Maternal Newborn
*C. Autosomal recessive* PKU is inherited by autosomal-recessive gene patterns. In these type of disorders, neither parent may actually have the disorder, but both mother and father must carry and contribute a variant gene for it to occur. Other autosomal-recessive disorders are cystic fibrosis and sickle cell anemia.
The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which inheritance patterns responsible for PKU? A. X-linked recessive B. X-linked dominant C. Autosomal recessive D. Autosomal dominant
*A. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy* Use the ABC priority-setting framework. An elevated bilirubin level can lead to kernicterus (a type of brain damage that can cause athetoid cerebral palsy and hearing loss); therefore it is imperative for the nurse to initiate phototherapy immediately to help prevent this dangerous outcome. Incorrect Answers: A. Phenylketonuria is an inborn error of phenylalanine metabolism. Without treatment with a phenylalanine-free diet, newborns who have this disorder can develop severe, irreversible developmental delays. Blood collection for this test prior to 24 hours after delivery can result in inconclusive results and the need for another specimen collection after at least 2 days of breast or formula feeding. The nurse should collect this specimen promptly; however, another client is the priority. C. & D. The nurse should monitor this newborn's weight to identify whether further intervention is needed to promote growth and development; however, another client is the priority.
A community health nurse is planning care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? A. A 1-week old newborn who needs another phenylketonuria screening. B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy. C. A 10-day-old newborn who is small for gestational age and requires daily weighing. D. A 2-week old newborn who was born at 35 weeks gestation and weighed 2,268 g (5 lb) at discharge)
*C. "You will probably first notice your baby moving when you are around 20 weeks gestation."* Fetal movement is typically noted by a pregnant client at 18-20 weeks gestation. Multiparous clients might notice the movement earlier. Incorrect Answers: A. Clients should avoid a supine position during the latter half of pregnancy due to the risk of vena cava compression. B. This is a common finding during the first and third trimester due to fetal pressure on the bladder. Urinary frequency and urgency during the second trimester should be reported to the provider. D. Recommended weight gain during pregnancy is typically 25-30 lbs.
A nurse in an outpatient setting is providing education for a client who is pregnant. Which of the following statements should the nurse include in the teaching? A. "During the last trimester, you should sleep mainly on your back." B. "During the second trimester, you will notice increased urinary frequency and urgency." C. "You will probably first notice your baby moving when you are around 20 weeks gestation." D. "You should plan to gain 40-45 lbs during your pregnancy."
*Baker's yeast* An allergy to baker's yeast is a contraindication to receiving the hepatitis B vaccine. The nurse should notify the client's provider. Incorrect Answers: A. Clients with an allergy to shellfish should not receive IV contrast dye, which contains iodine. B. A client who has an allergy to gelatin should not receive the MMR vaccine. D. A client who has an allergy to eggs should not receive the influenza vaccine and should contact the provider.
A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine? A. Shellfish B. Gelatin C. Baker's yeast D. Eggs
*B. "Place ice packs on your breasts"* The nurse should instruct the client to place ice packs on her breasts using a "15 minutes on and 45 minutes off" schedule to decrease swelling of the breast tissue as the body produces milk. Incorrect Answers: A. Warm water running over the breasts can stimulate milk production. C. The client should drink 2 to 3 L of fluid per day to promote normal bowel function.
A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which instructions should the nurse include in the teaching? A. "Stand under a hot shower with your breasts exposed." B. "Place ice packs on your breasts." C. "Wear a loose-fitting comfortable bra." D. "Limit fluid intake to 1 L per day."
*B. Assist the client to empty her bladder* When the client's fundus is deviated to the right or left, it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia (the normal discharge from the uterus after childbirth). Incorrect Answers: A. Dehydration can cause a client who is postpartum to have a temperature up to 38C (100.4 F) during the first 24 hrs following delivery. C. The nurse should not administer rectal suppositories and enemas to clients who have third- and fourth-degree lacerations due to the risk of injury to the suture line. D. The nurse does not need to massage the client's fundus because it is firm. The gush of blood when ambulating is expected due to blood pooling in the vagina when the client is lying in bed.
A nurse is assessing a client who is 14 hr postpartum and has a third-degree perineal laceration. The client's temperature is 37.8 C (100 F), and her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movement since delivery. Which of the following actions should the nurse take? A. Notify the provider about the client's elevated temperature B. Assist the client to empty her bladder C. Administer a bisacodyl suppository D. Massage the client's fundus
*B. "Decrease your intake of spice foods."* Spicy foods cause gastric irritation, which may increase during pregnancy as a result of various physiological changes. Incorrect Answers: A. Ingesting large amounts of food at once can cause bloating, distention, and nausea. The client should be counseled to eat small, frequent meals. C. This action might exacerbate indigestion, as it is known to cause heartburn and reflux of gastric contents. D. This action might exacerbate indigestion since it contributes to feelings of fullness and nausea, and the carbonation unnecessarily adds gas to the digestive tract.
A nurse is assessing a client who is at 20 weeks gestation and reports frequent episodes of indigestion and heartburn. Which of the following instructions should the nurse give to the client? A. "Limit your intake of food to twice per day." B. "Decrease your intake of spicy foods." C. "Rest in a supine position for a few minutes after eating." D. "Increase your intake of water and carbonated beverages."
*A. Symmetric rib cage* A newborn who was born at 39 wks gestation is full-term and should have a symmetric rib cage. Incorrect Answers: B. A newborn who is born at 39 wks gestation is full-term and should have normal, smooth skin with good turgor and the presence of subcutaneous fat pockets. A post-mature newborn (born after 42 wks gestation) will have dry, cracked skin with a wrinkled appearance. C. A newborn who was born at 39 wks of gestation is full-term and should have little to no vernix present. D. lanugo (fine, downy hair) is abundant in newborns who are preterm. Newborns who are born at full-term typically have sparse lanugo on the shoulders, pinna, and forehead.
A nurse is assessing a newborn who was born at 39 wks gestation. Which of the following findings should the nurse expect? A. Symmetric rib cage B. Dry, wrinkled skin C. Vernix over the entire body D. Abundant lanugo on the back
*D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract."* Oxytocin is released in response to breastfeeding. This hormone also causes the uterus to contract, which decreases the risk for postpartum hemorrhage and increases involution (the shrinkage of the uterus after childbirth). Incorrect Answers: A. Prolactin is responsible for milk production, not uterine contractions. B. Uterine contractions with breastfeeding do not indicate that the uterus is trying to expel clotted blood. Small clots are typically expressed in the lochia rubra. C. Breast tissue does not secrete hormones. The hormones that affect breast functions, such as milk production, are produced by the anterior pituitary gland.
A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements? A. "Prolactin is increasing the blood supply to your uterus, and you are feeling blood vessel engorgement." B. "You probably have a small blood clot in your uterus, which is causing the uterus to contract in order to expel it." C. "Your breasts are secreting a hormone that enters the bloodstream and causes your abdominal muscles to contract." D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract."
*A. Palpable fetal movement* Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal movement, is a presumptive sign of pregnancy. Incorrect Answers: B. Chadwick's sign is a bluish discoloration of the cervix, vagina, and vulva that occurs at 6-8 wks of pregnancy. This is a probable sign of pregnancy. After the client's first pregnancy, the discoloration can remains, reducing its value as an indicator in subsequent pregnancies. C. A positive pregnancy test is a probable sign of pregnancy. A client can also have a positive pregnancy test due to menopause, choriocarcinoma, and hydatidiform mole. D. Amenorrhea, or lack of menstrual period, is a presumptive sign of pregnancy. A client can also have amenorrhea due to stress, endocrine disorders, and significant weight loss.
A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Palpable fetal movement B. Chadwick's sign C. Positive pregnancy test D. Amenorrhea
*A. Massage the fundus* *C. Administer oxytocin with IV fluids* *D. Insert an indwelling urinary catheter* *E. Place the client in a lateral position with her legs elevated 30 degrees* The nurse should massage the fundus to expel clots and help the uterus contract. The nurse should add oxytocin to the intravenous drip and insert and indwelling urinary catheter to monitor urinary output and perfusion to the kidney. Finally, the nurse should place the client in a lateral position with her legs elevated 30 degrees. Incorrect Answer: B. The nurse should administer oxygen 10 L/min via nonrebreather face mask.
A nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (SATA) A. Massage the fundus B. Give oxygen at 2 L/min via nasal cannula C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30 degrees
*B. "You should walk for at least 30 min every day."* The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation. Incorrect Answers: A. The client should not consume mineral oil to treat constipation during pregnancy because this can lead to severe cramping, diarrhea, fluid loss, and preterm contractions. C. The nurse should not recommend a daily intake of red meat because it is high in iron and contributes to constipation. D. Instructing the client to stop taking her prescribed prenatal vitamin could harm the fetus.
A nurse is caring for a client who is at 26 wks gestation and reports constipation. Which of the following responses is appropriate? A. "You should drink 1 oz of mineral oil every morning." B. "You should walk for at least 30 min every day." C. "You should eat at least 3 oz of red meat per day." D. "You should stop taking your prenatal vitamin."
*D. April 15* Using Naegele's rule, the nurse determines the EDB by counting back 3 months from the first day of the LMP and adding 7 days.
A nurse is caring for a client whose last menstrual period (LMP) began on July 8. Using Naegele's rule, what is the client's estimated date of birth (EDB)? A. Oct 1 B. Apr 1 C. Oct 15 D. Apr 15
*D. Reducing ambient noise and lighting* Minimizing light and noise stimuli in the nursery is an important aspect of promoting optimal development. Lightning should be dimmed at night, and blankets should be placed over the incubators during the daylight hours. Noise levels should always be kept to a minimum. Incorrect Answers: A. Body containment within blankets promotes self-regulation and decreases stimuli. The flexed position promotes proper body alignment., which is necessary for optimal development. B. The preferred positions are prone and side-lying. These positions promote flexion of the arms and legs, which is essential for the developmental care of preterm infants. C. Physical care should be clustered to allow longer intervals of sleep.
A nurse is caring for a preterm infant in the NICU. Which of the following actions by the nurse will promote the infant's optimal development? A. Avoid swaddling B. Placing the infant in the supine position C. Providing physical care at short, frequent intervals D. Reducing ambient noise and lighting
*C. Maintain the client in a side-lying position for 30 min after insertion* The client should maintain a side-lying or supine position with a lateral tilt for 30-40 min after the insertion of the medication to allow the gel to stay in contact with the cervix. Incorrect answers: A. Fetal HR and contractions should be assessed continuously because prostaglandin E2 gel can cause tachysystole (≥6 contractions in 10 minutes) and fetal distress. B. Using a warm-water bath or microwave to accelerate the warming of the gel can inactivate the ingredients. The gel should be allowed to thaw at room temperature. D. The initiation of an oxytocin infusion should be delayed for 6-12 hrs after the last instillation of prostaglandin E2 gel.
A nurse is planning care for a client who is scheduled to have prostaglandin E2 gel inserted for cervical ripening. Which of the following actions should the nurse take? A. Assess fetal heart rate and contraction pattern every 15 min after insertion B. Thaw the frozen gel in a warm water bath prior to insertion C. Maintain the client in a side-lying position for 30 min after insertion D. Initiate an oxytocin infusion for induction 1 hr after gel insertion
*D. Provide examples of how eating well will help maintain a healthy weight during pregnancy.* Adolescents are typically preoccupied with self and lack the ability to understand outcomes that will occur in the future. Effective teaching for this age group should mainly focus on benefits to the client and positive outcomes that will occur in the near future. Incorrect Answers: A. Watching a video may be helpful for some clients but does not address this client's concerns about weight gain. B. C. Providing information about proper nutrition may be effective for some clients but will typically not meet the needs of an adolescent client who is expressing concerns about gaining weight.
A nurse is providing care for a pregnant adolescent who is at 12 weeks gestation and verbalizes a fear of gaining weight during pregnancy. Which of the following actions should the nurse take? A. Have the client watch a video on fetal growth and development during pregnancy. B. Supply pamphlets that discuss the importance of nutrition during pregnancy. C. Explain how poor nutrition can prevent the baby from growing properly. D. Provide examples of how eating well will help maintain a healthy weight during pregnancy.
*C. Cow's milk-base formula is recommended for healthy newborns.* The nurse should identify that cow's milk-based formulas are similar to human breast milk and are recommended for newborns and infants unless prescribed otherwise by the provider. Certain conditions that might indicate a need to switch to an alternate formula include galactosemia, a congenital lactose deficiency, and immunoglobulin E allergies. Incorrect Answers: A. The nurse should identify that soy-based formula is not known to decrease the manifestations of colic. B. The nurse should identify that amino acid formula are recommended for newborns and infants who have protein intolerance. D. The nurse should identify that iron-fortified formulas are recommended since they meet the newborn's daily iron requirements.
A nurse is providing teaching about the selection of commercial formula to the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Soy-based formula is recommended to decrease colic. B. Amino acid formula is recommended to increase the newborn's protein intake. C. Cow's milk-based formula is recommended for healthy newborns. D. Low-iron formula is recommended to prevent excess iron intake.
*C. Progesterone* Progesterone maintains the endometrium and has a relaxant effect on the uterus so that the fetus is not expelled. Incorrect Answers: A. Oxytocin stimulates uterine contractions and is responsible for the excretion of milk during lactation. B. Prolactin prepares the breasts to synthesize and secrete milk. D. Estrogen stimulates uterine contractility and growth of the uterus and breast glandular tissue. Estrogen levels rise near the end of pregnancy to prepare for the onset of labor.
A nurse is providing teaching for a client about hormonal changes during pregnancy. The nurse identifies that which of the following hormones plays a key role in preventing miscarriage? A. Oxytocin B. Prolactin C. Progesterone D. Estrogen
*D. Boil water for powdered formula for 1-2 min.* The parents should run tap water for 2 min and then boil it for 1-2 min before mixing it with the formula to decrease the risk of contamination. Incorrect Answers: A. The parents should not dilute ready-to-feed formula because the newborn will get full before consuming the appropriate amount of calories and nutrients. B. The parents should always hold the bottle when feeding the newborn to prevent aspiration and the development of caries. C. the parents should only keep unused prepared formula for 48 hrs. to decrease the risk of contamination.
A nurse is providing teaching to the parents of a newborn about bottle-feeding. Which of the following instructions should the nurse include in the teaching? A. Dilute ready-to-feed formula if the newborn is gaining weight too quickly. B. Prop the bottle with a blanket for the last feeding of the day. C. Discard unused refrigerated formula after 72 hr. D. Boil water for powdered formula for 1-2 min.
*C. Rooting* The rooting reflex is elicited when the cheek is stroked and the newborn turns the head while making sucking motions with the mouth. The reflex supports effective sucking. Incorrect Answers: A. This is a reflex of the lower extremities. When the newborn is held vertically, he or she will make leg movements that look like walking. B. This reflex, also known as the startle reflex, is elicited by striking the surface next to the newborn. The pattern of abduction and extension of the arms that follows is expected. D. The Babinski reflex is elicited by stroking upward along the lateral edge of the sole of the foot. In infancy, hyperextension of the toes with dorsiflexion of the great to is expected. An absence of the response warrants neurological evaluation.
A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? A. Stepping B. Moro C. Rooting D. Babinski