very frequent loose stools and vomiting after each formula feeding. She and her husband are both lactose intolerant. What is the best advice for her?

Switch your newborn to soy formula and see if that improves tolerance

The nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago. All of the following are reportable to postpartum signs and symptoms EXCEPT?

Temperature of 38° C (100.4° F)

Which client is a candidate for the administration of human immune globulin (RhoGam) after delivery?

The Rh-negative mother who delivers a Rh-positive baby

Which statement by a postpartum client indicates that further teaching is not needed regarding thrombus formation?

"I'll put my support stockings on every morning before rising."

Which 2 interventions facilitate parent-infant bonding for the premature newborn infant:

-Allow parents to touch infant as soon as possible -Teach parents kangaroo care, if appropriate

Which information should the nurse recognize as contributing to mastitis in the breastfeeding mother? (Select all that apply)

-Blisters on both nipples -Supplementing feedings -Insufficient emptying of breast

A new mother of a spina bifida infant is watching you provide care to her baby. What things are you going to teach her while you're caring for her son? (Select all that apply)

-Ensure that your son sleeps on his stomach to prevent pressure on his back -This dressing is sterile and soaked with saline to prevent the sac from drying out

As part of your postpartum assessment for an uncomplicated vaginal delivery, you would assess the following items: (Select all that apply)

-Height and tone of the fundus -Patient's level of comfort -Urinary and bowel elimination -The perineum and vaginal drainage

Characteristics of a Down's Syndrome infant are: (Select all that apply)

-Protruding tongue -Close set eyes -Hypotonia -Flat nose -Deep set creases on palms

What are signs of intraventricular hemorrhage in the newborn after a rapid delivery?

-Respiratory deterioration -Low tone, lethargy, decreased reflexes, bulging fontanels, poor feeding, apnea and cyanosis

What is the scale used to determine the newborns gestational age?

Ballard scale

A mother is breastfeeding her newborn infant but is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The best nursing response would be to:

Breast feed on demand at least every 2-3 hours

The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which is important to understand about vitamin K?

It is not initially synthesized because of a sterile bowel at birth

Infants who develop cephalohematoma are at increased risk for:

Jaundice

An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should be included in the child's postoperative care? (Select all that apply)

-Monitor for abdominal distention -Maintain an accurate record of intake and output -Pump the shunt reservoir to maintain patency -Observe closely for signs of infection

Which of the following interventions must be performed by the nurse immediately after birth of the infant? (Select all that apply)

-Umbilical cord care -Vitamin K prophylaxis -Ophthalmic prophylaxis

A nurse is assisting in caring for a postpartum client experiencing uterine hemorrhage. In planning to meet the psychosocial needs of the client, the nurse would:

Keep the client and her family members informed of progress

Which principle is important in providing and teaching cord care?

Keeping the cord dry will decrease bacterial growth

A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered?

Activated partial thromboplastin time

A first time mother asks you why you are putting erythromycin ointment in her baby's eyes. Your best answer is:

This ointment is for the prevention of neonatal conjunctivitis

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot?

Babinski

As you receive a report, which assessment finding should you recognize as indicative of a vaginal laceration?

Bright red continuous trickle of blood from vagina

A mother who is preparing for discharge begins asking the practical nurse (PN) questions about bottle feeding her infant. What information should the LPN reinforce?

Burp the newborn periodically during the feeding

The nurse is conducting a staff in-service on common problems associated with myelomeningocele. Which common problem is associated with this defect?

Hydrocephalus

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?

Hypoglycemia

When taking care of an infant of a diabetic mother, what things do you want to make sure that you check on mother and baby?

Hypoglycemia, trauma during birth

A nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which of the following would best indicate a hematoma?

Changes in vital signs

The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infant's postoperative care include:

Cleansing the suture line, supine and side-lying positions, and arm restraints

A new mother asks whether she should feed her newborn colostrum because it is not real milk. The nurse's best answer includes which information?

Colostrum is high in immunoglobulins, protein, vitamins, and minerals

A first time mother asks about the milk production that she will experience. As a competent prudent nurse, you explain the stages of milk production as:

Colostrum, transitional milk, mature milk

A new father is not sure about allowing his baby to be put under the "bili-lites". What is your best explanation?

If we don't treat your baby's jaundice it could lead to a worse condition called kernicterus

Which of the following would indicate respiratory distress in a newborn?

Intercostal retractions

A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?

It involves swelling of tissue over the presenting part of the presenting head

What condition is a "pavlik harness" used to treat?

Developmental hip dysplasia

The mother of a male newborn calls the clinic to inquire about the formation of a yellow crust over her son's circumcision area. What information should the practical nurse (PN) provide?

Do not remove the yellow crust from the site

A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate?

Document the findings

The practical nurse (PN) quickly moves the crib of a male newborn and notices that his legs flex, arms fan out, and then return toward his midline. What action should the PN implement?

Document the newborn demonstrates a Moro reflex

A 3-day old newborn who weighed 7 pounds, 8 ounces at birth is breast feeding and now weighs 6 pound and 15 ounces. Which action should the practical nurse take?

Document the weight loss

A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by:

Drying the infant in a warm blanket and place under a radiant warmer

Which nursing intervention would be considered a priority for a newborn infant who is receiving phototherapy in an isolette?

Ensure eye patches are in place

A maculopapular rash with a red base and a small white papule in the center is:

Erythema toxicum

An Rh negative mother forms antibodies when blood from an Rh positive fetus enters her circulation. This condition leads to which congenital hemolytic disease?

Erythroblastosis Fetalis

The mother of a post-term infant asks the nurse why the baby is being watched so closely. Your best explanation is:

May be at risk for asphyxia and hypoxia

You are doing your assessment on a premature baby in the NICU. You note that the baby has abdominal distention, decreased bowel sounds and bloody diarrhea. You alert the provider that you think this baby has:

Necrotizing Enterocolitis

The nurse expecting a uterine infection in a postpartum client should assess the:

Odor of the lochia

The nurse should expect medical intervention for subinvolution to include:

Oral methylergonovine maleate (Methergine) for 48 hours

Why are premature infants often gavage fed?

Preterm infants often have an inability to coordinate sucking and/or swallowing reflexes

Three days post-delivery, you observe for the first time a new mother as being anxious, irritable, and tearful and fatigue. What is the most appropriate action?

Provide empathy for the mother

When newborns have been on formula for 36-48 hours, they should have a:

Screening for PKU

A baby is born with talipes valgus (club foot). The mother asks you as the LPN what can be done to fix the problem and how long will it take? Your best answer is:

Serial casting can be done beginning now and it may take 4-6 weeks

The practical nurse (PN) places a newborn who is 4 hours old with an axillary temperature of 97.2°F under the radiant heat warmer. Which rationale supports the PN's action?

The newborn's thin layer of subcutaneous fat provides poor insulation

A new mother asks about being told that she has a positive Coombs test but doesn't know what that means. The most correct explanation is:

There are antibodies present in her blood that fight against fetal blood

The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum?

Thigh and gluteal creases are asymmetric

The nurse is preparing to admit a newborn with myelomeningocele to the neonatal intensive care nursery. Which describes this newborn's defect?

Visible defect with an external saclike protrusion containing meninges, spinal fluid, and nerves

The physician has ordered your postpartum client to receive sitz baths to promote healing of her 2nd degree episiotomy. Which is the best explanation:

You can't start sitz baths until 24 hours after delivery