Exam 3 ob ch 16-24

7. After the birth of a newborn, which action would the nurse do first to assist in thermoregulation? A. Dry the newborn thoroughly. B. Put a hat on the newborn's head. C. Check the newborn's temperature. D. Wrap the newborn in a blanket.

Answer: A Rationale: Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.

6. A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates: A. normal progression of behavior. B. probable hypoglycemia. C. physiological abnormality. D. inadequate oxygenation.

Answer: A Rationale: From 30 to 120 minutes of age, the newborn enters the second stage of transition, that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.

1. A newborn with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which measure would the nurse anticipate as possibly necessary for this newborn? A. extracorporeal membrane oxygenation (ECMO) B. respiratory support with a ventilator C. insertion of a laryngoscope for deep suctioning D. replacement of an endotracheal tube via X-ray

Answer: A Rationale: If conventional measures are ineffective, then the nurse would need to prepare the newborn for ECMO. Hyperoxygenation, ventilatory support, and direct tracheal suctioning are typically used initially to promote tissue perfusion. However, if these are ineffective, ECMO would be the next step.

4. Assessment of a newborn reveals a heart rate of 180 beats per minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A. How many hours old is this newborn? B. How long ago did this newborn eat? C. What was the newborn's birthweight? D. Is acrocyanosis present?

Answer: A Rationale: The typical heart rate of a newborn ranges from 110 to 160 beats per minute with wide fluctuation during activity and sleep. Typically heart rate is assessed every 30 minutes until stable for 2 hours after birth. The time of the newborn's last feeding and his birthweight would have no effect on his heart rate. Acrocyanosis is a common normal finding in newborns.

5. Which action would be most appropriate for the nurse to take when a newborn has an unexpected anomaly at birth? A. Show the newborn to the parents as soon as possible while explaining the defect. B. Remove the newborn from the birthing area immediately. C. Inform the parents that there is nothing wrong at the moment. D. Tell the parents that the newborn must go to the nursery immediately.

Answer: A Rationale: When an anomaly is identified at or after birth, parents need to be informed promptly and given a realistic appraisal of the severity of the condition, the prognosis, and treatment options so that they can participate in all decisions concerning their child. Removing the newborn from the area or telling them that the newborn needs to go to the nursery immediately is inappropriate and would only add to the parents' anxieties and fears. Telling them that nothing is wrong is inappropriate because it violates their right to know.

20. A neonate is born at 42 weeks' gestation weighing 4.4 kg (9 lb, 7 oz) with satisfactory Apgar scores. Two hours later birth the neonate's blood sugar indicates hypoglycemia. Which symptoms would the baby demonstrate? Select all that apply. A. poor sucking B. respiratory distress C. weak cry D. jitteriness E. blood glucose >40 mg/dl

Answer: A, B, C, D Rationale: Some of the common problems associated with newborns experiencing a variation in gestational age, such as a postterm newborn, are respiratory distress, jitteriness, feeble sucking, weak cry, and a blood glucose of 40 mg/dl.

29. After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify which concept as reflecting the enduring nature of their relationship, one that involves placing the infant at the center of their lives and finding their own way to assume the parental identity? A. reciprocity B. commitment C. bonding D. attachment

Answer: B Rationale: Commitment refers to the enduring nature of the relationship. The components of this are twofold: centrality and parent role exploration. In centrality, parents place the infant at the center of their lives. They acknowledge and accept their responsibility to promote the infant's safety, growth, and development. Parent role exploration is the parents' ability to find their own way and integrate the parental identity into themselves. The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.

5. After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A. presence of lochia serosa B. frequent scant voidings C. fundus firm, below umbilicus D. milk filling in both breasts

Answer: B Rationale: Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.

5. The nurse prepares to assess a newborn who is considered to be large-for-gestational-age (LGA). Which characteristic would the nurse correlate with this gestational age variation? A. strong, brisk motor skills B. difficulty in arousing to a quiet alert state C. birthweight of 7 lb, 14 oz (3,572 g) D. wasted appearance of extremities

Answer: B Rationale: LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb, 13 oz (3,997 g) at term.

10. A nurse is reviewing the maternal history of a large-for-gestational-age (LGA) newborn. Which factor, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of this newborn? A. substance use disorder B. diabetes C. preeclampsia D. infection

Answer: B Rationale: Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdate gestation, maternal obesity, male fetus, and genetics. Substance use disorder is associated with small-for-gestational-age (SGA) newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth.

10. A postpartum client is prescribed medication therapy as part of the treatment plan for postpartum hemorrhage. Which medication would the nurse expect to administer in this situation? A. Magnesium sulfate B. methylergonovine C. Indomethacin D. nifedipine

Answer: B Rationale: Methylergonovine, along wiht oxytocin and carboprost are drugs used to manage postpartum hemorrhage. Magnesium sulfate, indomethecin, and nifedipine are used to control preterm labor.

7. During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: A. milia. B. Mongolian spots. C. stork bites. D. birth trauma.

Answer: B Rationale: Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Milia are unopened sebaceous glands frequently found on a newborn's nose. Stork bites are superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling, and possible deformity.

8. Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: A. habituation. B. motor maturity. C. orientation. D. social behaviors.

Answer: B Rationale: Motor maturity is evidenced by rhythmic, spontaneous movements. Habituation is manifested by the newborn's ability to respond to the environment appropriately. Orientation involves the newborn's response to new stimuli, such as turning the head to a sound. Social behaviors involve cuddling and snuggling into the arms of a parent.

3. When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is some soft bedding material, and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching for which reason? A. The newborn should not be sleeping on his back. B. Soft bedding material should not be in areas where infants sleep. C. The bulb syringe should not be kept in the bassinet. D. This newborn should be sleeping in a crib.

Answer: B Rationale: The nurse should instruct the mother to remove all fluffy bedding, quilts, stuffed animals, and pillows from the crib to prevent suffocation. Newborns and infants should be placed on their backs to sleep. Having the bulb syringe nearby in the bassinet is appropriate. Although a crib is the safest sleeping location, a bassinet is appropriate initially.

10. The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? A. evaporation B. conduction C. convection D. radiation

Answer: B Rationale: Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

3. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed? A. ferrous sulfate B. methylergonovine C. docusate D. bromocriptine

Answer: C Rationale: A stool softener such as docusate may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.

20. When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which area? A. superficial structures above the muscle B. through the perineal muscles C. through the anal sphincter muscle D. through the anterior rectal wall

Answer: C Rationale: A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only the skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

27. When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes? A. gastrointestinal and hepatic B. urinary and hematologic C. respiratory and cardiovascular D. neurological and integumentary

Answer: C Rationale: Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

24. A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which measure would the nurse include as the most cost-effective method for prevention? A. prophylactic heparin administration B. compression stockings C. early ambulation D. warm compresses

Answer: C Rationale: Although compression stockings and prophylactic heparin administration may be appropriate, the most cost-effective preventive method is early ambulation. It is also the easiest method. Warm compresses are used to treat superficial venous thrombosis.

14. A postpartum woman is having difficulty voiding for the first time after giving birth. Which action would be least effective in helping to stimulate voiding? A. pouring warm water over her perineal area B. having her hear the sound of water running nearby C. placing her hand in a basin of cool water D. standing her in the shower with the warm water on

Answer: C Rationale: Helpful measures to stimulate voiding include placing her hand in a basin of warm water, pouring warm water over her perineal area, hearing the sound of running water nearby, blowing bubbles through a straw, standing in the shower with the warm water turned on, and drinking fluids.

2. A nurse is providing care to a newborn. The nurse suspects that the newborn is developing sepsis based on which assessment finding? A. increased urinary output B. interest in feeding C. temperature instability D. wakefulness

Answer: C Rationale: Manifestations of sepsis are typically nonspecific and may include hypothermia (temperature instability), oliguria or anuria, lack of interest in feeding, and lethargy.

20. A postpartum woman is prescribed oxytocin to stimulate the uterus to contract. Which action would be most important for the nurse to do? A. Administer the drug as an IV bolus injection. B. Give as a vaginal or rectal suppository. C. Piggyback the IV infusion into a primary line. D. Withhold the drug if the woman is hypertensive.

Answer: C Rationale: When giving oxytocin, it should be diluted in a liter of IV solution and the infusion set up to be piggy-backed into a primary line to ensure that the medication can be discontinued readily if hyperstimulation or adverse effects occur. It should never be given as an IV bolus injection. Oxytocin may be given if the woman is hypertensive. Oxytocin is not available as a vaginal or rectal suppository.

28. As part of an in-service program to a group of home health care nurses who care for postpartum women, a nurse is describing postpartum depression. The nurse determines that the teaching was successful when the group identifies that this condition becomes evident at which time after birth of the newborn? A. in the first week B. within the first 2 weeks C. in approximately 1 month D. within the first 6 weeks

Answer: D Rationale: PPD usually has a gradual onset and becomes evident within the first 6 weeks postpartum. Postpartum blues typically manifests in the first week postpartum. Postpartum psychosis usually appears about 3 months after birth of the newborn.

11. A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn? A. symmetrical chest movements B. periodic breathing C. respirations of 40 breaths/minute D. sternal retractions

Answer: D Rationale: Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life.

9. A woman who is experiencing postpartum hemorrhage is extremely apprehensive and diaphoretic. The woman's extremities are cool and her capillary refill time is increased. Based on this assessment, the nurse suspects that the client is experiencing approximately how much blood loss? A. 20% B. 30% C. 40% D. 60%

Answer: D Rationale: The client's assessment indicated mild shock, which is associated with a 20% blood loss. Moderate shock occurs with a blood loss of 30 to 40%. Severe shock is associated with a blood loss greater than 40%.

8. While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first? A. Alert the primary care provider stat, and turn the newborn to her right side. B. Administer oxygen via facial mask by positive pressure. C. Lower the newborn's head to stimulate crying. D. Aspirate the oral and nasal pharynx with a bulb syringe.

Answer: D Rationale: The nurse's first action would be to suction the oral and nasal pharynx with a bulb syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the blockage due to secretions. Administering oxygen via positive pressure is not indicated at this time. Lowering the newborn's head would be inappropriate.

17. A term neonate has been admitted to the observational newborn nursery with the diagnosis of being small for gestational age. Which factors would predispose the neonate to this diagnosis? Select all that apply. A. The mother had chronic placental abruption. B. At birth the placenta was noted to be decreased in weight. C. On assessment the placenta had areas of infarction. D. At birth the placenta was a shiny Schultz presentation. E. Placental talipes was present at birth.

Answer: A, B, C, D Rationale: Placental factors that can contribute to a small for gestational age infant include chronic placental abruption, infarction on surface of placenta, and a decreased placental weight. A shiny Schultz placenta is a normal description because the fetal side of the placenta comes out first, which is shiny. Placenta talipes does not exist.

21. Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild shock. Which finding would the nurse expect to assess? Select all that apply. A. diaphoresis B. tachycardia C. oliguria D. cool extremities E. confusion

Answer: A, D Rationale: Signs and symptoms of mild shock include diaphoresis, increased capillary refill, cool extremities, and maternal anxiety. Tachycardia and oliguria suggest moderate shock. Confusion suggests severe shock.

10. Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when the Ortolani maneuver is performed. What would the nurse suspect? A. slipping of the periosteal joint B. developmental hip dysplasia C. normal newborn variation D. overriding of the pelvic bone

Answer: B Rationale: A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the area. This, along with uneven gluteal creases, suggests developmental hip dysplasia. These findings are not a normal variation and are not associated with slipping of the periosteal joint or overriding of the pelvic bone.

3. A nurse is providing care to a newborn who is receiving phototherapy. Which action would the nurse most likely include in the plan of care? A. keeping the newborn in the supine position B. covering the newborn's eyes while under the bililights C. ensuring that the newborn is covered or clothed D. reducing the amount of fluid intake to 8 ounces daily

Answer: B Rationale: During phototherapy, the newborn's eyes are covered to protect them from the lights. The newborn is turned every 2 hours to expose all areas of the body to the lights and is kept undressed, except for the diaper area, to provide maximum body exposure to the lights. Fluid intake is increased to allow for added fluid, protein, and calories.

8. The nurse is providing care to a newborn who was born at 36 weeks' gestation. Based on the nurse's understanding of gestational age, the nurse identifies this newborn as: A. preterm. B. late preterm. C. term. D. postterm.

Answer: B Rationale: Gestational age is typically measured in weeks: a newborn born before completion of 37 weeks is classified as a preterm newborn, and one born after completion of 42 weeks is classified as a postterm newborn. An infant born from the first day of the 38th week through 42 weeks is classified as a term newborn. The late preterm newborn (near term) is one who is born between 34 weeks and 36 weeks, 6 days of gestation.

22. After teaching a group of nurses during an in-service program about risk factors associated with postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which risk factors? Select all that apply. A. prolonged labor B. placenta previa C. null parity D. hydramnios E. labor augmentation

Answer: B, D, E Rationale: Risk factors for postpartum hemorrhage include precipitous labor less than 3 hours, placenta previa or abruption, multiparity, uterine overdistention such as with a large infant, twins, or hydramnios, and labor induction or augmentation. Prolonged labor over 24 hours is a risk factor for postpartum infection.

2. A nurse is assessing a postterm newborn. Which finding would the nurse correlate with this gestational age variation? A. moist, supple, plum skin appearance B. abundant lanugo and vernix C. thin umbilical cord D. absence of sole creases

Answer: C Rationale: A postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet.

31. A neonate is diagnosed with Erb's palsy after birth. The parents are concerned about their neonate's limp arm. The nurse explains the neonate will be scheduled to receive what recommended treatment for this condition first? A. Physical therapy to the joint and extremity B. Nothing but time and let nature take its course C. Surgery to correct the joint and muscle alignment D. Immobilization of the shoulder and arm

Answer: D Rationale: Treatment for a neonate with Erb palsy usually involves immobilization of the upper arm across the upper abdomen/chest to protect the shoulder from excessive motion for the first week; then gentle passive range-of-motion exercises are performed daily to prevent contractures. Surgery is not needed to regain function since there is no structural injury. Doing nothing will not help the neonate regain function in the extremity.

28. A nurse is teaching a group of new parents about their newborns' sensory capabilities. The nurse would identify which sense as being well-developed at birth? A. hearing B. touch C. taste D. vision

Answer: A Rationale: Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Vision is the least mature sense at birth. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

25. A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's: A. finger. B. heel. C. scalp vein. D. umbilical vein.

Answer: B Rationale: Screening tests for genetic and inborn errors of metabolism require a few drops of blood taken from the newborn's heel. The finger, scalp vein, or umbilical vein are inappropriate sites for the blood sample.

28. The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation? A. respiratory rate of 54 breaths/minute B. abdominal breathing C. nasal flaring D. acrocyanosis

Answer: C Rationale: Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.

16. Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chest circumference would be: A. 30 cm. B. 32 cm. C. 34 cm. D. 36 cm.

Answer: B Rationale: The newborn's chest should be round, symmetric, and 2 to 3 cm smaller than the head circumference. Therefore, this newborn's chest circumference of 31 to 32 cm would be normal.

23. During a neonate resuscitation attempt, the neonatologist has ordered 0.1 mL/kg IV epinephrine (adrenaline) in a 1:10,000 concentration to be given stat. The neonate weighs 3000 grams and is 38 centimeters long. How many millimeters (mL) should the nurse administer? Record your answer using one decimal place.

Answer: 0.3 Rationale: Epinephrine should be given if heart rate is 60 after 30 seconds of compressions and ventilation.

21. The pediatrician prescribes morphine sulphate 0.2 mg/kg orally q 4 hour for a neonate suffering from drug withdrawal. The neonate weighs 3,800 grams. How much of drug will the nurse give in 24 hours? Record your answer using two decimal places.

Answer: 4.56 Rationale: 3800 grams = 3.8 kg 3.8 kg/kg x 0.20 mg x 6 doses = 4.56 mg in 24 hours

6. A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn? A. infection B. hemorrhage C. trauma D. hypovolemia

Answer: A Rationale: Although hemorrhage, trauma, and hypovolemia may be problems, the prolonged labor with the prolonged premature rupture of membranes places the client at high risk for a postpartum infection. The rupture of membranes removes the barrier of amniotic fluid, so bacteria can ascend.

11. A newborn has an Apgar score of 6 at 5 minutes. Which action would be the priority? A. initiating IV fluid therapy B. beginning resuscitative measures C. promoting kangaroo care D. obtaining a blood culture

Answer: B Rationale: An Apgar score below 7 at 1 or 5 minutes indicates the need for resuscitation. Intravenous fluid therapy and blood cultures may be done once resuscitation is started. Kangaroo care would be appropriate once the newborn is stable.

19. When assessing a newborn's reflexes, the nurse strokes the newborn's cheek, and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive? A. palmar grasp reflex B. tonic neck reflex C. Moro reflex D. rooting reflex

Answer: D Rationale: The rooting reflex is elicited by stroking the newborn's cheek. The newborn should turn toward the side that was stroked and should begin to make sucking movements. The palmar grasp reflex is elicited by placing a finger on the newborn's open palm. The baby's hand will close around the finger. Attempting to remove the finger causes the grip to tighten. The tonic neck reflex is elicited by having the newborn lie on the back and turning the head to one side. The arm toward which the baby is facing should extend straight away from the body with the hand partially open, whereas the arm on the side away from the face is flexed and the fist is clenched tightly. Reversing the direction to which the face is turned reverses the position. The Moro reflex is elicited by placing the newborn on his or her back, supporting the upper body weight of the supine newborn by the arms using a lifting motion without lifting the newborn off the surface. The arms are released suddenly, the newborn will throw the arms outward and flex the knees, and then the arms return to the chest. The fingers also spread to form a C.

29. The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism? A. evaporation B. conduction C. convection D. radiation

Answer: A Rationale: Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

28. A client has given birth to a full-term infant weighing 10 pounds 5 ounces (4678 grams). What priority assessment should be completed by the nurse? A. Blood glucose B. Temperature control C. Feeding difficulty D. Perfusion

Answer: A Rationale: Hypoglycemia is a common concern with a large-for-gestational age (LGA) infant. This infant will deplete the glucose stores very rapidly. Therefore, it is important to assess the glucose level within 30 minutes of birth and to repeat every hour until stable. Hypoglycemia is defined as a gluose level less than 35 to 45 mg/dl (1.94 to 2.50 mmol/l) in the first 4 hours of life, and intervention should occur when the glucose is less than 40 mg/dl (2.22 mmol/l). Intervention should also occur if the blood glucose is less than 45 mg/dl (2.50 mmol/l) at 4 and 24 hours of life respectively. Generally the nurse assesses symptoms of jitteriness, irritability and tachypnea first. These symptoms can progress to temperature instability, lethargy, bradycardia, hyponia and seizures.

13. When describing the neurologic development of a newborn to parents, the nurse would explain that it occurs in which fashion? A. head-to-toe B. lateral-to-medial C. outward-to-inward D. distal-caudal

Answer: A Rationale: Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center to outside) pattern.

15. A new mother asks the nurse, "Why has my baby lost weight since he was born?" The nurse integrates knowledge of which cause when responding to the new mother? A. insufficient calorie intake B. shift of water from extracellular space to intracellular space C. increase in stool passage D. overproduction of bilirubin

Answer: A Rationale: Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth, shifting of intracellular water to extracellular space, and insensible water loss. Stool passage and bilirubin have no effect on weight loss.

12. When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure? A. early parent-infant contact following birth B. expert medical care for the labor and birth C. good nutrition and prenatal care during pregnancy D. grandparent involvement in infant care after birth

Answer: A Rationale: Optimal bonding requires a period of close contact between the parents and newborn within the first few minutes to a few hours after birth. Expert medical care, nutrition and prenatal care, and grandparent involvement are not associated with the promotion of bonding.

29. A newborn infant has been diagnosed with persistent pulmonary hypertension of the newborn (PPHN). In providing care for this newborn what intervention should be the nurse's priority? A. Measure blood pressure B. Obtain arterial blood gases C. Monitor oxygen saturation D. Suction the newborn

Answer: A Rationale: PPHN occurs when there is persistent fetal circulation after birth. The pulmonary pressures do not decrease at birth when the newborn begins breathing causing hypoxemia, acidosis and vasoconstriction of the pulmonary artery. This newborn requires much care and possibly extracorporeal membrane oxygenation (ECMO). The nurse should monitor the newborn's blood pressure regularly, because hypotension can occur from ensuing heart failure and the persistent hypoxemia. Vasopressors may be needed for this newborn. The newborn should not be suctioned. Doing so causes more stimulation and worsens respiratory issues. Arterial blood gases will be obtained regularly, but they are not a priority nursing intervention. Oxygen saturation should always be monitored in a newborn with respiratory distress.

13. A nurse is making a home visit to a postpartum client. Which finding would lead the nurse to suspect that a woman is experiencing postpartum psychosis? A. delirium B. feelings of guilt C. sadness D. insomnia

Answer: A Rationale: Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. It is manifested by depression that escalates to delirium, hallucinations, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings of guilt, sadness, and insomnia are associated with postpartum depression.

30. On a follow-up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition? A. delusional beliefs B. feelings of anxiety C. sadness D. insomnia

Answer: A Rationale: Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. It is manifested by depression that escalates to delirium, hallucinations, delusional beliefs, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings of anxiety, sadness, and insomnia are associated with postpartum depression.

1. A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take? A. Document the finding, as it is a normal finding at this time. B. Contact the primary care provider, as it indicates early DIC. C. Contact the primary care provider, as it is a first sign of postpartum eclampsia. D. Obtain a prescription for a CBC, as it suggests postpartum anemia.

Answer: A Rationale: Pulse rates of 60 to 80 beats per minute at rest are normal during the first week after birth. This pulse rate is called puerperal bradycardia.

5. A multipara client develops thrombophlebitis after birth. Which assessment findings would lead the nurse to intervene immediately? A. dyspnea, diaphoresis, hypotension, and chest pain B. dyspnea, bradycardia, hypertension, and confusion C. weakness, anorexia, change in level of consciousness, and coma D. pallor, tachycardia, seizures, and jaundice

Answer: A Rationale: Sudden unexplained shortness of breath and reports of chest pain along with diaphoresis and hypotension suggest pulmonary embolism, which requires immediate action. Other signs and symptoms include tachycardia, apprehension, hemoptysis, syncope, and sudden change in the woman's mental status secondary to hypoxemia. Anorexia, seizures, and jaundice are unrelated to a pulmonary embolism.

11. A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex? A. Babinski B. tonic neck C. stepping D. plantar grasp

Answer: A Rationale: The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The tonic neck reflex is tested by having the newborn lie on his back and then turn his head to one side. The stepping reflex is elicited by holding the newborn upright and inclined forward with the soles of the feet on a flat surface. The plantar grasp reflex is elicited by placing a finger against the area just below the newborn's toes.

12. While reviewing a newborn's medical record, the nurse notes that the chest X-ray shows a ground glass pattern. The nurse interprets this as indicative of: A. respiratory distress syndrome. B. transient tachypnea of the newborn. C. asphyxia. D. persistent pulmonary hypertension.

Answer: A Rationale: The chest X-ray of a newborn with RDS reveals a reticular (ground glass) pattern. For TTN, the chest X-ray shows lung overaeration and prominent perihilar interstitial markings and streakings. A chest X-ray for asphyxia would reveal possible structural abnormalities that might interfere with respiration, but the results are highly variable. An echocardiogram would be done to evaluate persistent pulmonary hypertension.

3. Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as: A. a good time to initiate breast-feeding. B. the period of decreased responsiveness preceding sleep. C. a sign that the infant is being overstimulated. D. evidence that the newborn is becoming chilled.

Answer: A Rationale: The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breastfeeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. None of the behaviors indicate overstimulation. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.

5. When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority? A. hypothermia B. impaired parenting C. deficient fluid volume D. risk for infection

Answer: A Rationale: The newborn's heart rate is slightly below the accepted range of 120 to 160 beats per minute; the respiratory rate is at the high end of the accepted range of 30 to 60 breaths per minute. However, the newborn's temperature is significantly below the accepted range of 97.7 to 99.7? (36.5 to 37.6?). Therefore, the priority problem area is hypothermia. There is no information to suggest impaired parenting. Additional information is needed to determine if there is deficient fluid volume or a risk for infection.

7. A nurse is developing the plan of care for a small-for-gestational-age newborn. Which action would the nurse determine as a priority? A. Preventing hypoglycemia with early feedings B. Observing for newborn reflexes C. Promoting bonding between the parents and the newborn D. Monitoring vital signs every 2 hours

Answer: A Rationale: The nurse must consider the implications of a small-for-gestational-age newborn. With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for newborn reflexes, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn.

23. While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next? A. Document this as pseudo menstruation. B. Notify the primary care provider immediately. C. Obtain a culture of the discharge. D. Inspect for engorgement.

Answer: A Rationale: The nurse should assess pseudomenstruation, a vaginal discharge composed of mucus mixed with blood, which may be present during the first few weeks of life. This discharge requires no treatment. The discharge is a normal finding and thus does not need to be reported immediately. It is not an indication of infection. The female genitalia normally will be engorged, so assessing for engorgement is not indicated.

18. The nurse is inspecting the external genitalia of a male newborn. Which finding would alert the nurse to a possible problem? A. limited rugae B. large scrotum C. palpable testes in scrotal sac D. negative engorgement

Answer: A Rationale: The scrotum usually appears relatively large and should be pink in white neonates and dark brown in neonates of color. Rugae should be well formed and should cover the scrotal sac. There should not be bulging, edema(engorgement), or discoloration. Testes should be palpable in the scrotal sac and feel firm and smooth and be of equal size on both sides of the scrotal sac.

7. When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage because: A. these measurements may not change until after the blood loss is large. B. the body's compensatory mechanisms activate and prevent any changes. C. they relate more to change in condition than to the amount of blood lost. D. maternal anxiety adversely affects these vital signs.

Answer: A Rationale: The typical signs of hemorrhage do not appear in the postpartum woman until as much as 1,800 to 2,100 ml of blood has been lost. In addition, accurate determination of actual blood loss is difficult because of blood pooling inside the uterus and on perineal pads, mattresses, and the floor.

19. Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also reports significant pelvic pain and is experiencing problems with voiding. The nurse suspects which condition? A. hematoma B. laceration C. bladder distention D. uterine atony

Answer: A Rationale: The woman most likely has a hematoma based on the findings: firm uterus with bright-red bleeding; localized bluish bulging area just under the skin surface in the perineal area; severe perineal or pelvic pain; and difficulty voiding. A laceration would involve a firm uterus with a steady stream or trickle of unclotted bright-red blood in the perineum. Bladder distention would be palpable along with a soft, boggy uterus that deviates from the midline. Uterine atony would be noted by a uncontracted uterus.

18. A pregnant woman gives birth to a small for gestational age neonate who is admitted to the neonatal intensive care unit with seizure activity. The neonate appears to have abnormally small eyes and a thin upper lip. The infant is noted to be microcephalic. Based on these findings, which substance would the nurse suspect the women of using during pregnancy? A. alcohol B. cocaine C. heroin D. methamphetamine

Answer: A Rationale: This child's features match those of fetal alcohol syndrome, including microcephaly, small palpebral (eyelid) fissures, abnormally small eyes, and fetal growth restriction.

30. A newborn is exhibiting symptoms of withdrawal and toxicology test have been prescribed. Which type of specimen should the nurse collect to obtain the most accurate results? A. Meconium B. Blood C. Urine D. Sputum

Answer: A Rationale: Toxicology screening of a newborn can include testing from blood, urine and meconium. These tests identify which drugs the newborn has been exposed to in utero. A meconium sample can detect which drugs the mother has been using from the second trimester of pregnancy until birth. It is the preferred method of testing. A urine screen identifies only the drugs the mother has used recently. The nurse should be careful not to mix the meconium sample with urine as it alters the results of the test. Blood samples can be taken and they will yield results of current drugs in the newborn's system, but they are invasive and noninvasive testing will provide the same results. If possible, testing on the mother is preferred. This testing provides quick results of what drugs the mother has been exposing the fetus to in utero. This will help in planning and providing care for the drug-exposed newborn. Sputum is not used for toxicology studies.

15. The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which action would be a priority? A. placing the call light within her reach B. teaching her how the sitz bath works C. telling her to use the sitz bath for 30 minutes D. cleaning the perineum with the peri-bottle

Answer: A Rationale: Tremendous hemodynamic changes are taking place within the woman, and safety must be a priority. Therefore, the nurse makes sure that the emergency call light is within her reach should she become dizzy or lightheaded. Teaching her how to use the sitz bath, including using it for 15 to 20 minutes, is appropriate but can be done once the woman's safety is ensured. The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can be done once the woman's safety needs are met.

1. Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess? A. respiratory rate 45 breaths/minute, irregular B. costal breathing pattern C. nasal flaring, rate 65 breaths/minute D. crackles on auscultation

Answer: A Rationale: Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and crackles suggest a problem.

6. A preterm newborn has received large concentrations of oxygen therapy during a 3-month stay in the NICU. As the newborn is prepared to be discharged home, the nurse anticipates a referral for which specialist? A. ophthalmologist B. nephrologist C. cardiologist D. neurologist

Answer: A Rationale: Use of large concentrations of oxygen and sustained oxygen saturations higher than 95% while on supplemental oxygen have been associated with the development of retinopathy of prematurity (ROP) and further respiratory complications in the preterm newborn (Martin & Deakins, 2020). For these reasons, oxygen should be used judiciously to prevent the development of further complications. A guiding principle for oxygen therapy is it should be targeted to levels appropriate to the condition, gestational age, and postnatal age of the newborn. As a result, an ophthalmology consult for follow-up after discharge is essential for preterm infants who have received extensive oxygen. Although referrals to other specialists may be warranted depending on the newborn's status, there is no information to suggest that any would be needed.

15. A postpartum woman is diagnosed with endometritis. The nurse interprets this as an infection involving which area? Select all that apply. A. endometrium B. decidua C. myometrium D. broad ligament E. ovaries F. fallopian tubes

Answer: A, B, C Rationale: Endometritis is an infectious condition that involves the endometrium, decidua, and adjacent myometrium of the uterus. Extension of endometritis can result in parametritis, which involves the broad ligament and possibly the ovaries and fallopian tubes, or septic pelvic thrombophlebitis.

21. A premature, 36-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply. A. increased serum bilirubin levels B. clay-colored stools C. tea-colored urine D. cyanosis E. Mongolian spots

Answer: A, B, C Rationale: Hyperbilirubinemia is indicated when the newborn presents with elevated serum bilirubin levels, tea-colored urine, and clay-colored stools. Cyanosis would not be seen in infants in this scenario. Mongolian spots are not associated with newborn jaundice.

25. A preterm newborn is admitted to the neonatal intensive care with the diagnosis of an omphalocele. What nursing actions would the nurse perform? Select all that apply. A. The abdominal contents are protected. B. Fluid loss of the neonate will be minimized. C. Perfusion to the exposed abdominal contents will be maintained. D. Neonatal weight loss will be prevented. E. Assessment of hyperbilirubinemia will be monitored.

Answer: A, B, C Rationale: Nursing management of newborns with omphalocele or gastroschisis focuses on preventing hypothermia, maintaining perfusion to the eviscerated abdominal contents by minimizing fluid loss, and protecting the exposed abdominal contents from trauma and infection. Weight loss at this point is not a priority, and neither is assessing bilirubin.

23. A 33 weeks' gestation neonate is being assessed for necrotizing enterocolitis (NEC). Which nursing actions would the nurse implement? Select all that apply. A. Perform hemoccult tests on stools. B. Monitor abdominal girth. C. Measure gastric residual before feeds. D. Assess bowel sounds before each feed. E. Assess urine output.

Answer: A, B, C, D Rationale: Always keep the possibility of NEC in mind when dealing with preterm newborns, especially when enteral feedings are being administered. Note feeding intolerance, diarrhea, bilestained emesis, or grossly bloody stools. Perform hemoccult tests on the bloody stool. Assess the neonate's abdomen for distention, tenderness, and visible loops of bowel. Measure the abdominal circumference, noting an increase. Listen to bowel sounds before each feeding. Determine residual gastric volume prior to feeding; when it is elevated, be suspicious for NEC. Assessing urine output is not essential.

24. A macrosomic infant in the newborn nursery is being observed for a possible fractured clavicle. For which would the nurse assess? Select all that apply. A. facial grimacing with movement B. bruising over area C. asymmetrical movement D. edema present E. positive Babinski reflex

Answer: A, B, C, D Rationale: Birth trauma for LGA newborns would be demonstrated by an obvious deformity, with bruising at the site and edema noted. There would be asymmetrical movement when the newborn moves the limb. Babinski reflex is a neurological test and would be normal to be positive.

26. The nurse in the neonatal intensive care unit is caring for a neonate she suspects is at risk for an intraventricular hemorrhage (IVH). Which nursing actions would be priorities? Select all that apply. A. Maintain fetal flexed position. B. Administer fluids slowly. C. Assess for bulging fontanel. D. Measure head circumference daily. E. Assess Moro reflex. F. Measure intake and output.

Answer: A, B, C, D Rationale: Care of the newborn with IVH is primarily supportive. Correct anemia, acidosis, and hypotension with fluids and medications. Administer fluids slowly to prevent fluctuations in blood pressure. Avoid rapid volume expansion to minimize changes in cerebral blood flow. Keep the newborn in a flexed, contained position with the head elevated to prevent or minimize fluctuations in intracranial pressure. Continuously monitor the newborn for signs of hemorrhage, such as changes in the level of consciousness, bulging fontanel, seizures, apnea, and reduced activity level. Also, measuring head circumference daily to assess for expansion in size is essential in identifying complications early. Moro reflex and intake and output are routine and not associated with IVH.

16. At a preconception counseling class, a client expresses concern and wonders how Healthy People 2030 will improve maternal-infant outcomes. Which response(s) by the nurse is appropriate? Select all that apply. A. Healthy People 2030 will reduce the rate of fetal and infant deaths. B. Healthy People 2030 will decrease the number of all infant deaths (within 1 year). C. Healthy People 2030 will decrease the number of neonatal deaths (within the first year). D. Healthy People 2030 will foster early and consistent prenatal care.

Answer: A, B, C, D Rationale: One of the leading health indicators as identified by Healthy People 2030 refers to decreasing the number of infant deaths. Acquired and congenital conditions account for a significant percentage of infant deaths. Specific objectives include reducing the rate of fetal deaths at 20 or more weeks of gestation though the nursing action of fostering early and consistent prenatal care; reducing the rate of all infant deaths (within 1 year) through the nursing actions of including education to place infants on their backs for naps and sleep to prevent sudden infant death syndrome (SIDS), avoiding exposing newborns to cigarette smoke, and ensuring that infants with birth defects receive health care needed in order to thrive; and reducing the occurrence of fetal alcohol syndrome (FAS) through the nursing actions or counseling girls and women to avoid alcohol use during pregnancy, and participating in programs for at-risk groups, including adolescents, about the effects of substance use, especially alcohol, during pregnancy.

27. A 20-hour-old neonate is suspected of having polycythemia. Which nursing intervention(s) will the nurse utilize to provide care for this neonate? Select all that apply. A. Obtain hemoglobin and hematocrit laboratory tests B. Provide early feedings to prevent hypoglycemia C. Maintain oxygen saturation parameters D. Monitor urinary output E. Insert a peripheral IV

Answer: A, B, C, D Rationale: Polycythemia in a neonate is defined as a hematocrit above 65% (0.65) and a hemoglobin level above 20 g/dl (200 g/l). The hematocrit and hemoglobin peak between 6 and 12 hours of life and then start to decrease. If these values do not decrease as expected, then hypoperfusion will occur and polycythemia will develop. In the beginning, the nurse may assess feeding difficulties, hypoglycemia, jitteriness and respiratory distress. As the condition worsens, a ruddy skin color could be seen, cyanosis could develop, the neonate could become lethargic and seizures could develop. Nursing care for this neonate requires obtaining hematocrit and hemoglobin laboratory tests at 2 hours, 12 hours and 24 hours. Feeding should be started to provide fluid, nutrition and prevent hypoglycemia. The oxygen saturation should be monitored. If the levels are below the established parameters from the health care provider, oxygen therapy will be needed. The urine output should be monitored continuously because polycythemia can cause real failure. A peripheral IV may or may not be needed. This would depend on the neonate's condition and if IV fluids would be required.

29. A client expresses concerns that her grandmothers had complicated pregnancies. What principle(s) should the nurse discuss to allay the fears of the client? Select all that apply. A. "We work to ensure that birth of high-risk infants happens in settings where we are able to care for them." B. "We will work with you to identify prenatal risk factors early and take actions to reduce their impact." C. "We support those at risk of having a preterm births with the goal of delaying early births." D. "We work to ensure care for mothers and infants to reduce infant illnesses, disabilities, and death." E. "We allow families to grieve the loss of a newborn, should it occur."

Answer: A, B, C, D Rationale: The nurse will attempt to allay the client's fears by discussing the actions the facility enacts to promote a healthy brith and infant. This includes ensuring the birth of high-risk infants takes place in settings that have the technological capacity to care for them, identifying risk factors early and taking action to reduce their impact, working to delay the birth of those pregancies identified at risk of preterm birht, and promoting an overall reduction in infant illness, disability, and death to proper care of the mother and infant. Although allowing a family to greive in instances of infant death, discussing this factor with the client is likely to create more fear.

26. A neonate is admitted to the newborn observation nursery with the possible diagnosis of polycythemia. The nurse would be observing for which findings? Select all that apply. A. ruddy skin color B. respiratory distress C. cyanosis D. pink gums and tongue E. jitteriness

Answer: A, B, C, E Rationale: Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy) and monitor blood results.

16. A 42-year-old woman is 26 weeks' pregnant. She lives at a shelter for female victims of intimate partner violence. Her blood pressure is 170/90 mm Hg, the fetal heart rate is 140 bpm, TORCH studies are positive, and she is bleeding vaginally. What findings put her at risk of giving birth to a small-for-gestational-age (SGA) infant? Select all that apply. A. the age of the client B. living in a shelter for victims of intimate partner violence C. vaginal bleeding D. fetal heart rate E. blood pressure F. positive test for TORCH

Answer: A, B, C, E, F Rationale: Some factors contributing to the birth of SGA newborns include maternal age of 20 or 35 years old, low socioeconomic status, and preeclampsia with increased blood pressure. The vaginal bleeding indicates placental problems, and she tests positive for sexually transmitted diseases by TORCH group infections.

18. A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply. A. Assess the axillary temperature every hour. B. Review maternal history. C. Assess environment for sources of heat loss. D. Bathe the neonate with warmer water. E. Minimize kangaroo care. F. Encourage skin-to-skin contact.

Answer: A, B, C, F Rationale: Proper care to promote thermoregulation include assessing the axillary temperature every hour, reviewing the maternal history to identify risk factors contributing to problem, assessing the environment for sources of heat loss, avoiding bathing and exposing newborn to prevent cold stress, and encouraging kangaroo care (mother or father holds preterm infant underneath clothing skin-to-skin and upright between breasts) to provide warmth.

24. A 30 weeks' gestation neonate born with low Apgar scores is in the neonatal intensive care unit with respiratory distress syndrome and underwent an exchange transfusion for anemia. Which factors place the neonate at risk for necrotizing enterocolitis? Select all that apply A. preterm birth B. respiratory distress syndrome C. low Apgar scores D. hyperthermia E. hyperglycemia F. exchange transfusion

Answer: A, B, C, F Rationale: The predisposing factors for the development of necrotizing enterocolitis include preterm labor, respiratory distress syndrome, exchange transfusion, and low birth weight. Low Apgar scores, hypothermia, and hypoglycemia are also risk factors.

14. A nurse is conducting a refresher program for a group of nurses working in the newborn nursery. After teaching the group about variations in newborn head size and appearance, the nurse determines that the teaching was successful when the group identifies which variation as normal? Select all that apply. A. cephalhematoma B. molding C. closed fontanels D. caput succedaneum E. posterior fontanel diameter 1.5 cm

Answer: A, B, D Rationale: Normal variations in newborn head size and appearance include cephalhematoma, molding, and caput succedaneum. Microcephaly, closed fontanels, or a posterior fontanel diameter greater than 1 cm are considered abnormal.

28. A 2-hour-old neonate born via caesarean birth has begun having a respiratory rate of 110 breaths/min and is in respiratory distress. What intervention(s) is a priority for the nurse to include in this neonates's care? Select all that apply. A. Keep the head in a "sniff" position B. Administer oxygen C. Insert an orogastric tube D. Ensure thermoregulation E. Obtain an arterial blood gas

Answer: A, B, D Rationale: This neonate is experiencing manifestations of transient tachypnea of the newborn (TTN). It occurs from delayed clearing of the lungs from fluid, and can be seen in neonates born via cesarean birth, because they have not had the experience of the compression on the thorax during vaginal delivery. This starts within the first 6 hours of life and can last up to 72 hours. The priority interventions for this neonate are oxygen, thermoregulation and minimal stimulation. Keeping the head in a neutral or "sniff " position allows for optimal airway. If the neonate becomes cold, then respiratory distress and or sepsis can develop. Minimal stimulation conserves the neonate's respiratory and heat requirements. The neonate may need placement of a peripheral IV for hydration and/or a feeding tube for formula or breast milk. The neonate should not be nipple fed until the respirations are under 60 breaths/min. A chest x-ray and an arterial blood gas may be needed also, but they would only be necessary if the neonate is in severe distress. The arterial blood gas results would show mild hypoxemia, a midly elevated CO2 level, and a normal pH.

22. A nurse is providing a refresher class for a group of postpartum nurses. The nurse reviews the risk factors associated with postpartum hemorrhage. The group demonstrates understanding of the information when they identify which risk factors associated with uterine tone? Select all that apply. A. rapid labor B. retained blood clots C. hydramnios D. operative birth E. fetal malpostion

Answer: A, C Rationale: Risk factors associated with uterine tone include hydramnios, rapid or prolonged labor, oxytocin use, maternal fever, or prolonged rupture of membranes. Retained blood clots are a risk factor associated with tissue retained in the uterus. Fetal malposition and operative birth are risk factors associated with trauma of the genital tract.

26. The nurse is developing a discharge teaching plan for a postpartum woman who has developed a postpartum infection. Which measures would the nurse most likely include in this teaching plan? Select all that apply. A. taking the prescribed antibiotic until it is finished B. checking temperature once a week C. washing hands before and after perineal care D. handling perineal pads by the edges E. directing peribottle to flow from back to front

Answer: A, C, D Rationale: Teaching should address taking the prescribed antibiotic until finished to ensure complete eradication of the infection; checking temperature daily and notifying the practitioner if it is above 100.4° F (38° C); washing hands thoroughly before and after eating, using the bathroom, touching the perineal area, or providing newborn care; handling perineal pads by the edges and avoiding touching the inner aspect of the pad that is against the body; and directing peribottle so that it flows from front to back.

23. A nurse is preparing a class on newborn adaptations for a group of soon-to-be parents. When describing the change from fetal to newborn circulation, which information would the nurse include? Select all that apply. A. Decrease in right atrial pressure leads to closure of the foramen ovale. B. Increase in oxygen levels leads to a decrease in systemic vascular resistance. C. Onset of respirations leads to a decrease in pulmonary vascular resistance. D. Increase in pressure in the left atrium results from increases in pulmonary blood flow. E. Closure of the ductus venosus eventually forces closure of the ductus arteriosus.

Answer: A, C, D, E Rationale: When the umbilical cord is clamped, the first breath is taken, and the lungs begin to function. As a result, systemic vascular resistance increases and blood return to the heart via the inferior vena cava decreases. Concurrently with these changes, there is a rapid decrease in pulmonary vascular resistance and an increase in pulmonary blood flow (Boxwell, 2010). The foramen ovale functionally closes with a decrease in pulmonary vascular resistance, which leads to a decrease in right-sided heart pressures. An increase in systemic pressure, after clamping of the cord, leads to an increase in left-sided heart pressures. Ductus arteriosus, ductus venosus, and umbilical vessels that were vital during fetal life are no longer needed.

12. A 22-year-old woman experiencing homelessness arrives at a walk-in clinic seeking pregnancy confirmation. The nurse notes on assessment her uterus suggests 12 weeks' gestation, a blood pressure of 110/70 mm Hg, and a BMI of 17.5. The client admits to using cocaine a few times. The client has been pregnant before and indicates she "loses them early." What characteristic(s) place the client in the high-risk pregnancy category? Select all that apply. A. BMI 17.5 B. blood pressure 110/70 mm Hg C. prenatal history D. homelessness E. age F. prenatal care

Answer: A, C, D, F Rationale: The key to identifying a newborn with special needs related to birthweight or gestational age variation is an awareness of the factors that could place a newborn at risk. These factors are similar to those that would suggest a high-risk pregnancy and include maternal nutrition (malnutrition or overweight), substandard living conditions or low socioeconomic status, maternal age of less than 20 or more than 35 years, lack of prenatal care, and history of previous preterm birth.

20. A newborn is experiencing cold stress. Which findings would the nurse expect to assess? Select all that apply. A. respiratory distress B. decreased oxygen needs C. hypoglycemia D. metabolic alkalosis E. jaundice

Answer: A, C, E Rationale: Cold stress in the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production.

30. A new parent is talking with the nurse about feeding the newborn. The parent has chosen to use formula. The parent asks, "How can I make sure that my baby is getting what is needed?" Which response(s) by the nurse would be appropriate? Select all that apply. A. "Make sure to use an iron-fortified formula until your baby is about 1 year old." B. "Start giving your baby fluoride supplements now so your baby develops strong teeth." C. "Since you are not breastfeeding, your baby needs a baby multivitamin each day." D. "Your baby gets enough fluid with formula, so you do not need to give extra water." E. "It is important to give your baby vitamin D each day."

Answer: A, D, E Rationale: Fluid requirements for the newborn and infant range from 100 to 150 mL/kg daily. This requirement can be met through breastfeeding or bottle feeding. Additional water supplementation is not necessary. Adequate carbohydrates, fats, protein, and vitamins are achieved through consumption of breast milk or formula. Iron-fortified formula is recommended for all infants who are not breastfed from birth to 1 year of age. The breastfed infant draws on iron reserves for the first 6 months and then needs iron-rich foods or supplementation added at 6 months of age. All infants (breastfed and bottle fed) should receive a daily supplement of 400 International Units of vitamin D starting within the first few days of life to prevent rickets and vitamin D deficiency. It is also recommended that fluoride supplementation be given to infants not receiving fluoridated water after the age of 6 months.

16. A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply. A. history of diabetes B. labor of 12 hours C. rupture of membranes for 16 hours D. hemoglobin level 10 mg/dL E. placenta requiring manual extraction

Answer: A, D, E Rationale: Risk factors for postpartum infection include history of diabetes, labor over 24 hours, hemoglobin less than 10.5 mg/dL, prolonged rupture of membranes (more than 24 hours), and manual extraction of the placenta.

17. A home health care nurse is assessing a postpartum woman who was discharged 2 days ago. The woman tells the nurse that she has a low-grade fever and feels "lousy." Which finding would lead the nurse to suspect endometritis? Select all that apply. A. lower abdominal tenderness B. urgency C. flank pain D. breast tenderness E. anorexia

Answer: A, E Rationale: Manifestations of endometritis include lower abdominal tenderness or pain on one or both sides, elevated temperature, foul-smelling lochia, anorexia, nausea, fatigue and lethargy, leukocytosis, and elevated sedimentation rate. Urgency and flank pain would suggest a urinary tract infection. Breast tenderness may be related to engorgement or suggest mastitis.

32. A nurse is providing education to a woman who is experiencing postpartum hemorrhage and is to receive a uterotonic agent. The nurse determines that additional teaching is needed when the woman identifies which drug as possibly being prescribed as treatment? A. oxytocin B. methylergonovine C. carboprost D. magnesium sulfate

Answer: D Rationale: Magnesium sulfate is during labor as a tocolytic agent to slow or halt preterm labor. It is not be used to treat postpartum hemorrhage. Oxytocin, methylergonovine, and carboprost are drugs used to manage postpartum hemorrhage.

29. Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate? A. Assess the newborn's gestational age. B. Rewarm the newborn gradually. C. Observe the newborn every hour. D. Notify the primary care provider if the temperature goes lower.

Answer: B Rationale: A newborn's temperature is typically maintained at 97.7° F to 99.7° F (36.5° C to 37.5° C). Since this newborn's temperature is significantly lower, the nurse should institute measures to rewarm the newborn gradually. Assessment of gestational age is completed regardless of the newborn's temperature. Observation would be inappropriate because lack of action may lead to a further lowering of the temperature. The nurse should notify the primary care provider of the newborn's current temperature since it is outside normal parameters.

17. The nurse observes the stool of a newborn who has begun to breastfeed. Which finding would the nurse expect? A. greenish black, tarry stool B. yellowish-brown, seedy stool C. yellow-gold, stringy stool D. yellowish-green, pasty stool

Answer: B Rationale: After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. Meconium stool is greenish black and tarry. The last development in the stool pattern is the milk stool. Milk stools of the breastfed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically soursmelling. The milk stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.

4. A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program? A. administering broad-spectrum antibiotics B. inspecting the placenta after delivery for intactness C. manually removing the placenta at birth D. applying pressure to the umbilical cord to remove the placenta

Answer: B Rationale: After the placenta is expelled, a thorough inspection is necessary to confirm its intactness because tears or fragments left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to uterine inversion, which in turn would result in hemorrhage.

1. A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description? A. The cardiac murmur heard at birth disappears by 48 hours of age. B. Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. C. Heart rate remains elevated after the first few moments of birth. D. Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed.

Answer: B Rationale: Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life. With the first breath, PVR decreases, and the heart rate initially increases but then decreases to 120 to 130 bpm after a few minutes. The ductal murmur will go away in 80+% of infants by 48 hours. Rhonchi caused by retained amniotic fluid is an abnormal finding and would not be expected.

11. A nurse is preparing a couple and their newborn for discharge. Which instructions would be most appropriate for the nurse to include in discharge teaching? A. introducing solid foods immediately to increase sleep cycle B. demonstrating comfort measures to quiet a crying infant C. encouraging daily outings to the shopping mall with the newborn D. allowing the infant to cry for at least an hour before picking him or her up

Answer: B Rationale: Discharge teaching typically would focus on several techniques to comfort a crying newborn. The nurse needs to emphasize the importance of responding to the newborn's cues, not allowing the infant to cry for an hour before being comforted. Information about solid foods is inappropriate for a newborn because solid foods are not introduced at this time. The mother and newborn need rest periods. Therefore, daily outings to a shopping mall would be inappropriate. Information about newborn sleep-wake cycles and measures for sensory enrichment and stimulation would be more appropriate.

10. A nurse is reviewing the policies of a facility related to bonding and attachment with newborns. Which practice would the nurse identify as needing to be changed? A. allowing unlimited visiting hours on maternity units B. offering round-the-clock nursery care for all infants C. promoting rooming-in D. encouraging infant contact immediately after birth

Answer: B Rationale: Factors that can affect attachment include separation of the infant and parents for long times during the day, such as if the infant was being cared for in the nursery throughout the day. Unlimited visiting hours, rooming-in, and infant contact immediately after birth promote bonding and attachment.

6. The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea based on the understanding that this type of feeding is necessary because: A. lactase enzymatic activity is not adequate. B. oxygen demands need to be reduced. C. renal solute lead must be considered. D. hyperbilirubinemia is likely to develop.

Answer: B Rationale: For the newborn with transient tachypnea, the newborn's respiratory rate is high, increasing the oxygen demand. Thus, measures are initiated to reduce this demand. Gavage feedings are one way to do so. With transient tachypnea, enzyme activity and kidney function are not affected. This condition typically resolves within 72 hours. The risk for hyperbilirubinemia is not increased.

30. A nurse is teaching a new mother about her newborn's immune status. The nurse determines that the teaching was successful when the mother states which immunoglobulin as having crossed the placenta? A. IgA B. IgG C. IgM D. IgE

Answer: B Rationale: IgG is the major immunoglobulin and the most abundant, making up about 80% of all circulating antibodies. It is found in serum and interstitial fluid. It is the only class able to cross the placenta, with active placental transfer beginning at approximately 20 to 22 weeks' gestation. No other immunoglobulin crosses the placenta.

27. A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression? A. "I just feel so overwhelmed and tired." B. "I'm feeling so guilty and worthless lately." C. "It's strange, one minute I'm happy, the next I'm sad." D. "I keep hearing voices telling me to take my baby to the river."

Answer: B Rationale: Indicators for postpartum depression include feelings related to restlessness, worthlessness, guilt, hopeless, and sadness along with loss of enjoyment, low energy level, and loss of libido. The statements about being overwhelmed and fatigued and changing moods suggest postpartum blues. The statement about hearing voices suggests postpartum psychosis.

25. A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman makes which statement? A. "I will use a soft toothbrush to brush my teeth." B. "I can take ibuprofen if I have any pain." C. "I need to avoid drinking any alcohol." D. "I will call my health care provider if my stools are black and tarry."

Answer: B Rationale: Individuals receiving anticoagulant therapy need to avoid use of any over-the-counter products containing aspirin or aspirin-like derivatives such as NSAIDs (ibuprofen) to reduce the risk for bleeding. Using a soft toothbrush and avoiding alcohol are appropriate measures to reduce the risk for bleeding. Black, tarry stools should be reported to the health care provider.

5. A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate? A. "You probably took iron during your pregnancy and that is what causes this type of stool." B. "This is meconium stool and is normal for a newborn." C. "I'll take a sample and check it for possible bleeding." D. "This is unusual, and I need to report this to your pediatrician. "

Answer: B Rationale: Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.

4. A nurse is observing a new mother interacting with her newborn. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn? A. "You have your daddy's eyes." B. "He looks like a frog to me." C. "Where did you get all that hair?" D. "He seems to sleep a lot."

Answer: B Rationale: Negative comments may indicate impaired bonding. Pointing out commonalities such as "daddy's eyes" and expressing pride such as "all that hair" are positive attachment behaviors. The statement about sleeping a lot indicates that the mother is assigning meaning to the newborn's actions, another positive attachment behavior.

26. A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how much should my newborn drink at each feeding?" The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding? A. 1 to 2 ounces B. 2 to 4 ounces C. 4 to 6 ounces D. 6 to 8 ounces

Answer: B Rationale: Newborns need about 108 cal/kg or approximately 650 cal/day (Dudek, 2010). Therefore, a newborn will need to 2 to 4 ounces to feel satisfied at each feeding.

22. A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern? A. hemoglobin 19 g/dL B. platelets 75,000/μL C. white blood cells 20,000/mm3 D. hematocrit 52%

Answer: B Rationale: Normal newborn platelets range from 150,00 to 350,000/μL. Normal hemoglobin ranges from 17 to 23g/dL, and normal hematocrit ranges from 46% to 68%. Normal white blood cell count ranges from 10,000 to 30,000/mm3.

7. Which information would the nurse include when teaching a new mother about the difference between pathologic and physiologic jaundice? A. Physiologic jaundice results in kernicterus. B. Pathologic jaundice appears within 24 hours after birth. C. Both are treated with exchange transfusions of maternal O- blood. D. Physiologic jaundice requires transfer to the NICU.

Answer: B Rationale: Pathologic jaundice appears within 24 hours after birth whereas physiologic jaundice commonly appears around the third or fourth days of life. Kernicterus is more commonly associated with pathologic jaundice. An exchange transfusion is used only if the total serum bilirubin level remains elevated after intensive phototherapy. With this procedure, the newborn's blood is removed and replaced with nonhemolyzed red blood cells from a donor. Physiologic jaundice often is treated at home.

10. After teaching the parents of a newborn with periventricular hemorrhage about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A. "We'll make sure to cover both of his eyes to protect them." B. "Our newborn could develop a learning disability later on." C. "Once the bleeding ceases, there won't be any more worries." D. "We need to get family members to donate blood for transfusion."

Answer: B Rationale: Periventricular hemorrhage has long-term sequelae such as seizures, hydrocephalus, periventricular leukomalacia, cerebral palsy, learning disabilities, vision or hearing deficits, and intellectual disability. Covering the eyes is more appropriate for the newborn receiving phototherapy. The bleeding in the brain can lead to serious long-term effects. Blood transfusions are not used to treat periventricular hemorrhage.

28. A nurse is conducting a class for pregnant women who are in their third trimester. The nurse is reviewing information about the emotional changes that occur in the postpartum period, including postpartum blues and postpartum depression. After reviewing information about postpartum blues, the group demonstrates understanding when they make which statement about this condition? A. "Postpartum blues is a long-term emotional disturbance." B. "Getting some outside help for housework can lessen feelings of being overwhelmed." C. "The mother loses contact with reality." D. "Extended psychotherapy is needed for treatment."

Answer: B Rationale: Postpartum blues require no formal treatment other than support and reassurance because they do not usually interfere with the woman's ability to function and care for her infant. Nurses can ease a mother's distress by encouraging her to vent her feelings and by demonstrating patience and understanding with her and her family. Suggest that getting outside help with housework and infant care might help her to feel less overwhelmed until the blues ease. Provide telephone numbers she can call when she feels down during the day. Making women aware of this disorder while they are pregnant will increase their knowledge about this mood disturbance, which may lessen their embarrassment and increase their willingness to ask for and accept help if it does occur.

20. A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents make which statement? A. "We can put a tiny bit of lotion on his skin, and then rub it in gently." B. "We should avoid using any kind of baby powder." C. "We need to bathe him at least four to five times a week." D. "We should clean his eyes after washing his face and hair."

Answer: B Rationale: Powders should not be used, because they can be inhaled, causing respiratory distress. If the parents want to use oils and lotions, have them apply a small amount onto their hand first, away from the newborn; this warms the lotion. Then the parents should apply the lotion or oil sparingly. Parents need to be instructed that a bath two or three times weekly is sufficient for the first year because too frequent bathing may dry the skin. The eyes are cleaned first and only with plain water; then the rest of the face is cleaned with plain water.

13. A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant? A. The neonate is average for its gestational age. B. The neonate is small for its gestational age. C. The neonate is large for its gestational age. D. The neonate is fetal growth restricted.

Answer: B Rationale: Small for gestational age (SGA) describes newborns that typically weigh less than 2,500 g (5 lb, 8 oz) at term due to less growth than expected in utero. A newborn is also classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with the number of weeks of gestation. In some SGA newborns, the rate of growth does not meet the expected growth pattern. These infants are considered to have fetal growth restriction resulting in pathology.

8. A nurse is teaching the mother of a newborn experiencing cocaine withdrawal about caring for the neonate at home. The mother stopped using cocaine near the end of her pregnancy. The nurse determines that additional teaching is needed when the mother identifies which action as appropriate for her newborn? A. wrapping the newborn snugly in a blanket B. waking the newborn every hour C. checking the newborn's fontanels D. offering a pacifier

Answer: B Rationale: Stimuli need to be decreased. Waking the newborn every hour would most likely be too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive sucking. Checking the fontanels provides evidence of hydration.

18. A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which finding? A. nonpalpable fundus B. moderate lochia serosa C. bruising on arms and legs D. fever

Answer: B Rationale: Subinvolution is usually identified at the woman's postpartum examination 4 to 6 weeks after birth. The clinical picture includes a postpartum fundal height that is higher than expected, with a boggy uterus; the lochia fails to change colors from red to serosa to alba within a few weeks. Normally, at 4 to 6 weeks, lochia alba or no lochia would be present and the fundus would not be palpable. Thus evidence of lochia serosa suggests subinvolution. Bruising would suggest a coagulopathy. Fever would suggest an infection.

18. The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse interprets this finding as indicating which amount of blood loss? A. 10 mL B. 10 to 25 mL C. 25 to 50 mL D. over 50 mL

Answer: B Rationale: The amount of lochia is described as light or small for an approximately 4-inch stain and indicates a blood loss of 10 to 25 mL. Scant refers to a 1- to 2-inch stain of lochia and approximately 10 mL of blood loss; moderate refers to a 4- to 6-inch stain, suggesting a 25 to 50 mL blood loss; and large or heavy refers to a pad that is saturated within 1 hour after changing, indicating over 50 mL blood loss.

19. The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which description? A. scant B. light C. moderate D. large

Answer: B Rationale: The amount of lochia is described as light or small for an approximately 4-inch stain. Scant refers to a 1- to 2-inch stain of lochia; moderate refers to a 4- to 6-inch stain; and large or heavy refers to a pad that is saturated within 1 hour after changing.

31. A nurse is assessing a client who gave birth vaginally about 4 hours ago. The client tells the nurse that she changed her perineal pad about an hour ago. On inspection, the nurse notes that the pad is now saturated. The uterus is firm and approximately at the level of the umbilicus. Further inspection of the perineum reveals an area, bluish in color and bulging just under the skin surface. Which action would the nurse do next? A. Apply warm soaks to the area. B. Notify the health care provider. C. Massage the uterine fundus. D. Encourage the client to void.

Answer: B Rationale: The client is experiencing postpartum hemorrhage secondary to a perineal hematoma. The nurse needs to notify the health care provider about these findings to prevent further hemorrhage. Applying warm soaks to the area would do nothing to control the bleeding. With a perineal hematoma, the uterus is firm, so massaging the uterus or encouraging the client to void would not be appropriate.

22. A nurse is teaching a postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching? A. "We can put him in the tub to bathe him once the cord falls off and is healed." B. "The cord stump should change from brown to yellow." C. "Exposing the stump to the air helps it to dry." D. "We need to call the primary care provider if we notice a funny odor."

Answer: B Rationale: The cord stump should change color from yellow to brown or black. Therefore the parents need additional teaching if they state the color changes from brown to yellow. Tub baths are avoided until the cord has fallen off and the area is healed. Exposing the stump to the air helps it to dry. The parents should notify their primary care provider if there is any bleeding, redness, drainage, or foul odor from the cord stump.

29. A nurse suspects that a client may be developing disseminated intravascular coagulation. The woman has a history of placental abruption (abruptio placentae) during birth. Which finding would help to support the nurse's suspicion? A. severe uterine pain B. board-like abdomen C. appearance of petechiae D. inversion of the uterus

Answer: C Rationale: A complication of abruptio placentae is disseminated intravascular coagulation (DIC), which is manifested by petechiae, ecchymoses, and other signs of impaired clotting. Severe uterine pain, a board-like abdomen, and uterine inversion are not associated with DIC and placental abruption.

21. A nurse is observing a postpartum client interacting with her newborn and notes that the mother is engaging with the newborn in the en face position. Which behavior would the nurse be observing? A. mother placing the newborn next to bare breast B. mother making eye-to-eye contact with the newborn C. mother gently stroking the newborn's face D. mother holding the newborn upright at the shoulder

Answer: B Rationale: The en face position is characterized by the mother interacting with the newborn through eye-to-eye contact while holding the newborn. Bonding is a vital component of the attachment process and is necessary in establishing parent-infant attachment and a healthy, loving relationship. During this early period of acquaintance, mothers touch their infants in a characteristic manner. Mothers visually and physically "explore" their infants, initially using their fingertips on the infant's face and extremities and progressing to massaging and stroking the infant with their fingers. This is followed by palm contact on the trunk. Eventually, mothers draw their infant toward them and hold the infant. Kangaroo care refers to skin-to-skin contact between the mother and newborn.

14. A nurse is reviewing a journal article on the causes of postpartum hemorrhage. Which condition would the nurse most likely find as the most common cause? A. labor augmentation B. uterine atony C. cervical or vaginal lacerations D. uterine inversion

Answer: B Rationale: The most common cause of postpartum hemorrhage is uterine atony, failure of the uterus to contract and retract after birth. The uterus must remain contracted after birth to control bleeding from the placental site. Labor augmentation is a risk factor for postpartum hemorrhage. Lacerations of the birth canal and uterine inversion may cause postpartum hemorrhage, but these are not the most common cause.

16. A group of nurses are reviewing information about mastitis and its causes in an effort to develop a teaching program on prevention for postpartum women. The nurses demonstrate understanding of the information when they focus the teaching on ways to minimize risk of exposure to which organism? A. E. coli B. S. aureus C. Proteus D. Klebsiella

Answer: B Rationale: The most common infectious organism that causes mastitis is S. aureus, which comes from the breast-feeding infant's mouth or throat. E. coli is another, less common cause. E. coli, Proteus, and Klebsiella are common causes of urinary tract infections.

12. The nurse is teaching a group of parents about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed? A. "The newborn's skin and that of an adult are similar in thickness." B. "The newborn's sweat glands function fully, just like those of an adult." C. "Skin development in the newborn is not complete at birth." D. "The newborn has fewer fibrils connecting the dermis and epidermis."

Answer: B Rationale: The newborn has sweat glands, like an adult, but full adult functioning is not present until the second or third year of life. The newborn and adult epidermis is similar in thickness and lipid composition, but skin development is not complete at birth. Fewer fibrils connect the dermis and epidermis in the newborn when compared with the adult.

25. After teaching an in-service program to a group of nurses working in newborn nursery about a neutral thermal environment, the nurse determines that the teaching was successful when the group identifies which process as the newborn's primary method of heat production? A. convection B. nonshivering thermogenesis C. cold stress D. bilirubin conjugation

Answer: B Rationale: The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. Convection is a mechanism of heat loss. Cold stress results with excessive heat loss that requires the newborn to use compensatory mechanisms to maintain core body temperature. Bilirubin conjugation is a mechanism by which bilirubin in the blood is eliminated.

23. A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action: A. determines that the procedure is effective. B. helps support the lower uterine segment. C. aids in expressing accumulated clots. D. prevents uterine muscle fatigue.

Answer: B Rationale: The nurse places the nondominant hand on the area above the symphysis pubis to help support the lower uterine segment. The hand, usually the dominant hand that is placed on the fundus, helps to determine uterine firmness (and thus the effectiveness of the massage). Applying gentle downward pressure on the fundus helps to express clots. Overmassaging the uterus leads to muscle fatigue.

30. A late preterm newborn is being prepared for discharge to home after being in the neonatal intensive care unit for 4 days. The nurse instructs the parents about the care of their newborn and emphasizes warning signs that should be reported to the pediatrician immediately. The nurse determines that additional teaching is needed based on which parental statement? A. "We will call 911 if we start to see that our newborn's lips or skin are looking bluish." B. "If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." C. "If our newborn does not have a wet diaper in 12 hours, we will call our pediatrician." D. "We will let the pediatrician know if our newborn's temperature goes above 100.4°F (38°C)."

Answer: B Rationale: The parents of a preterm newborn need teaching about when to notify their pediatrician or nurse practitioner. These include: displaying a yellow color to the skin (jaundice); having difficulty breathing or turning blue (call for emergency services in this case); having a temperature below 97°F (36.1°C) or above 100.4°F (38°C); and failing to void for 12 hours.

17. The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location? A. just superior to the nipple, at the midsternum B. lateral to the midclavicular line at the fourth intercostal space C. at the fifth intercostal space to the left of the sternum D. directly adjacent to the sternum at the second intercostals space

Answer: B Rationale: The point of maximal impulse (PMI) in a newborn is a lateral to midclavicular line located at the fourth intercostal space.

9. A newborn is suspected of having fetal alcohol syndrome. Which finding would the nurse expect to assess? A. bradypnea B. hydrocephaly C. flattened maxilla D. hypoactivity

Answer: C Rationale: A newborn with fetal alcohol syndrome exhibits characteristic facial features such as microcephaly (not hydrocephaly), small palpebral fissures, and abnormally small eyes, flattened or absent maxilla, epicanthal folds, thin upper lip, and missing vertical groove in the median portion of the upper lip. Bradypnea is not typically associated with fetal alcohol syndrome. Fine and gross motor development is delayed, and the newborn shows poor hand-eye coordination but not hypoactivity.

24. A nurse is describing the advantages and disadvantages of circumcision to a group of expectant parents. Which statement by the parents indicates effective teaching? A. "Sexually transmitted infections are more common in circumcised males." B. "The rate of penile cancer is less for circumcised males." C. "Urinary tract infections are more easily treated in circumcised males." D. "Circumcision is a risk factor for acquiring HIV infection."

Answer: B Rationale: The risk for penile cancer appears to be slightly lower for males who are circumcised. However, penile cancer is rare and other risk factors such as genital warts and HPV infection seem to play a larger role. Sexually transmitted infections are less common in circumcised males, but the risk is believed to be related more to behavioral factors than circumcision status. Circumcised males have a 50% lower risk of acquiring HIV infection. Urinary tract infections are slightly less common in circumcised boys. However, rates are low in both circumcised and uncircumcised boys and are easily treated without long-term sequelae.

30. A woman gave birth to a healthy term neonate today at 1330. It is now 1430 and the nurse has completed the client's assessment. At which time would the nurse next assess the client? A. 1445 B. 1500 C. 1530 D. 1830

Answer: B Rationale: The woman is in her second hour postpartum. Typically, the nurse would assess the woman every 30 minutes. In this case, this would be 1500. During the first hour, assessments are usually completed every 15 minutes. After the second hour, assessments would be made every 4 hours for the first 24 hours and then every 8 hours.

12. After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching? A. "I need to call my doctor if my temperature goes above 100.4° F (38° C)." B. "When I put on a new pad, I'll start at the back and go forward." C. "If I have chills or my discharge has a strange odor, I'll call my doctor." D. "I'll point the spray of the peri-bottle so it the water flows front to back."

Answer: B Rationale: The woman needs additional teaching when she states that she should apply the perineal pad starting at the back and going forward. The pad should be applied using a front-toback motion. Notifying the health care provider of a temperature above 100.4° F (38° C), aiming the peri-bottle spray so that the flow goes from front to back, and reporting danger signs such as chills or lochia with a strange odor indicate effective teaching.

7. The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rhpositive newborn based on the understanding that this drug will prevent her from: A. becoming Rh positive. B. developing Rh sensitivity. C. developing AB antigens in her blood. D. becoming pregnant with an Rh-positive fetus.

Answer: B Rationale: The woman who is Rh-negative and whose infant is Rh-positive should be given Rho(D) immune globulin within 72 hours after birth to prevent sensitization.

24. A nurse is preparing a presentation about ways to minimize heat loss in the newborn. Which measure would the nurse include to prevent heat loss through convection? A. placing a cap on a newborn's head B. working inside an isolette as much as possible. C. placing the newborn skin-to-skin with the mother D. using a radiant warmer to transport a newborn

Answer: B Rationale: To prevent heat loss by convection, the nurse would keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment, work inside an isolette as much as possible and minimize opening portholes that allow cold air to flow inside, and warm any oxygen or humidified air that comes in contact with the newborn. Placing a cap on the newborn's head would help minimize heat loss through evaporation. Placing the newborn skin-to-skin with the mother helps to prevent heat loss through conduction. Using a radiant warmer to transport a newborn helps minimize heat loss through radiation.

25. After teaching a postpartum woman about breastfeeding, the nurse determines that the teaching was successful when the woman makes which statement? A. "I should notice a decrease in abdominal cramping during breast-feeding." B. "I should wash my hands before starting to breastfeed." C. "The baby can be awake or sleepy when I start to feed him." D. "The baby's mouth will open up once I put him to my breast."

Answer: B Rationale: To promote successful breastfeeding, the mother should wash her hands before breast feeding and make sure that the baby is awake and alert and showing hunger signs. In addition, the mother should lightly tickle the infant's upper lip with her nipple to stimulate the infant to open the mouth wide and then bring the infant rapidly to the breast with a wide-open mouth. The mother also needs to know that her afterpains will increase during breastfeeding.

15. A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding? A. Conduction heat loss is a problem in the baby. B. The supply of brown adipose tissue is not developed. C. Axillary temperatures are not accurate. D. This is a normal temperature.

Answer: B Rationale: Typically newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. However, this preterm newborn has an inadequate supply of brown fat because he or she left the uterus early before the supply was adequate. Conduction heat loss allows an increased transfer of heat from their bodies to the environment, but there is nothing to substantiate conduction heat loss. Axillary temperatures are accurate and the mode of taking temperatures for neonates.

9. Which intervention would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A. Avoid using the terms "death" or "dying." B. Provide opportunities for them to hold the newborn. C. Refrain from initiating conversations with the parents. D. Quickly refocus the parents to a more pleasant topic.

Answer: B Rationale: When dealing with grieving parents, nurses should provide them with opportunities to hold the newborn if they desire. In addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn. These interventions help to validate the parents' sense of loss, relive the experience, and attach significance to the meaning of loss. The nurse should use appropriate terminology, such as "dying," "died," and "death," to help the parents accept the reality of the death. Nurses need to demonstrate empathy and to respect the parents' feelings, responding to them in helpful and supportive ways. Active listening and allowing the parents to vent their frustrations and anger help validate the parents' feelings and facilitate the grieving process.

18. A nurse is assessing a newborn who is about 4½ hours old. The nurse would expect this newborn to exhibit which behavior? Select all that apply. A. sleeping B. interest in environmental stimuli C. passage of meconium D. difficulty arousing the newborn E. spontaneous Moro reflexes

Answer: B, C Rationale: The newborn is in the second period of reactivity, which begins as the newborn awakens and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal newborn (Boxwell, 2010). Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period. In addition, motor activity and muscle tone increase in conjunction with an increase in muscular coordination. Spontaneous Moro reflexes are noted during the first period of reactivity. Sleeping and difficulty arousing the newborn reflect the period of decreased responsiveness.

15. The nurse is assessing a newborn's eyes. Which findings would the nurse identify as normal? Select all that apply. A. slow blink response B. able to track object to midline C. transient deviation of the eyes D. involuntary repetitive eye movement E. absent red reflex

Answer: B, C, D Rationale: Assessment of the eyes should reveal a rapid blink reflex, ability to track objects to the midline, transient strabismus (deviation or wandering of the eyes independently), searching nystagmus (involuntary repetitive eye movement), and a red reflex.

25. A set of newborn twins has been admitted to the neonatal intensive care unit with the diagnosis of fetal growth restriction (FGR). Which maternal factors would predispose the newborn to this diagnosis? Select all that apply. A. hemoglobin 15 g/dl (150 g/l) B. A1C levels of 8% (0.08) C. heroin use disorder D. blood pressure baseline of 170/90 mm Hg E. age 39 years F. multiple gestation

Answer: B, C, D, E, F Rationale: Assessment of the small-for-gestational-age (SGA) or FGR infant begins by reviewing the maternal history to identify risk factors such as maternal age over 30 years, a substance use disorder, hypertension, multiple gestation. Gestational diabetes or diabetes mellitus is also a factor. Normal A1C level is 5.7% (0.57) for a person without diabetes. Hemoglobin is normal for pregnant woman in third trimester.

17. A neonate is exhibiting signs of neonatal abstinence syndrome. Which findings would confirm this diagnosis? Select all that apply. A. adequate rooting and sucking B. frequent sneezing C. persistant fever D. shrill, high-pitched cry E. hypotonic reflexes F. frequent yawning

Answer: B, C, D, F Rationale: Manifestations of neonatal abstinence syndrome include a shrill, high-pitched cry; persistent fever; frequent yawning; and frequent sneezing. Rather than adequate rooting and sucking, these actions will be frantic in a neonate with abstinence syndrome. In addition, these neonates will have hypertonic muscle tone, not hypotonic reflexes.

27. At the breech forceps birth of a 32 weeks' gestation neonate, the nurse notes olygohydramnios with green thick amniotic fluid. The maternal history reveals a mother of Hispanic ethnicity with marked hypertension, who admits to using cocaine daily. Which factor(s) may contribute to meconium aspiration syndrome (MAS)? Select all that apply. A. the preterm pregnancy B. the forceps breech birth C. maternal cocaine use D. maternal hypertension E. Hispanic ethnicity F. oligohydramnios present

Answer: B, C, D, F Rationale: The predisposing factors for meconium aspiration syndrome include postterm pregnancy and breech presentation with forceps. Ethnicity (Pacific Islander, Indigenous Australian, Black African) is a factor. Postterm neonates are at risk for MAS, but preterm neonates are not. Exposure to drugs during pregnancy, especially tobacco and cocaine, predispose the neeonate to MAS. Maternal hypertension and oligohydramnios also contribute to MAS.

24. A nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breastfeeding. Which information would the nurse most likely include? Select all that apply. A. resumption of sexual intercourse about two weeks after birth B. possible experience of fluctuations in sexual interest C. use of a water-based lubricant to ease vaginal discomfort D. use of combined hormonal contraceptives for the first three weeks E. possibility of increased breast sensitivity during sexual activity

Answer: B, C, E Rationale: Typically, sexual intercourse can be resumed once bright-red bleeding has stopped and the perineum is healed from an episiotomy or lacerations. This is usually by the third to the sixth week postpartum. Fluctuations in sexual interest are normal. In addition, breastfeeding women may notice a let-down reflex during orgasm and find that breasts are very sensitive when touched by the partner. Precoital vaginal lubrication may be impaired during the postpartum period, especially in women who are breastfeeding. Use of water-based gel lubricants can help. The Centers for Disease Control and Prevention recommend that postpartum women not use combined hormonal contraceptives during the first 21 days after birth because of the high risk for venous thromboembolism (VTE) during this period.

27. A nurse is observing a postpartum woman and her partner interact with the their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which behavior? Select all that apply. A. frequently ask for the newborn to be taken from the room B. identify common features between themselves and the newborn C. refer to the newborn as having a monkey-face D. make direct eye contact with the newborn E. refrain from checking out the newborn's features

Answer: B, D Rationale: Positive behaviors that indicate attachment include identifying common features and making direct eye contact with the newborn. Asking for the newborn to be taken out of the room, referring to the newborn as having a monkey-face, and refraining from checking out the newborn's features are negative attachment behaviors.

19. A couple has just given birth to a baby who has low Apgar scores due to asphyxia from prolonged cord compression. The neonatologist has given a poor prognosis to the newborn, who is not expected to live. Which interventions are appropriate at this time? Select all that apply. A. Advise the parents that the hospital can make the arrangements. B. Offer to pray with the family if appropriate. C. Leave the parents to talk through their next steps. D. Initiate spiritual comfort by calling the hospital clergy, if appropriate. E. Respect variations in the family's spiritual needs and readiness.

Answer: B, D, E Rationale: When assisting the parents to cope with a perinatal loss, the nurse must respect variations in the family's spiritual needs and readiness. The nurse will also initiate spiritual comfort by calling the hospital clergy, if appropriate, and can offer to pray with the family, if appropriate.

15. The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of: A. inability to clear fluids. B. immature respiratory control center. C. deficiency of surfactant. D. smaller respiratory passages.

Answer: C Rationale: A preterm newborn is at increased risk for respiratory distress syndrome (RDS) because of a surfactant deficiency. Surfactant helps to keep the alveoli open and maintain lung expansion. With a deficiency, the alveoli collapse, predisposing the newborn to RDS. An inability to clear fluids can lead to transient tachypnea. Immature respiratory control centers lead to an increased risk for apnea. Smaller respiratory passages led to an increased risk for obstruction.

13. A newborn is suspected of developing persistent pulmonary hypertension. The nurse would expect to prepare the newborn for which procedure to confirm the suspicion? A. chest X-ray B. blood cultures C. echocardiogram D. stool for occult blood

Answer: C Rationale: An echocardiogram is used to reveal right-to-left shunting of blood to confirm the diagnosis of persistent pulmonary hypertension. Chest X-ray would be most likely used to aid in the diagnosis of RDS or TTN. Blood cultures would be helpful in evaluating for neonatal sepsis. Stool for occult blood may be done to evaluate for NEC.

2. A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure? A. Offer warm blankets. B. Encourage the woman to void. C. Apply an ice pack to the site. D. Offer a warm sitz bath.

Answer: C Rationale: An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.

21. A group of nurses are reviewing information about the changes in the newborn's lungs that must occur to maintain respiratory function. The nurses demonstrate understanding of this information when they identify which event as occurring first? A. expansion of the lungs B. increased pulmonary blood flow C. initiation of respiratory movement D. redistribution of cardiac output

Answer: C Rationale: Before the newborn's lungs can maintain respiratory function, the following events must occur: respiratory movement must be initiated; lungs must expand, functional residual capacity must be established, pulmonary blood flow must increase, and cardiac output must be redistributed.

2. The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? A. to aid in maturing the newborn's sucking reflex B. to encourage the development of maternal antibodies C. to facilitate maternal-infant bonding D. to enhance the clearing of the newborn's respiratory passages

Answer: C Rationale: Breastfeeding can be initiated immediately after birth. This immediate mother- newborn contact takes advantage of the newborn's natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn's temperature, blood glucose level, and respiratory rate. It is not associated with maturing the sucking reflex, encouraging the development of maternal antibodies, or aiding in clearing of the newborn's respiratory passages.

9. While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: A. molding. B. microcephaly. C. caput succedaneum. D. cephalhematoma.

Answer: C Rationale: Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of the skull.

13. The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as: A. harlequin sign. B. nevus flames. C. erythema toxicum. D. port wine stain.

Answer: C Rationale: Erythema toxicum (newborn rash) is a benign, idiopathic, generalized, transient rash that occurs in up to 70% of all newborns during the first week of life. It consists of small papules or pustules on the skin resembling flea bites. The rash is common on the face, chest, and back. One of the chief characteristics of this rash is its lack of pattern. It is caused by the newborn's eosinophils reacting to the environment as the immune system matures. Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. It gives a distinct midline demarcation, which is described as pale on the nondependent side and red on the opposite, dependent side. Nevus flammeus or port wine stain is a capillary angioma located directly below the dermis. It is flat with sharp demarcations and is purple-red. This skin lesion is made up of mature capillaries that are congested and dilated.

6. A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction by the nurse would be most appropriate to aid in relieving her discomfort? A. "Express some milk from your breasts every so often to relieve the distention." B. "Remove your bra to relieve the pressure on your sensitive nipples and breasts." C. "Apply ice packs to your breasts to reduce the amount of milk being produced." D. "Take several warm showers daily to stimulate the milk let-down reflex."

Answer: C Rationale: For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the woman who was breastfeeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.

14. A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as: A. cardiac distress. B. respiratory alkalosis. C. bronchial pneumonia. D. respiratory distress.

Answer: D Rationale: Ineffective breathing pattern related to immature respiratory system and respiratory distress as evidenced by tachypnea, nasal flaring, sternal retractions, and/or oxygen saturation less than 87 %. These assessment findings do not indicate bronchial pneumonia respiratory alkalosis or cardiac distress at this time.

23. A postpartum woman who is breastfeeding tells the nurse that she is experiencing nipple pain. After teaching the woman about possible suggestions, the nurse determines that more teaching is needed when the woman makes which statement? A. "I use a mild analgesic about 1 hour before breastfeeding." B. "I apply expressed breast milk to my nipples." C. "I apply glycerin-based gel to my nipples." D. "My baby latches on."

Answer: C Rationale: Nipple pain is difficult to treat, although a wide variety of topical creams, ointments, and gels are available to do so. This group includes beeswax, glycerin-based products, petrolatum, lanolin, and hydrogel products. Many women find these products comforting. Beeswax, glycerin-based products, and petrolatum all need to be removed before breastfeeding. These products should be avoided in order to limit infant exposure because the process of removal may increase nipple irritation. Mild analgesics such as acetaminophen or ibuprofen are considered relatively safe for breastfeeding mothers. Applying expressed breast milk to nipples and allowing it to dry has been suggested to reduce nipple pain. Usually the pain is due to incorrect latch-on and/or removal of the nursing infant from the breast. Early assistance with breastfeeding to ensure correct positioning can help prevent nipple trauma. In addition, applying expressed milk to nipples and allowing it to dry has been suggested to result in less nipple pain for many women.

8. Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage? A. multiparity, age of mother, operative birth B. size of placenta, small baby, operative birth C. uterine atony, placenta previa, operative procedures D. prematurity, infection, length of labor

Answer: C Rationale: Risk factors for postpartum hemorrhage include a precipitous labor less than three hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.

21. A new mother who is breastfeeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate? A. "If he seems content after feeding, that should be a sign." B. "Make sure he drinks at least 5 minutes on each breast." C. "He should wet between 6 to 10 diapers each day." D. "If his lips are moist, then he's okay."

Answer: C Rationale: Soaking 6 to 10diapers a day indicates adequate hydration. Contentedness after feeding is not an indicator for adequate hydration. Typically a newborn wakes up 8 to 12 times per day for feeding. As the infant gets older, the time on the breast increases. Moist mucous membranes help to suggest adequate hydration, but this is not the best indicator.

26. While observing the interaction between a newborn and the mother, the nurse notes the newborn nestling into the arms of the mother. The nurse identifies this as which behavior? A. habituation B. self-quieting ability C. social behaviors D. orientation

Answer: C Rationale: Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held. Self-quieting ability refers to newborns' ability to quiet and comfort themselves, such as by hand-to-mouth movements and sucking, alerting to external stimuli and motor activity. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Orientation refers to the response of newborns to stimuli, becoming more alert when sensing a new stimulus in their environment.

19. The nurse is developing a plan of care for a neonate experiencing symptoms of drug withdrawal. What should be included in this plan? A. Administer glucose between feedings. B. Schedule feedings every 4 to 6 hours. C. Swaddle the infant between feedings. D. Rock horizontally.

Answer: C Rationale: Supportive interventions to promote comfort include swaddling, low lighting, gentle handling, quiet environment with minimal stimulation, use of soft voices, pacifiers to promote "self-soothing," frequent small feedings, and vertical rocking, which will soothe the newborn's neurological system.

3. The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A. Suggest that the parents stay for just a few minutes to reduce their anxiety. B. Reassure them that their newborn is progressing well. C. Encourage the parents to touch their preterm newborn. D. Discuss the care they will be giving the newborn upon discharge.

Answer: C Rationale: The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated.

9. When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The nurse refers to this process by which term? A. reciprocity B. engrossment C. bonding D. attachment

Answer: C Rationale: The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.

13. Which method would be most effective in evaluating the parents' understanding about their newborn's care? A. Demonstrate all infant care procedures. B. Allow the parents to state the steps of the care. C. Observe the parents performing the procedures. D. Routinely assess the newborn for cleanliness.

Answer: C Rationale: The most effective means to evaluate the parents' learning is to observe them performing the procedures. Parental roles develop and grow through interaction with their newborn. The nurse would involve both parents in the newborn's care and praise them for their efforts. Demonstrating the procedures to the parents and having the parents state the steps are helpful but do not guarantee that the parents understand them. Assessing the newborn for cleanliness would provide little information about parental learning.

11. A client is experiencing postpartum hemorrhage, and the nurse begins to massage her fundus. Which action would be most appropriate for the nurse to do when massaging the woman's fundus? A. Place the hands on the sides of the abdomen to grasp the uterus. B. Use an up-and-down motion to massage the uterus. C. Wait until the uterus is firm to express clots. D. Continue massaging the uterus for at least 5 minutes.

Answer: C Rationale: The uterus must be firm before attempts to express clots are made because application of firm pressure on an uncontracted uterus could lead to uterine inversion. One hand is placed on the fundus and the other hand is placed on the area above the symphysis pubis. Circular motions are used for massage. There is no specified amount of time for fundal massage. Uterine tissue responds quickly to touch, so it is important not to overmassage the fundus.

1. Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition? A. retained placental fragments B. hypertension C. thrombophlebitis D. uterine subinvolution

Answer: C Rationale: The woman is at risk for thrombophlebitis due to the prolonged second stage of labor, necessitating an increased amount of time in bed, and venous pooling that occurs when the woman's legs are in stirrups for a long period of time. These findings are unrelated to retained placental fragments, which would lead to uterine subinvolution, or hypertension.

26. Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which factor in the newborn's history would the nurse identify as playing a role in this this condition? A. vaginal birth B. shortened labor C. central nervous system depressant during labor D. maternal hypertension

Answer: C Rationale: Transient tachypnea of the newborn occurs when the fetal liquid in the lungs is removed slowly or incompletely. This can be due to the lack of thoracic squeezing that occurs during a cesarean birth or diminished respiratory effort if the mother received central nervous system depressant medication. Prolonged labor, macrosomia of the fetus, and maternal asthma also have been associated with this condition.

17. A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem? A. lochia rubra with a fleshy odor B. respiratory rate of 16 breaths per minute C. temperature of 101° F (38.3° C) D. pain rating of 2 on a scale from 0 to 10

Answer: C Rationale: Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range. Some women experience a slight fever, up to 100.4º F (38º C), during the first 24 hours. A temperature above 100.4º F (38º C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Foul-smelling lochia or lochia with an unexpected change in color or amount, shortness of breath, or respiratory rate below 16 or above 20 breaths per minute would also be a cause for concern. The goal of pain management is to have the woman's pain scale rating maintained between 0 to 2 points at all times, especially after breast-feeding.

27. A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which suggestions would the nurse include in the teaching? Select all that apply. A. Supplement with iron if the woman is breastfeeding. B. Provide supplemental water intake with feedings. C. Feed the newborn every 2 to 4 hours during the day. D. Burp the newborn frequently throughout each feeding. E. Use feeding time for promoting closeness.

Answer: C, D, E Rationale: Most newborns are on demand feeding schedules and are allowed to feed when they awaken. When they go home, mothers are encouraged to feed their newborns every 2 to 4 hours during the day and only when the newborn awakens during the night for the first few days after birth. Newborns swallow air during feedings, which causes discomfort and fussiness. Parents can prevent this by burping them frequently throughout the feeding. Feeding is also more than an opportunity to get nutrients into the newborn. It is also a time for closeness and sharing. Iron supplementation is recommended for infants who are bottle-fed. Fluid requirements for the newborn and infant do range from 100 to 150 mL/kg daily. This requirement can be met through breast or bottle feedings. Thus, additional water supplementation is not necessary.

22. A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment findings would indicate that the neonate is in pain? Select all that apply. A. There is flaccid muscle tone of the affected limb. B. Respiration rate is 52 breaths per minute. C. Heart rate is 180 beats per minutes. D. Oxygen saturation level is 88%. E. The infant has facial grimacing and quivering chin.

Answer: C, D, E Rationale: Suspect pain if the newborn exhibits a sudden high-pitched cry; facial grimace is noted with furrowing of the brow and quivering of the chin with an increase in muscle tone when disturbed. Oxygen desaturation will be noted with an increase in heart rate. Increase in the normal blood pressure, pulse, and respiration are noted.

4. Rapid assessment of a newborn indicates the need for resuscitation. The newborn has copious secretiohs. The newborn is dried and placed under a radiant warmer. Which action would the nurse do next? A. Intubate with an appropriate-sized endotracheal tube. B. Give chest compressions at a rate of 80 times per minute. C. Administer epinephrine intravenously. D. Clear the airway with a bulb syringe.

Answer: D Rationale: After placing the newborn's head in a neutral position, the nurse would clear the airway with a bulb syringe or suction. This is followed by assessment of breathing and bagging if needed, placing a pulse oximeter, ventilating the newborn, assessing the heart rate and giving chest compressions if needed, and then admnistering epinephrine and/or volume expansion if needed.

14. The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest? A. 38 breaths per minute B. 46 breaths per minute C. 54 breaths per minute D. 68 breaths per minute

Answer: D Rationale: After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). Thus a newborn with a respiratory rate below 30 or above 60 breaths per minute would require further evaluation.

6. The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal? A. Prevent cold stress. B. Increase surfactant levels in the lungs. C. Promote respiratory stability. D. Decrease the serum bilirubin level.

Answer: D Rationale: Jaundice reflects elevated serum bilirubin levels; phototherapy helps to break down the bilirubin for excretion. Phototherapy has no effect on body temperature, surfactant levels, or respiratory stability.

3. A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom? A. an inverted nipple on the affected breast B. no breast milk in the affected breast C. an ecchymotic area on the affected breast D. hardening of an area in the affected breast

Answer: D Rationale: Mastitis is characterized by a tender, hot, red, painful area on the affected breast. An inverted nipple is not associated with mastitis. With mastitis, the breast is distended with milk, the area is inflamed (not ecchymotic), and there is breast tenderness.

4. A newborn has been diagnosed with a group B streptococcal infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which cause? A. improper hand washing B. contaminated formula C. nonsterile catheter insertion D. mother's birth canal

Answer: D Rationale: Most often, a newborn develops a group B streptococcus infection during the birthing process when the newborn comes into contact with an infected birth canal. Improper hand washing, contaminated formula, and nonsterile catheter insertion would most likely lead to a late-onset infection, which typically occurs in the nursery due to horizontal transmission.

4. The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: A. have a smaller body surface compared to body mass. B. lose more body heat when they sweat than adults. C. have an abundant amount of subcutaneous fat all over. D. are unable to shiver effectively to increase heat production.

Answer: D Rationale: Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.

19. A nurse is assessing a newborn and observes the newborn moving his head and eyes toward a loud sound. The nurse interprets this as which behavior? A. habituation B. motor maturity C. social behavior D. orientation

Answer: D Rationale: Orientation refers to the response of newborns to stimuli. It reflects newborns' response to auditory and visual stimuli, demonstrated by their movement of head and eyes to focus on that stimulus. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held.

20. A neonate born addicted to cocaine is now being treated with medication for acute neonatal abstinence syndrome. Which medication will be prescribed to relieve withdrawal symptoms? A. meperidine B. adrenalin C. naloxone D. morphine sulphate

Answer: D Rationale: Pharmacologic treatment is warranted if conservative measures are not adequate. Common medications used in the management of newborn withdrawal include an opioid (morphine or methadone) and phenobarbital as a second drug if the opiate does not adequately control symptoms. The other drugs are not used in NAS treatment.

2. The nurse is conducting a class for postpartum women about mood disorders. The nurse describes a transient, self-limiting mood disorder that affects mothers after birth. The nurse determines that the women understood the description when they identify the condition as postpartum: A. depression. B. psychosis. C. bipolar disorder. D. blues.

Answer: D Rationale: Postpartum blues are manifested by mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, feelings of being overwhelmed, and fatigue. They are usually self-limiting and require no formal treatment other than reassurance and validation of the woman's experience as well as assistance in caring for herself and her newborn. Postpartum depression is a major depressive episode associated with birth. Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. Bipolar disorder refers to a mood disorder typically involving episodes of depression and mania.

1. The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn? A. fewer visible blood vessels through the skin B. more subcutaneous fat in the neck and abdomen C. well-developed flexor muscles in the extremities D. greater body surface area in proportion to weight

Answer: D Rationale: Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone.

8. A nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest concern? A. leg pain on ambulation with mild ankle edema B. calf pain with dorsiflexion of the foot C. perineal pain with swelling along the episiotomy D. sharp, stabbing chest pain with shortness of breath

Answer: D Rationale: Sharp, stabbing chest pain with shortness of breath suggests pulmonary embolism, an emergency that requires immediate action. Leg pain on ambulation with mild edema suggests superficial venous thrombosis. Calf pain on dorsiflexion of the foot may indicate deep vein thrombosis or a strained muscle or contusion. Perineal pain with swelling along the episiotomy might be a normal finding or suggest an infection. Of the conditions, pulmonary embolism is the most urgent.

2. A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. Which factor would the nurse integrate into the response? A. newborn being placed prone after feeding B. limited ability of digestive enzymes C. underdeveloped pyloric sphincter D. relaxed cardiac sphincter

Answer: D Rationale: The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in their ability to digest complex carbohydrates and fats; this results in fatty stools, not regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric contents.

16. The nurse observes the stool of a newborn who is being bottle-fed. The newborn is 2 days old. What would the nurse expect to find? A. greenish black, tarry stool B. yellowish-brown, seedy stool C. yellow-gold, stringy stool D. yellowish-green, pasty stool

Answer: D Rationale: The milk stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor. After breast-feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. Meconium stool is greenish black and tarry. The last development in the stool pattern is the milk stool. Milk stools of the breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically sour-smelling.

14. A preterm newborn is receiving enteral feedings. Which finding would alert the nurse to suspect that the newborn is developing NEC? A. irritability B. sunken abdomen C. clay-colored stools D. feeding intolerance

Answer: D Rationale: The newborn with NEC may exhibit feeding intolerance with lethargy, abdominal distention and tenderness, and bloody stools.

11. A nurse is assessing a preterm newborn. Which finding would alert the nurse to suspect that a preterm newborn is in pain? A. bradycardia B. oxygen saturation level of 94% C. decreased muscle tone D. sudden high-pitched cry

Answer: D Rationale: The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone.

22. The nurse is admitting a term, large-for-gestational-age neonate weighing 4,610 g (10 lb, 2 oz), born vaginally with a mid-forceps assist, to a 15-year-old primipara. What would the nurse anticipate as a result of the birth? A. fracture of the tibia B. fracture of the femur C. fracture of a rib D. midclavicular fracture

Answer: D Rationale: Trauma to the newborn may result from the use of mechanical forces, such as forceps during birth. Primarily injuries are found in large babies and babies with shoulder dystocia. Associated traumatic injuries include fracture of the clavicle or humerus or subluxations of the shoulder or cervical spine.

9. When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature? A. hearing B. touch C. taste D. vision

Answer: D Rationale: Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

12. The nurse administers vitamin K intramuscularly to the newborn based on which rationale? A. Stop Rh sensitization. B. Increase erythropoiesis. C. Enhance bilirubin breakdown. D. Promote blood clotting.

Answer: D Rationale: Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the liver. Rho(D) immune globulin prevents Rh sensitization. Erythropoietin stimulates erythropoiesis. Phototherapy enhances bilirubin breakdown.