Maternal newborn final part 2
The nurse is teaching the parents of a female baby how to change a baby's diapers. Which of the following should be included in the teaching? Select one: a. Always wipe the perineum from front to back. b. Use an antibiotic ointment at the first sign of diaper rash c. Put powder on the buttocks every time the baby stools. d. Weigh every diaper in order to assess for hydration.
A Clean female genitals by washing from front to back to decrease the risk of cystitis
Approximately 8 hours ago, Juanita, a 32-year-old G1 P0, gave birth after 2 hours of pushing. She required an episiotomy and an assisted birth (forceps) due to the weight and size of her baby (9 lb. 9 oz.). The perinatal nurse is performing an assessment of Juanita's perineal area. A slight bulge is palpated and the presence of ecchymoses to the right of the episiotomy is noted. The area feels "full" and is approximately 4 cm in diameter. Juanita describes this area as "very tender." The most likely cause of these signs and symptoms is: Select one: a. Hematoma formation b. Sepsis in the episiotomy site c. Inadequate repair of the episiotomy d. Postpartum hemorrhage
*a. Hematoma formation A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. The most common sign or symptom of a hematoma is unremitting pain and pressure. Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as "full."
A baby boy was just born to a mother who had positive vaginal cultures for group B streptococci. The mother was admitted to the labor room 30 minutes before the birth. For which of the following should the nursery nurse closely observe this baby? Select one: a. Grunting b. Acrocyanosis c. Pseudostrabismus d. Hydrocele
A Group B Strep (GBS) is the primary cause of neonatal meningitis and sepsis in the US. GBS+ mothers should be treated with IV penicillin every 4 hours until delivery; usually an initial dose repeated after 4 hours is sufficient treatment. When GBS+ mothers or not treated appropriately or when GBS status is unknown, infants must be carefully observed for signs on infection which are often nonspecific and subtle. Signs of neonatal infection include apnea, grunting, retractions, tachypnea, cyanosis, hypothermia, fever, tachycardia, tremors, irritability to name a few.
The NICU nurse recognizes that respiratory distress syndrome results from a developmental lack of: Select one: a. Lecithin b. Calcium c. Surfactant d. Magnesium
C Respiratory distress syndrome (RDS) is a life-threatening lung disorder resulting from underdeveloped and small alveoli and insufficient level of pulmonary surfactant.
The nurse is advising parents of a full-term neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? Select one: a. Put the car seat facing forward only after the baby reaches 20 pounds b. The infant car seat should be placed facing the rear seat in the front seat of the car. c. Car seats are recommended only when traveling longer distances from home; holding the infant is safe for short trips d. It is safe to leave an infant in a car seat alone as long as the windows are down at least 1 inch.
A Infants are safest when secured in the back seat. Rear-facing car seats are used with infants until they are 1 year of age and weigh 20 pounds. It is never safe to leave an infant unattended in a car seat and car seats should be used whenever traveling in a motor vehicle.
A postpartum woman has been diagnosed with postpartum psychosis and will shortly be admitted to the psychiatric unit. Which of the following actions should the nurse perform to ensure safety for both mother and infant? Select one: a. Closely monitor all mother-infant interactions b. Maintain client on strict bed rest. c. Restrict visitation to her partner. d. Carefully monitor toileting.
A Postpartum psychosis (PPP) is a variant of bipolar disorder and is the most serious form of postpartum mood disorders. Onset of symptoms can be as early as the 3rd postpartum day. Assessment findings include paranoia, delusions associated with the baby, mood swings, extreme agitation, confused thinking, and strange beliefs.
General skin care for full-term infants includes which of the following? (Select all that apply.) Select one or more: a. Avoid daily bathing with soap. b. Use a cleanser with a neutral pH. c. Avoid fragrant soaps. d. Apply petrolatum-based ointments sparingly to dry skin, but avoid head and face.
A,B,C,D It is not necessary to bathe an infant daily. Daily bathing with soap can cause dry skin in the infant. The cleanser should be of neutral pH and free of additives such as fragrances that could be irritants.
a. Promote rest and rehydration and recheck in 1 hour b. Explain to the patient that she needs to change her position c. Immediately medicate the patient with 500 mg of acetaminophen d. Call the patient's physician or midwife to report the elevated temperature.
A A mild temperature elevation within a few hours of birth can be related to dehydration and exhaustion. Acetaminophen is given if the temperature remains elevated after the woman has been hydrated and rested. The physician or midwife is notified if temperature remains elevated after initial interventions.
The most appropriate time to give prophylactic antibiotics to the women undergoing cesarean section is: Select one: a. One hour before the surgery b. Two hours before the surgery c. Not indicated unless she has an act
A Administration of narrow spectrum prophylactic antibiotics should occur within 60 minutes prior to the skin incision.
One of the following neonates is at highest risk for cold stress: Select one: a. LGA neonate at 38 weeks gestation b. AGA neonate at 32 weeks gestation c. SGA neonate at 33 weeks gestation d. SGA neonate at 40 weeks gestation
C Risk factors for cold stress include prematurity, small for gestational age (SGA); hypoglycemia, prolonged resuscitation efforts, sepsis, neurological/endocrine/cardiorespiratory problems
Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb. 13 oz. daughter. She experiences severe cramps with breastfeeding. The perinatal nurse best describes this condition as: Select one: a. Afterpains b. Uterine hypertonia c. Bladder hypertonia d. Rectus abdominis diastasis
A Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Patients often describe the sensation as a discomfort similar to menstrual cramps. Afterpains are also related to the increase of oxytocin released in response to infant suckling.
The nurse is about to elicit the rooting reflex on a newborn baby. Which of the following responses should the nurse expect to see? Select one: a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.
A An infant exhibits Rooting reflex when the neonate turns his head toward the direction of the stimulus and opens his mouth. Choice 2 is the Babinski reflex; Choice 3 is the Startle or Moro reflex; Choice 4 is the Tonic Neck reflex
The perinatal nurse is caring for a woman in the recovery room immediately following cesarean birth. Which of the following assessment findings would indicate the need for immediate notification of the obstetrical provider? Select one or more: a. Catheter is draining blood-tinged urine. b. Woman complains of itching c. Woman complains of nausea d. Lochia is moderate
A Blood in the urine occurs when there has been trauma to the bladder. Bladder, ureter, and bowel trauma are surgical complications requiring prompt attention. Itching and nausea are common reactions to anesthesia and are treated with ordered medications. Moderate lochia is an expected finding.
The nursery nurse notes the presence of diffuse edema on a baby girl's head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edema has disappeared. The nurse documents the following condition in the infant's chart. Select one: a. Caput succedaneum b. Cephalhematoma c. Subperiosteal hemorrhage d. Epstein pearls
A Caput succedaneum is localized soft tissue edema of the scalp; feels spongy; may cross suture lines; results from prolonged pressure of the head against the maternal cervix during labor; resolves within the first week of life.
A 65-year-old woman is complaining of jaw pain, nausea, shortness of breath without chest pain, and sweating. These are warning signs of: Select one: a. Heart attack b. Stroke c. Diabetes d. Dental disease
A
A mother of a 10-day-old infant calls the clinic and reports that her baby is having loose, green stools. The mother is breastfeeding her infant. Which of the following is the best nursing action? Select one: a. Instruct the woman to bring her infant to the clinic b. Instruct the woman to decrease the amount of feeding for 24 hours and to call if the stools continue to be loose. c. Explain that this is a normal stool pattern. d. Instruct the woman to eat a bland diet for the next 24 hours and call back if the stools continue to be loose and green.
A
To accurately measure the neonate's head, the nurse places the measuring tape around the head: Select one: a. Just above the ears and eyebrows b. Middle of the ear and over the eyes c. Middle of the ear and over the bridge of the nose d. Just below the ears and over the upper lip
A
Which of the following is an indication for the administration of methylergonovine (Methergine)? Select one: a. Boggy uterus that does not respond to massage and oxytocin therapy b. Woman with a large hematoma c. Woman with a deep vein thrombosis d. Woman with severe postpartum depression
A
Which of the following is correct regarding endometriosis? A.The physical symptoms of endometriosis can affect the woman's mental health B.The abnormal tissue bleeds into surrounding tissue during the secretory stage of the menstrual cycle. C.Endometriosis causes severe headaches. D.Metronidazole is used to treat endometriosis.
A
Which of the following women is at highest risk for osteoporosis? A. A 70-year-old non-Hispanic Caucasian woman who has smoked for 50 years B. A 70-year-old non-Hispanic black woman who is a heavy drinker C.A 60-year-old Asian woman who takes steroids to treat SLE D. A 70-year-old Hispanic woman who has had weight loss surgery
A
Tanya, a 30 year old woman, is being prepared for an elective cesarean birth. The perinatal nurse assists the anesthesiologist with the spinal block and then positions Tanya in a supine position. Tanya's blood pressure drops to 90/52, and there is a decrease in the fetal heart rate to 110 bpm. The perinatal nurse's best response is to: Select one: a. Place Tanya in a left lateral tilt b. Discontinue Tanya's intravenous administration. c. Have naloxone (Narcan) ready for administration. d. Have epinephrine ready for administration.
A Reposition the woman after epidural or spinal anesthesia in a supine position with a left lateral tilt to decrease the pressure from the uterus on the inferior vena cava and to maintain placental perfusion.
Which of the following breath sounds are normal to hear in the neonate during the first few hours postbirth? Select one: a. Scattered crackles b. Wheezes c. Stridor d. Grunting
A Scattered crackles may be detected during the first few hours after birth due to retained amniotic fluid. Persistent crackles, wheezes, stridor, grunting, paradoxical breathing, decreased breath sounds, and/or prolonged periods of apnea are signs of respiratory distress. Decreased or absent breath sounds are often related to meconium aspiration or pneumothorax.
A post-cesarean birth woman has been diagnosed with paralytic ileus. Which of the following symptoms would the nurse expect to see? Select one: a. Abdominal distension b. Polyuria c. Diastasis recti d. Dependent edema
A Signs and symptoms of paralytic ileus include abdominal distention, diffuse and persistent abdominal pain, and nausea or vomiting
The nurse is developing a plan of care for a client who is in the "taking-in" phase after delivering a healthy baby boy. Which of the following should the nurse include in the plan? Select one: a. Assist the woman in selecting a nutritious meal plan. b. Teach baby care skills like diapering. c. Discuss the pros and cons of circumcision. d. Counsel her regarding future sexual encounters.
A The "taking-in" phase is a period of dependent behaviors and occurs during the first 24-48 hours. Assisting her in ordering her meals allows her to focus on her comfort while acknowledging her decreased ability to make decisions. Teaching infant skills is probably more appropriate during the "taking-hold" phase.
A 37 year old gravida 8 para 8 woman was admitted to the postpartum unit at 2 hours post birth. On admission to the unit, her fundus was palpated at the umbilicus, midline, and firm; lochia was moderate rubra. An hour later, her fundus is midline and boggy, and the lochia is heavy with small clots. Based on this assessment data, the first nursing action is: Select one: a. Massage the fundus of the uterus. b. Assist the woman to the bathroom and reassess the fundus. c. Notify the physician or midwife. d. Start IV oxytocin therapy as per standing orders.
A Uterine atony is a decreased tone of the uterine muscle and the major cause of postpartum hemorrhage (PPH). Uterine atony results in soft, boggy fundus; bleeding may be slow and steady or sudden and massive; blood clots may be presents; tachycardia; hypotension. Nursing management for a boggy uterus is massage and reassessment. If the uterus is displaced to either side of midline, consider full bladder as the cause for atony.
Painful nipples are a major reason why women stop breastfeeding. A primary intervention to decrease nipple irritation is: Select one: a. Teaching proper techniques for latching-on and releasing of suction b. Applying hot compresses to breast prior to feeding c. Instructing woman to express colostrum or milk at the end of the feeding session and rub it on her nipples d. Air drying nipples for 10 minutes at the end of the feeding session
A While all these interventions are correct, the primary intervention is to ensure correct latching-on and suction release as problems with these lead to early cessation of breastfeeding.
A 42-weeks' gestation neonate is admitted to the NICU (neonatal intensive care unit). This neonate is at risk for which complication? Select one: a. Meconium aspiration b. Failure to thrive c. Necrotizing enterocolitis d. Intraventricular hemorrhage
A post-term neonate is one who is delivered after the completion of 41 weeks' gestation and is at higher risk of morbidity and mortality. Post mature infants are at risk for meconium aspiration, fetal hypoxia related to placental insufficiency, neurological complications related to asphyxia, hypoglycemia, hypothermia, polycythemia, and birth trauma related to macrosomia ( birth weight above 4000-4500 grams).
The postpartum nurse caring for a 20-year-old G1 P1 woman who 3 hours ago delivered a healthy full-term infant, observes the woman who is lightly touching her baby girl with her fingertips but who seems to be uncomfortable holding her baby close to her body. Which of the following is an accurate interpretation of these observed behaviors? Select one: a. The woman is in the initial stage of maternal touch. b. The woman is in the taking-in phase. c. The woman is having difficulty in bonding with her baby. d. The woman needs to be medicated for pain.
A These are classical signs of the initial stage of Rubin's maternal touch.
A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation for administration of Vitamin K to the infant, the nurse will explain to the parents that an injection of this medication: Select one: a. Influences the activation of coagulation factors to prevent delayed clotting and hemorrhagic disease b. Prevents high levels of unconjugated bilirubin in the newborn's blood c. Prevents the excessive loss of RBCs d. Aids the liver in regulation of blood glucose
A Vitamin K (phytonadione) influences the activation of coagulation factors II, VII, IX, and X.
The perinatal nurse observed the pediatrician completing the Ballard Maturational Score (BMS). The maturity components used with this assessment are (select all that apply): Select one or more: a. Physical b. Behavioral c. Reflexive d. Neuromuscular
A, D With the BMS, the infant examination yields a score of neuromuscular and physical maturity that can be extrapolated onto a corresponding age scale to reveal the infant's gestational age in weeks.
Nursing actions that decrease the risk of skin breakdown include which of the following? (Select all that apply.) Select one or more: a. Using gelled mattresses b. Using emollients in dry areas c. Using transparent adhesive dressings d. Few diaper changes
A,B
The clinic nurse teaches expectant mothers about the differences between breast milk and commercially prepared infant formulas. When compared to commercially prepared formulas, breast milk has (select all that apply): Select one or more: a. More carbohydrates b. Less protein c. Fewer nutrients d. Less cholesterol
A,B Human breast milk contains more carbohydrates, less protein, and more cholesterol than cow's milk or infant formulas. Commercially prepared infant formulas use vegetable oils which are void of cholesterol.
Menorrhagia may result from (select all that apply): Select one or more: a. Anovulatory cycle b. Metritis c. Anorexia d. Emotional distress
A,B Menorrhagia is menstrual bleeding excessive in number of days and amount of blood. It may result from an anovulatory cycle, fibroids, inflammatory or infectious disease such as metritis or salpingitis, endometrial issues, or intrauterine device (IUD)
During a health visit, a 23-year-old patient shares with her health-care provider that she has been experiencing a yellowish mucus vaginal discharge, pain during sexual intercourse, and burning on urination. A culture of the cervical epithelial cells is obtained. Based on the patient information, the culture is obtained to assist in the diagnosis of which of the following? (Select all that apply.) Select one or more: a. Chlamydia b. Gonorrhea c. Genital herpes d. Syphilis
A,B These are symptoms that can be related to either chlamydia or gonorrhea. Syphilis is diagnosed via blood test. Genital herpes has symptoms similar to the flu, and the person usually has an itching or burning sensation in the genital or anal area.
A G2 P2 woman who experienced a prolonged labor and prolonged rupture of membranes is at risk for metritis. Which of the following nursing actions are directed at decreasing this risk? (Select all that apply.) Select one or more: a. Instruct woman to increase her fluid intake b. Instruct woman to change her peri-pads after each voiding c. Instruct woman to ambulate in the halls four times a day d. Instruct woman to apply ice packs to the perineum
A,B, C Metritis is an infection of the endometrium, myometrium, and/or parametrial tissue. Risk factors include cesarean birth, prolonged rupture of membranes, prolonged labor, etc. Symptoms include elevated temp, lower abdominal pain, uterine tenderness, tachycardia, subinvolution. Metritis is generally treated with antibiotics based on culture results. Nursing actions include proper hand washing techniques, proper pericare/wipe front to back after urination, change peripad after each urination, early ambulation, rehydration, diet high in protein/vitamin C, and monitoring for symptoms.
A woman who is receiving radiation therapy for treatment of stage I cervical cancer is experiencing diarrhea. She contacts the oncology advice nurse. The advice nurse recommends that the woman (select all that apply): Select one or more: a. Eat five or six small meals a day instead of three large meals b. Eat cooked vegetables instead of raw vegetables c. Use baby wipes instead of toilet paper d. Reduce fluid intake to four glasses of water
A,B,C
The perinatal nurse is caring for Christy following the birth of her first child. Base on Christy's history, the RN recognizes that risk factors for postpartum depression include: Select one or more: a. Loss of friends based on upcoming divorce; family is unable to assist b. Separated from spouse pending divorce c. Unplanned cesarean delivery secondary to Category III fetal tracing d. Good prenatal care with uneventful pregnancy
A,B,C Recognized risk factors for postpartum depression include a history of depression before pregnancy, depression or anxiety during pregnancy, poor quality relationship with partner, life/child care stresses, and complications of pregnancy/childbirth.
The woman's health clinic nurse is providing information to a 21-year-old woman who is being scheduled for a pelvic exam and Pap test. This information should include (select all that apply): Select one or more: a. The Pap test is a diagnostic test for cervical cancer. b. The woman should not use tampons or vaginal medication or engage in sexual intercourse within 48 hours of the exam. c. The best time to have a Pap test is 5 days after the menstrual period has ended. d. The woman should have a yearly Pap test.
A,B,C The Pap test is a screening versus a diagnostic test. Women should not douche; use tampons; use vaginal creams, spermicide foams, creams, or jellies; use vaginal lubricants or moisturizers; use vaginal medications; or have sexual intercourse for 48 hours prior to the exam. The best time to obtain a Pap test is 5 days after the period ends. Women ages 21 to 29 should have a Pap test every 3 years.
The perinatal nurse describes infant feeding cues to a new mother. These feeding cues include (select all that apply): Select one or more: a. Awake and alert b. Mouth movements c. Moving the hand to the mouth d. Yawning
A,B,C The infant demonstrates readiness for feeding when he or she is awake and alert, makes hand-to-mouth or hand-to-hand movements, exhibits sucking or licking, exhibits rooting, and demonstrates increased activity with the arms and legs flexed and the hands in a fist.
Which of the following are primary risk factors for subinvolution of the uterus? (Select all that apply.) Select one or more: a. Fibroids b. Retained placental tissue c. Metritis d. Urinary tract infection
A,B,C Uterine fibroids can interfere with involution. Retained placental tissue does not allow the uterus to remain contracted. Infection in the uterus is a risk factor for subinvolution. UTI does not interfere with involution of the uterus.
Jennifer is 3 hours postpartum following the vaginal delivery of a 9lb 15oz baby girl. Estimated blood loss at delivery was 800 ml. The RN is aware that Jennifer experienced an early-postpartum hemorrhage). Select the appropriate nursing actions for the care of this patient. (Select all that apply.) Select one or more: a. Maintain IV site in case fluids/medication for PPH are indicated b. Frequent fundal assessment to prevent uterine atony and further blood loss c. d. Assess lochia for amount and for clots
A,B,C, D PPH is blood loss greater than 500 ml for vaginal deliveries and 1000 ml for cesarean with a 10% drop in hemoglobin and/or hematocrit. Unfortunately, postpartum women may not show signs/symptoms of PPH until about 1/3 of entire blood volume is lost. RNs must frequently assess uterine tone, location, and position as well as blood loss amount and characteristics (slow, steady, sudden, massive, presence of clots, possible distended bladder). Keeping the IV site intact will allow immediate access to fluids and/or medications should PPH worsen.
A first time mother informs her nurse that she is concerned about infant abduction. The nurse should explain to the parents which of the following? (Select all that apply.) Select one or more: a. Do not allow a person without proper unit specific hospital ID to take their baby. b. Encourage parents to accompany any person who removes their infant from the hospital room c. Instruct parents not to leave their newborn unattended at any time d. Inform parents that ID bands with matching identification numbers are placed on the parents and infant at birth to ensure identification of the correct infant with the correct parents
A,B,C,D
A nurse is caring for a 10-day-old neonate who was born at 33 weeks' gestation. Which of the following actions assist the nurse in assessing appropriateness for transition from gavage to oral feedings? (Select all that apply.) Select one or more: a. Stable cardiorespiratory pattern b. Coordinated suck, swallow, and breathe c. Shows hunger cues. d. Quiet, alert state
A,B,C,D
A nurse is caring for a 2-day-old neonate born at 31 weeks' gestation. The neonate has a diagnosis of respiratory distress syndrome (RDS). Which of the following medical treatments would the nurse anticipate for this neonate? (Select all that apply.) Select one or more: a. Umbilical artery and vein catheters b. Dopamine or dobutamine for treatment of hypotension c. Nasal continuous positive airway pressure (NCPAP) d. Continuous pulse oximetry
A,B,C,D
Postoperative nursing care and education for a woman who had an abdominal hysterectomy includes (select all that apply): Select one or more: a. Administering hormone replacement therapy as per provider orders b. Informing the woman that she will experience small amounts of vaginal bleeding for several days c. Instructing the woman not to use tampons until advised by surgeon d. Instructing the woman to increase her ambulation to facilitate return of normal intestinal peristalsis
A,B,C,D
The let-down reflex occurs in response to the release of oxytocin. Which of the following can stimulate the release of oxytocin? (Select all that apply.) a. Emotional response to thinking about her baby b. Infant suckling c. Emotional response to hearing an infant crying d. Sexual activity
A,B,C,D
The nurse is teaching the parents of a healthy newborn about infant safety. Which of the following should be included in the teaching plan? Select one or more: a. Water temperature for the infant's bath should be 100.4 degrees F. b. Do not cook while holding an infant c. Cover electrical outlets d. Remove strings from infant sleepwear, bedding, and pacifiers to prevent strangulation.
A,B,C,D
Which of the following are indications for cesarean birth? (Select all that apply.) Select one or more: a. Previous cesarean birth b. Placental abnormalities c. Previous uterine surgery d. Failure to progress
A,B,C,D
Which of the following nursing actions can assist a man in his transition to fatherhood? (Select all that apply.) Select one or more: a. Ask the man to share his ideas of what it means to be a father. b. Demonstrate infant care such as diapering and feeding. c. Engage couple in a discussion regarding each other's expectations of the fathering role. d. Provide the man with information on infant care.
A,B,C,D
A 60-year-old woman is scheduled for a dual-energy X-ray absorptiometry scan (DXA). The woman's health clinic nurse should provide the following information: Select one or more: Select one or more: a. DXA is a diagnostic test for osteoporosis. b. DXA measures the bone density of the hip, spine, and forearm. c. The T score is a comparison of the woman's bone density with that of other women her same race. d. Osteoporosis can cause a stooped posture.
A,B,C,D All of these are true statements. A 60-year-old woman is scheduled for a dual-energy X-ray absorptiometry scan (DXA). T-score is a comparison of the woman's bone density with that of a woman 30 years of age and the same race. Osteoporosis can cause loss of height and stooped posture related to collapsed vertebra
A nurse is completing the initial assessment on a neonate of a mother with type I diabetes. Important assessment areas for this neonate include which of the following? (Select all that apply.) Select one or more: a. Assessment of cardiovascular system b. Assessment of respiratory system c. Assessment of musculoskeletal system d. Assessment of neurological system
A,B,C,D Complications of high maternal levels of glucose during pregnancy include cardiac anomalies, skeletal defects, risk for RDS, neurological damage and seizures. Assessment findings of the macrosomic infant may include fractured clavicle, brachial nerve damage, hypoglycemia, hypocalcemia and hypomagnesemia, poycythemia, hyperbilirubinemia, low muscle tone, and poor feeding abilities
Nursing actions focused at reducing a postpartum woman's risk for cystitis include which of the following? (Select all that apply.) Select one or more: a. Voiding within a few hours post-birth b. Oral intake of a minimum of 3000 mL per day c. Changing peri-pads every 3 to 4 hours or more frequently as indicated d. Reminding the woman to void every 3 to 4 hours while awake
A,B,C,D Early voiding helps flush bacteria from the urethra. Voiding every 3 to 4 hours will decrease the risk of bacterial growth in the bladder. Soiled peri-pads are a media for bacterial growth. It is recommend that a postpartum woman drink a minimum of 3000 mL/day to help dilute urine and promote frequent voiding.
You are working in the ED and assessing a patient who presents with a fractured radius. Which of the following observations might lead you to believe your patient is a victim of intimate partner violence (IPV)? (Select all that apply) Select one or more: a. Her husband refuses to leave the room and answers your questions to his wife b. Presence of bruises on her shoulders and chest at various stages of healing c. Evasive when giving you her health history d. You note chart documentation of 4 previous visits to the Emergency Department over the last 3 months for vague complaints
A,B,C,D Intimate partner violence (IPV), also called domestic violence, is physical, sexual, and/or psychological harm by a current or former intimate partner or casual dating partner. Signs of IPV include: overuse of health care system; hesitancy, embarrassment, or evasiveness in relating history of injury; overly solicitous partner who stays close to the woman and attempts to answer questions directed at her; injuries in areas covered by a one-piece bathing suit or during pregnancy.
Lesbians are at higher risk for breast, cervical, endometrial, and ovarian cancer than heterosexual women due to (select all that apply): Select one or more: a. A higher percentage of lesbians are smokers b. Lesbians are less likely to have a Pap test c. A higher percentage of lesbians are obese d. Lesbians are less likely to exercise
A,B,C,D Lesbians have higher rates of smoking, alcohol use, and obesity. They are also less likely to follow the recommended frequency of health screening tests. These behaviors place a woman at higher risk for breast and gynecological cancers.
Heat loss through radiation can be reduced by: Select one or more: a. Removing wet blankets used to dry the infant after birth from the crib b. Placing a stocking cap on the neonate's head and placing in a crib c. Providing skin-to-skin contact with the mother and covering both with a warm blanket when the room temperature is cool d. Placing crib near a warm wall
A,B,C,D Loss of body heat through radiation results from transfer of heat from the neonate to cooler objects not in direct contact with the neonate, such as cold walls of the crib, cold equipment, wet blankets, cold room temperature, etc.
During a routine physical of a 31-year-old non-Hispanic black woman, it was noted that the woman's BMI is 32, her only exercise is taking care of her two children, her last pelvic exam and Pap test were 4 years ago, and her last clinical breast exam was 4years ago. Based on this information the woman (select all that apply): Select one or more: a. Needs to be scheduled for a Pap test b. Needs to be scheduled for a clinical breast exam c. Is at risk for type 2 diabetes d. Is at risk for depression related to lowered physical activity
A,B,C,D The correct answer is: Needs to be scheduled for a Pap test, Needs to be scheduled for a clinical breast exam, Is at risk for type 2 diabetes, Is at risk for depression related to lowered physical activity Recommended screenings for women ages 19 to 39 are clinical breast exams and Pap test every 3 years. Obesity (a BMI of 30 or greater) places the woman at risk for type 2 diabetes; decreased physical activity places the woman at risk of depression.
The perinatal nurse is teaching the new mother who has chosen to formula feed her infant. Appropriate instructions to be given to this mother include (select all that apply): Select one or more: a. Mix the formula according to manufacturer's instructions; b. Periodically check the nipple for slow flow. c. Prepare only enough formula to last for 24 hours and discard open containers or prepared formula after 24 hours. d. Discard any unused formula that remains in a bottle following use.
A,B,C,D do not overdilute or underdilute Parents should be advised to read and follow the manufacturer's instructions explicitly when preparing the formula, because some require no water and some need to be diluted with water. Cold water should be used to mix the powder, only the amount to be used for each feeding should be prepared, and any unused formula should be discarded. The nipples should be checked periodically during feedings for correct flow and should be replaced regularly.
Which of the following actions can decrease the risk for a postpartum infection? (Select all that apply.) Select one or more: a. Diet high in protein and vitamin C b. Increased fluid intake c. Ambulating within a few hours after delivery d. Good hand washing techniques by staff and patients
A,B,C,D protein and vitamin C assist with tissue healing. Rehydrating a woman after delivery can assist with decreasing risk for infections. Early ambulation decreases risk for infection by promoting uterine drainage. Hand washing by staff and patients has been shown to be the number one measure in the transmission of infection.
A nurse is caring for a 40 weeks' gestation neonate. The neonate is 12 hours post-birth and has been admitted to the NICU for meconium aspiration. The nurse recalls that the following are potential complications related to meconium aspiration (select all that apply): Select one or more: a. Obstructed airway b. Hyperinflation of the alveoli c. Hypoinflation of the alveoli d. Decreased surfactant proteins
A,B,D
Which of the following nursing actions are directed at promoting bonding? (Select all that apply.) Select one or more: a. Providing opportunity for parents to hold their newborn as soon as possible following the birth. b. Providing opportunities for the couple to talk about their birth experience and about becoming parents. c. Promoting rest and comfort by keeping the newborn in the nursery at night. d. Providing positive comments to parents regarding their interactions with their newborn.
A,B,D
Secondary amenorrhea results from (select all that apply): Select one or more: a. Polycystic ovary syndrome b.Uncontrolled Diabetes c. Nutritional disturbance d. Preganacy
A,B,D Secondary amenorrhea is no menses in 6 months in a woman who has had normal menstrual cycles. May result from: lack of ovarian production, pregnancy, polycystic ovary syndrome, nutritional and endocrine disturbances, uncontrolled diabetes, heavy athletic activity, or emotional distress.
A healthy, full-term baby boy is scheduled for a circumcision. Nursing actions prior to the procedure include which of the following? (Select all that apply.) Select one or more: a. Obtain written consent from the parents b. Administer acetaminophen PO 1 hour before procedure per provider order. c. Feed the neonate glucose water 30 minutes before the procedure. d. Verify that the neonate has voided
A,B,D-Nursing actions include obtaining written consent, administering acetaminophen as per provider order, and ensuring the neonate has voided; neonate should not eat 2-3 hours prior to the procedure to avoid risk of vomiting and aspiration
Which of the following are common assessment findings of postmature neonates? (Select all that apply.) Select one or more: a. Dry and peeling skin b. Abundant vernix caseosa c. Hypoglycemia d. Thin, wasted appearance
A,C,D
Nonpharmacologic therapy would include which of the following (select all that apply): Select one or more: a. Quiet environment with low lighting and use of soft voices b. Use of oral morphine and methadone c. Clonidine for infants who do not respond to a single agent d. Swaddling, clustering care, use of pacifiers to promote "self-soothing".
A,D
A patient is admitted for a total hysterectomy. The RN knows this is removal of what organs? Select one: a. The uterus only b. The uterus and cervix c. The uterus, cervix, fallopian tubes, and ovaries d. The uterus, cervix, fallopian tubes, ovaries, upper portion of the vagina, and lymph nodes
B Total hysterectomy is the removal of the uterus and the cervix. Supracervical hysterectomy is removal of the uterus only. Hysterectomy with salpingo-oophorectomy is removal of the uterus, cervix, fallopian tubes and ovaries. Radical hysterectomy is the removal of the uterus, cervix, fallopian tubes, ovaries, upper portion of the vagina, and the lymph nodes.
The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, "I don't expect to have any more kids, but I hate the thought of being sterile." Which of the following contraceptive methods would be best for the nurse to recommend to this client? Select one: a. Intrauterine contraceptive device b. Contraceptive patch c. Bilateral tubal ligation d. Birth control pills
A-Intrauterine contraception (IUC) is the recommended method for this patient. IUC has a low failure rate and provides long-term contraception for up to 10 years. Bilateral tubal ligation (BTL) is a surgical procedure which results in sterilization. Due to her history of smoking, neither birth control pills nor contraceptive patch is recommended due to the increased risks for blood clots, heart disease, and strokes, also associated with smoking.
A nurse is performing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for congenital dislocation of the hip? Select one: a. Grasp the inner aspects of the baby's calves with thumbs and forefingers. b. Gently abduct the baby's thighs listening for clicks at the joints. c. Palpate the baby's patellae to assess for subluxation of the bones. d. Dorsiflex the baby's feet.
B
Polydrug use among some pregnant women makes it difficult to determine a given effect on the neonate. The symptoms of Neonatal Abstinence Syndrome (NAS) can be seen in many of the drug classes described and are often overlapping. The clinical presentation of a newborn with NAS is influenced by many factors including which of the following (select all that apply): a. Gestational age, weight, heredity factors b. Type or types of drugs used, timing and amount of the last drug use, metabolism and clearance of the drugs by the newborn. c. Type of drug, prematurity, weight of fetus d. Sex of fetus, length of labor, presence of decelerations during labor
B
The nurse assesses that a full-term neonate's temperature is 97.1°F (36.2°C). The first nursing action is to: Select one: a. Turn up the heat in the room. b. Place the neonate on the mother's chest with a warm blanket over the mother and baby. c. Take the neonate to the nursery and place in a radiant warmer. d. Notify the neonate's primary provider.
B
The perinatal nurse is preparing a woman for a scheduled cesarean birth. The woman will be receiving spinal anesthesia for the birth. In order to prevent maternal hypotension, the nurse: Select one: a. Assists the woman to lie down in a supine position. b. Administers an intravenous preload infusion of 500 mL of normal saline. c. Assesses blood pressure and pulse every 5 minutes, three times, before the spinal insertion. d. Encourages frequent cleansing breaths after the patient has been placed in the correct position for the anesthesia administration.
B An IV fluid preload of 500-1000 mL is given before administration of spinal or epidural anesthesia to increase fluid volume and decrease risk of hypotension related to the effects of anesthetic agents.
The perinatal nurse is preparing a woman for a scheduled cesarean birth. The woman will be receiving spinal anesthesia for the birth. In order to prevent maternal hypotension, the nurse: Select one: a. Assists the woman to lie down in a supine position. b. Administers an intravenous preload infusion of 500 mL of normal saline. c. Assesses blood pressure and pulse every 5 minutes, three times, before the spinal insertion. d. Encourages frequent cleansing breaths after the patient has been placed in the correct position for the anesthesia administration.
B An IV fluid preload of 500-1000 mL is given before administration of spinal or epidural anesthesia to increase fluid volume and decrease risk of hypotension related to the effects of anesthetic agents.
The perinatal nurse observes the new mother watching her baby daughter closely, touching her face, and asking many questions about infant feeding. This stage of mothering is best described as: Select one: a. Taking in b. Taking hold c. Taking charge d. Taking time
B As the mother's physical condition improves, she begins to take charge and enters the taking hold phase where she assumes care for herself and her infant. At this time, the mother eagerly wants information about infant care and shows signs of bonding with her infant. During this phase, the nurse should closely observe mother-infant interactions for signs of poor bonding, and if present, implement actions to facilitate attachment.
A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions would be appropriate for the nurse to delegate to the CNA? Select one: a. admit a newly delivered baby to the nursery b.Bathe and weigh a 3-hour-old baby c. Provide discharge teaching to the mother of a 4-day-old baby. d. Interpret a bilirubin level reported by the laboratory.
B Assessment and education are within the scope of practice of an RN; CNAs may perform basic skills under the supervision of the RN.
During the assessment of the newborn at 3 hours of age, the perinatal nurse documents the presence on the infant's scalp of a unilateral, well-defined mass which does not cross the suture lines. The mother's chart indicates a prolonged labor with use of a vacuum extractor. The RN identifies this finding as: Select one: a. Caput succedaneum b. Cephalohematoma c. Molding d. Intraventricular hemorrhage
B Cephalohematoma is hematoma formation between the periosteum and skull with unilateral swelling. It appears within a few hours of birth and can increase in size over the next few days. It has a well-defined outline and does not cross suture lines.
A perinatal nurse assesses a term newborn for respiratory functioning. The nurse knows that which of the following conditions is normal for newborns? Select one: a. A respiratory rate of 60 to 80 breaths per minute b. A breathing pattern that is often shallow, diaphragmatic, and irregular c. Periodic episodes of apnea d. Retractions of the chest wall
B Expected findings when assessing the neonate's respiratory system include 30-60 breaths per minute; slightly irregular,diaphragmatic/abdominal breathing; increase in rate when crying; decrease in rate when sleeping. Abnormal findings include periods of apnea >15 seconds; tachypnea; respirations <30 per minute
Karen, a G2 P2, experienced a precipitous birth 90 minutes ago. Her infant is 4200 grams and a repair of a second-degree laceration was needed following the birth. As part of the nursing assessment, the nurse discovers that Karen's uterus is boggy. Furthermore, it is noted that Karen's vaginal bleeding has increased. The nurse's most appropriate first action is to: Select one: a. Assess vital signs including blood pressure and pulse. b. Massage the uterine fundus with continual lower segment support. c. Measure and document each perineal pad changed in order to assess blood loss. d. Ensure appropriate lighting for a perineal repair if it is needed.
B Massage the uterine fundus with continual lower segment support. As the primary caregiver, the registered nurse may be the first person to identify excessive blood loss and initiate immediate actions. The nurse should first locate the uterine fundus and initiate fundal massage. Nursing actions performed after the massage are frequent vital sign measurements, measuring the length of time it takes for blood loss to saturate a pad, and assessing for bladder distention.
During a cesarean section, which action by the nurse is done to prevent compression of the descending aorta and vena cava? Select one: a. Right lateral tilt b. Left lateral tilt c. Elevate head of gurney at 30 degrees d. Administration of IV fluid preload of 500 to 1000 mL
B Positioning of the patient with a left tilt maintains a left uterine displacement to decrease the risk of aortocaval compression related to compression on the aorta and inferior vena cava due to weight of the gravid uterus.
The perinatal nurse understands that the purpose of the surgical "timeout" is to: Select one: a. Confirm that the surgeon is ready to begin b. Verify that it is the correct site, procedure, and patient c. Verify that anesthesia is adequate d. Confirm that the neonatal team is in attendance
B Surgical "timeout" is performed by the entire surgical team and the patient prior to the administration of anesthesia. The purpose is to validate correct patient, site, and procedure.
The perinatal nurse is teaching her new mother about breastfeeding and explains that the most appropriate time to breastfeed is: Select one: a. 3 to 4 hours after the last feeding b. When her infant is in a quiet alert state c. When her infant is in an active alert state d. When her infant exhibits hunger-related crying
B The optimal time to breastfeed is when the baby is in a quiet alert state. Crying is usually a late sign of hunger, and achieving satisfactory latch-on at this time is difficult. Latch-on is proper attachment of the infant to the breast for feeding. The neonate is most alert during the first 1 to 2 hours after an unmedicated birth, and this is the ideal time to put the infant to the breast.
A full-term neonate who is 30 hours old has a bilirubin level of 10 mg/dL. The neonate has a yellowish tint to the skin of the face. The mother is breastfeeding her newborn. The nurse caring for this neonate would anticipate which of the following interventions? Select one: a. Phototherapy b. Feeding neonate every 2 to 3 hours c. Switch from breastfeeding to bottle feeding d. Assess red blood cell count
B Treatment of jaundice is based on bilirubin levels and the age of the neonate in hours. At 30 hours of age and a bilirubin level of 10 mg/dL, the RN would ensure adequate hydration by feeding the neonate every 2-3 hours to promote excretion of bilirubin in the urine and stool. Phototherapy for this infant would be considered if bilirubin level was 12 mg/dL or higher with treatment most likely initiated at a level of 15 mg/dL or higher.
The perinatal nurse teaches the postpartum woman about warning signs regarding development of postpartum infection. Signs and symptoms that merit assessment by the health-care provider include the development of a fever and: Select one: a. Breast engorgement b. Uterine tenderness c. Diarrhea d. Emotional lability
B Uterine tenderness During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F, often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.
The perinatal nurse demonstrates for the student nurse the correct technique of postpartum uterine palpation. Support for the lower uterine segment is critical, as without it, there is an increased risk of: Select one: a. Uterine edema b. Uterine inversion c. Incorrect measurement d. Intensifying the patient's level of pain
B During pregnancy there is stretching of the ligaments that hold the uterus in place. Fundal pressure could result in uterine inversion. Supporting the lower uterine segment may prevent uterine inversion during fundal assessment or massage.
A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal problems could have resulted in this complication? (Select all that apply.) Select one or more: a. Cholecystitis b. Chronic Hypertension with Preclampsia c. Cigarette smoker. d. Candidiasis e. Cerebral palsy
B,C
Physical activity can lower a woman's risk for (select all that apply): Select one or more: a. Endometriosis b. Depression c. Colon cancer. d. Arthritis
B,C
Which of the following are disadvantages of bottle feeding? (Select all that apply.) Select one or more: a. Increases the frequency of feedings as digestion of formula does not take as long as digestion of breastmilk b. Increases cost compared to breastfeeding c. Increases risk of infection due to lack of maternal antibodies d. Increases risk of childhood obesity
B,C,D Disadvantages of formula feeding include need for increased time to prepare formula; increased cost compared to breastfeeding; increased risk of infection due to lack of antibodies that are naturally present in human milk; increased risk of childhood obesity and insulin-dependent diabetes. One of the advantages of formula feeding is the decrease in frequency of feedings because digestion of formula is slower than that of human milk.
Which of the following nursing actions are directed at assisting men in their transition to fatherhood? (Select all that apply.) Select one or more: a. Encourage the woman to take on the major responsibility for infant care. b. Talk to the couple about their expectations of the parenting role. c. Praise the father for his interactions with his infant. d. Provide information on infant care and behavior to both parents.
B,C,D It is important to first have the couple discuss with each other their expectations of the fathering role. Once this has occurred, then the woman and nurse need to support the man in his role of infant care. Both parents need to receive information about infant care and infant behaviors, and both parents need to be praised for their interactions with their baby.
Which of the following nursing actions are important in the care of a postpartum woman who is at risk for orthostatic hypotension? (Select all that apply.) Select one or more: a. Have patient remain in bed for the first 4 hours postbirth. b. Instruct patient to slowly rise to a standing position. c. Open an ammonia ampule and have the patient smell the ammonia prior to getting out of bed. d. Explain to the patient the cause and incidence of orthostatic hypotension.
B,D
During a postpartum assessment, the nurse notes that the uterus is mid-line and boggy. The immediate nursing action is: Select one: a. To notify the patient's midwife or physician b. Massage the fundus until firm and reevaluate within 30 minutes c. Give Syntocinon as per orders d. Assist the patient to the bathroom and ask her to void
B-Frequent assessment of the uterus for location, position, and tone will help to identify and/or prevent postpartum hemorrhage. If the uterus is boggy, fundal massage is indicted. Uterus should be in a midline position; distended bladder may be indicated if the uterus is shifted to the side.
A NICU nurse is caring for a full-term neonate being treated for group B streptococcus (GBS). The mother of the neonate is crying and shares that she cannot understand how her baby became infected. The best response by the nurse is: Select one: a. "Newborns are more susceptible to infections due to an immature immune system. Would you like additional information on the newborn immune system?" b. "The infection was transmitted to your baby during the birthing process. Do you have a history of sexual transmitted infections?" c. "Approximately 15% to 40% of women have no symptoms but are carriers of group B streptococcus which is found in the vaginal and lower intestinal areas. What other questions do you have regarding your baby's health?" d. "I see that this is very upsetting for you. I will come back later and answer your questions."
C
A multipara, 26 weeks' gestation and accompanied by her husband, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? Select one: a. Encourage the parents to pray for the baby's soul. b. Advise the parents that it is better for the baby to have died than to have had to live with a defect. c. Provide opportunities for grieving parents and family members to spend time with the baby d. Advise the parents to refrain from discussing the baby's death with their other children.
C
A postpartum woman, who gave birth 12 hours ago, is breastfeeding her baby. She tells her nurse that she is concerned that her baby is not getting enough food since her milk has not come in. The best response for this patient is: Select one: a. "I understand your concern, but your baby will be okay until your milk comes in." b. "Your baby seems content, so you should not worry about him getting enough to eat." c. "Milk normally comes in around the third day. Prior to that, he is getting colostrum which is high in protein and immunoglobulins which are important for your baby's health." d. "You can bottle feed until your milk comes in."
C
A primary topic for health promotion for a 25-year-old woman with a history of polycystic ovary syndrome (PCOS or Stein-Leventhal syndrome) is (select the most important topic): Select one: a. The adverse effects of cigarette smoking b. The adverse effects of excessive alcohol consumption c. Nutrition for prevention of obesity and Type 2 Diabetes d. Self-esteem issues
C
It is noted that the amniotic fluid of a 42-week gestation baby, born 30 seconds ago, is thick and green. Which of the following actions by the nurse is critical at this time? Select one: a. Perform a gavage feeding immediately. b. Assess the brachial pulse. c. Assist a physician with intubation and suctioning. d. Stimulate the baby to cry.
C
The nurse completes an initial newborn examination on a baby boy at 90 minutes of age. The baby was born at 40 weeks' gestation with no birth trauma. The nurse's findings include the following parameters: heart rate 136 beats per minute; respiratory rate 64 breaths per minute; temperature 98.2°F (36.8°C); length 49.5 cm; and weight 3500 g. The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate consultation with the baby's health-care provider? Select one: a. Respiratory rate b. Presence of a heart murmur c. Absent bowel sounds d. Weight
C
The nurse is assessing a baby girl on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? Select one: a. Intermittent strabismus b. Startling c. Grunting d. Vaginal bleeding
C
The nurse is teaching the parents of a 1-day-old baby how to give their baby a bath. Which of the following actions should be included? Select one: a. Clean the eye from the outer aspect to the inner aspect. b. Keep the door of the room open to allow for ventilation. c. Gather all supplies before beginning the bath. d. Bathe daily with warm soapy water.
C
When assessing the apical pulse (point of maximal impulse: PMI) of the neonate, the stethoscope should be placed at the: Select one: a. first or second intercostal space b. second or third intercostal space c. third or fourth intercostal space d. fourth or fifth intercostal space
C
Which of the following clients is most likely to complain of aftepains during her postpartum period? Select one: a. G1 P1, diagnosed with preeclampsia b. G2 P2, group B streptococci in the vagina c. G3 P2, gave birth to a 4100-gram baby and is breastfeeding d. G4 P1, diagnosed with preterm labor
C
Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? Select one: a. The baby with respirations 52, oxygen saturation 98% b. The baby with Apgar 9/9, weight 2960 grams c. The baby with temperature 96.3°F, length 17 inches d. The baby with glucose 60 mg/dL, heart rate 132
C Axillary temperature below 97.7°F is a sign of cold stress and must be treated immediately
The nurse is assessing the neonate's skin and notes the presence of a rash with red macules and papules on the trunk. The name for this common neonatal skin condition is: Select one: a. Milia b. Neonatal acne c. Erythema toxicum d. Pustular melanosis
C Erythema Toxicum, a benign rash which disappears without treatment.
The perinatal nurse accurately defines postpartum hemorrhage by including a decrease in hematocrit levels from preto postbirth by: Select one: a. 5% b. 8% c. 10% d. 15%
C Historically, practitioners have defined postpartum hemorrhage asa blood loss greater than 500 mL following a vaginal birth and 1000 mL ormore following a cesarean birth. Hematocrit levels that decrease 10% from pretopostbirth measurements are also included in the definition.
Approximately 8 hours ago, Juanita, a 32-year-old G1 P0, gave birth after 2 hours of pushing. She required an episiotomy and an assisted birth (forceps) due to the weight and size of her baby (9 lb. 9 oz.). The perinatal nurse is performing an assessment of Juanita's perineal area. A slight bulge is palpated and the presence of ecchymoses to the right of the episiotomy is noted. The area feels "full" and is approximately 4 cm in diameter. Juanita describes this area as "very tender." The perinatal nurse notifies the physician of the findings related to Juanita's assessment. The first step in care will most likely be to: Select one: a. Prepare Juanita for surgery b. Administer intravenous fluids c. Apply ice to the perineum d. Insert a urinary catheter
C If the hematoma is less than 3 to 5 centimeters in diameter, the physician usually orders palliative treatments such as ice to the area for the first 12 hours along with pain medication. After 12 hours, sitz baths are prescribed to replace the application of ice. However, a hematoma larger than 5 centimeters may require incision and drainage with the possible placement of a drain.
A new mother notices what appears to be bruising over her newborn's buttocks. She asks the nurse if the baby has been injured in some way. The nurse explains that this is: Select one: a. Erythema Toxicum b. Jaundice c. Mongolian spots d. Milia
C Mongolian spots are flat, bluish discolored areas on the lower back and/or buttock which might be mistaken for bruising. Nursing actions include documentation of size and location. Usually resolve by school age.
A woman who is 12 weeks postpartum presents with the following behavior: she reports severe mood swings and hearing voices, believes her infant is going to die, she has to be reminded to shower and put on clean clothes, and she feels she is unable to care for her baby. These behaviors are associated with which of the following? Select one: a. Postpartum blues b. Postpartum depression c. Postpartum psychosis d. Maladaptive mother-infant attachment
C Postpartum psychosis (PPP) is a variant of bipolar disorder and is the most serious form of postpartum mood disorders. Onset of symptoms can be as early as the 3rd postpartum day. Assessment findings include paranoia, delusions associated with the baby, mood swings, extreme agitation, confused thinking, inability to care for self or infant, and strange beliefs.
A woman on the day of discharge from the postpartum unit asks a number of questions regarding breastfeeding and shares that she is nervous about taking her baby home and not being able to remember everything she has been taught. These are behaviors associated with: Select one: a. Bonding b. Taking in c. Taking hold d. Attachment
C The "taking hold" phase indicates the movement between dependent and independent behaviors. During this phase, the mother may have feelings of inadequacy and being overwhelmed.
The nurse is about to elicit the Moro or Startle reflex. Which of the following responses should the nurse expect to see? Select one: a. When the cheek of the baby is touched, the newborn turns toward the side that is touched. b. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. c. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. d. When the newborn is supine and the head is turned to one side, the arm on that same side extends.
C The Moro or Startle Reflex is elicited when the neonate is suddenly lowered or exposed to a loud noise: symmetrical abduction and extension of the arms and legs with legs flexed up against the trunk. Choice 1 indicates the Rooting Reflex; Choice 2 indicates the Babinski Reflex; Choice 4 indicates the Tonic Neck Reflex
A nurse is providing discharge teaching to the parents of a 2-day-old neonate. Which of the following information should be included in the discharge teaching on umbilical cord care? Select one: a. Cleanse the cord twice a day with hydrogen peroxide. b. Remove the cord with sterile tweezers if the cord does not fall off by 10 days of age. c. Call the provider if greenish discharge appears. d. Cover the cord with sterile dressing until it falls off.
C The umbilical cord is clamped at birth and the clamp is removed after 24 hours of life. The cord falls off and the site heals within 2 weeks. The diaper is placed below the cord to facilitate drying. Parents should be instructed to contact the provider if there is bleeding from the cord site, foul-smelling drainage, redness, or fever. Follow institutional guidelines for cord cleaning; generally, the cord is left alone except when soiled with stool or urine - wipe clean with plain water and allow to dry.
Which of these medications is commonly used to control postpartum bleeding related to uterine atony? Select one: a. Magnesium sulfate b. Phytonadione c. Oxytocin d. Warfarin
C promotes contraction of the uterus by stimulating the smooth muscle of the uterus.
Which of the following statements indicates that a new mother needs additional teaching? Select one: a. "I need to supervise my cat when she is in the same room as my baby." b. "I will place my baby on her back when she is sleeping." c. "I will not leave my baby on an elevated flat surface after she is able to turn over on her own." d. "I have asked my husband to install safety latches on the lower cabinets."
C Infants should never be left unattended on an elevated flat surface
The nurse is caring for a recently immigrated Chinese woman in the postpartum unit. Based on cultural beliefs and practices of the woman, the nurse would anticipate which of the following? (Select all that apply.) Select one or more: a. The woman prefers cold water for drinking. b. The woman prefers not to shower. c. The woman prefers to have her female relatives care for her baby. d. The woman prefers a wide variety of foods to eat.
C The correct answer is: The woman prefers to have her female relatives care for her baby. In traditional Chinese beliefs and practices, the woman is to rest and female family members take care of the infant. During the first month, the woman is to avoid yin energy by eating specific foods and avoiding drinking or touching cold water.
Which of the following foods is highest in calcium? Select one: a. An 8 oz. glass of milk b. A 1.5 oz. piece of cheddar cheese c. An 8 oz. container of plain, low-fat yogurt d. A 3 oz. piece of salmon
C-Milk has 293 mg of calcium; cheddar cheese has 307 mg; yogurt has 415; salmon has 181 mg.
Felicity Chan, a new mother, is accompanied by her mother during her hospital stay on the postpartum unit. Felicity's mother makes specific, various requests of the nurses including bringing warm tea, a cot to sleep on, and that the baby not be bathed at this time. Felicity's mother is also concerned about the amount of work that Felicity may be doing in the provision of infant care. Felicity asks for help with breastfeeding. After Felicity has finished breastfeeding, her mother asks for a bottle so they can warm it and "feed" the baby. How would the perinatal nurse best respond to Felicity's mother in a culturally sensitive way? Select one: a. Ask Felicity's mother to leave for 30 minutes to allow for some private time with Felicity to explore her learning needs privately. b. Ask both Felicity and her mother about the preferred infant feeding method, and assess what they already know. c. Convey to Felicity and her mother an understanding of the concepts of "hot" and "cold" within their belief system. d. Ask Felicity what she knows about breastfeeding, and provide information to both women to support Felicity's decision.
D
On day four following the birth of an average size baby, the nurse would expect the fundus to be at: Select one: a. 1 cm below umbilicus b. 2 cm below umbilicus c. 3 cm below umbilicus d. 4 cm below umbilicus
D
A client delivered a 2800-gram neonate 4 hours ago by cesarean section with epidural anesthesia. Which of the following interventions should the nurse perform on the mother at this time? Select one: a. Maintain the client flat in bed. b. Assess the client's patellar reflexes. c. Monitor hourly urinary outputs. d. Assess the client's respiratory rate.
D
A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in the baby as a result? Select one: a. Skin color is dusky. b. Vital signs are labile. c. Glucose levels are subnormal. d. Circumcision site oozes blood.
D
A neonate is admitted to the nursery. The nurse makes the following assessments: weight 2845 grams, overriding sagittal suture, molding, and point of maximal impulse (PMI) at the xiphoid process. Which of the assessments should be reported to the health-care practitioner? Select one: a. Birth weight b. Sagittal suture line c. Closed posterior fontanel d. Point of maximum intensity
D
A nurse is admitting a woman for a scheduled cesarean section. Which of the following assessment data should be immediately reported to the physician? Select one: a. White cell count of 11,000 b. Hemoglobin of 11 g/dL c. Hematocrit of 33% d. Platelet count of 75,000
D
A nurse is caring for a woman 10 hours post cesarean birth. She received a dose of intrathecal morphine at the time of the birth. Which of the following assessment data would require immediate intervention? Select one: a. Itching of the palms and feet b. Nausea c. Urinary output of 300 mL in the past 4 hours d. Respiratory rate of 8 breaths/minute
D
A nurse is making a home visit on the twelth postpartum day to assess a 23-year-old primipara woman and her full-term, healthy baby. Breastfeeding is the method of infant nutrition. The woman tells the nurse that she does not think her milk is good because it looks very watery when she expresses a little before each feeding. The nurse's best response is: Select one: a. "This is normal. You only have to be concerned when your baby does not gain weight." b. "What types of foods are you eating? A lack of protein in the diet can cause watery looking breast milk." c. "How much fluid are you drinking while you are nursing your baby? Too much fluid during the feeding session can dilute the breast milk." d. "This is normal and is referred to as foremilk which is higher in water content. Later in the feeding the fat content increases and the milk becomes richer in appearance."
D
A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia, and tremors and is extremely irritable. Based on these observations, the nurse suspects which of the following? Select one: a. Hypoglycemia b. Hypercalcemia c. Cold stress d. Neonatal withdrawal
D
Which of the following factors increases the risk of necrotizing enterocolitis (NEC) in very premature neonates? (Select all that apply.) Select one or more: a. Prolonged hyperoxia b. Prolonged use of mechanical ventilation c. Hyperbilirubinemia d. Nasogastic feedings
D
The perinatal nurse listens as Chantal describes her labor and emergency cesarean birth. Providing an opportunity to review this experience may assist Chantal in: Select one: a. Her role development in the "letting go" stage b. Decreasing her ambivalence about her labor and birth c. Understanding her guilt involved in her labor and birth d. Developing more positive feelings about her labor and birth
D After a cesarean birth, especially when unplanned, nurses must be aware of the myriad of potential psychological issues that may arise. Research suggests that women may perceive cesarean birth to be a less positive experience than a vaginal birth. Unplanned or emergent cesarean deliveries and the experience of cesarean birth may be associated with more negative perceptions of the birthing experience. Allowing Chantal to talk about the experience can help her develop a more positive attitude about her own experience.
Instructions to a mother of an uncircumcised male infant should include which of the following? Select one: a. Instruct her to use a cotton swab to clean under the foreskin. b. Instruct her to clean the penis by retracting the foreskin. c. Instruct her to clean the penis with alcohol. d. Instruct her not to retract the foreskin.
D Do not force the foreskin over the penis or use cotton swabs to clean under the foreskin as this may damage the inner layer of the foreskin which can lead to adhesion formation. Gently cleanse the penis when bathing the infant and when changing the diaper.
The nurse is massaging a boggy uterus. The uterus does not respond to the massage. Which medication would the nurse expect would be given first: Select one: a. Methergine b. Epinephrine c. Carboprost (Hemabate) d. Oxytocin or pitocin
D If the cause of the hemorrhage is uterine atony, continual fundal massage with lower uterine segment support is mandatory. While one member of the team massages the fundus, another nurse establishes intravenous access with a large bore needle and administers oxytocic drugs in the following order: oxytocin (Pitocin), followed by methylergonovine (Methergine), and carboprost (Hemabate).
A nurse is preparing to administer RhoGam to a client who delivered a fetal demise. Which of the following must the nurse check before giving the injection? Select one: a. Verify that the direct Coombs test results are positive. b. Check that the fetus was at least 28 weeks' gestation. c. Make sure that the client is at least 3 days postdelivery. d. Confirm that the woman is Rh negative.
D RhoGam is given to Rh negative mothers who have given birth to an Rh positive infant, whether or not the fetus is born alive.
When intrathecal morphine is used for post-operative pain, the anesthesiologist manages the woman's pain for the first 24 hours. The perinatal RN is aware that the most serious complication of intrathecal morphine in the first 24 hours following surgery is: Select one or more: a. Urinary retention b. Nausea and itching c. Decreased sensation in the legs d. Respiratory depression
D Severe respiratory depression is a life-threatening adverse reaction to intrathecal morphine. Naloxone and resuscitative equipment need to be available whenever intrathecal morphine is administered and during the 24 hours post-procedure.
The clinic nurse sees Xiao and her infant in the clinic for their 2 week followup visit. Xiao appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. She is carrying her son in the infant carrier and when asked to put him on the examining table, she holds him away from her body. The clinic nurse's most appropriate question to ask would be: Select one: a. "What has happened to you?" b. "Do you have help at home?" c. "Is there anything wrong with your son?" d. "Would you tell me about the first few days at home?"
D The wellbaby checkup that generally takes place 1 to 2 weeks following the hospital discharge may offer the first opportunity to assess the mother-baby dyad. In this setting, the nurse needs to be alert for subtle cues from the new mother, such as making negative comments about the baby or herself, ignoring the baby's or other children's needs, as well as the mother's physical appearance. In a private area, the nurse should take time to explore the new mother's feelings. A nonthreatening way to open the dialogue might be to say: "Tell me how the first few days at home have gone." This statement provides the new mother with anopportunity to share both positive and negative impressions.
A nurse assesses that a 3-day-old neonate who was born at 34 weeks' gestation has abdominal distention and vomiting. These assessment findings are most likely related to: Select one: a. Respiratory Distress Syndrome (RDS) b. Bronchopulmonary Dysplasia (BPD) c. Periventricular Hemorrhage (PVH) d. Necrotizing Enterocolitis (NEC)
D-Necrotizing enterocolitis (NEC) findings include abdominal distention, bloody stools, abdominal tenderness, vomiting, increased gastric residuals, discoloration of abdomen, and visible bowel loops.
Bonding is bidirectional from parent to infant and infant to parent. Select one: True False
False
The clinic nurse recognizes that the longer an infant is formula fed, the greater is the immunity and resistance the infant will develop against bacterial and viral infections. Select one: True False
False
The postpartum nurse is caring for a couple who experienced an unplanned emergency cesarean birth. The nurse observes the following behaviors: Parents are gently touching their newborn. Mother is softly singing to her baby. Father is gazing into his baby's eyes. Based on this data, the correct nursing diagnosis is altered parent-infant bonding related to emergency cesarean birth. Select one: True False
False Cesarean birth can place the parents at risk for bonding, but based on the observed interaction with their newborn, the parents display positive signs of bonding.
During an emergency cesarean birth the "time-out" procedure may be omitted based on the obstetrical emergency. Select one: True False
Joint commission guidelines for patient safety necessitate there always be a time-out to prevent wrong patient, wrong site, wrong procedure, and medical errors. The correct answer is 'False'.
A hematoma is the collection of blood beneath the intact skin layer following an injury to a blood vessel. Select one: True False
True A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. At the time of injury, pressure necrosis and inadequate hemostasis occur.
The nurse assessing a newborn for heat loss is aware that non-shivering thermogenesis utilizes the newborn's stores of brown adipose tissue (BAT) to provide heat in the cold-stressed newborn. Select one: True False
True Brown adipose tissue, also known as "brown fat," is a unique highly vascular fat found only in newborns. BAT promotes an increase in metabolism, heat production, heat transfer to the peripheral system. Heat is produced by intense lipid metabolic metabolism but reserves are rapidly depleted during periods of cold stress.
Abruptio placenta is a risk factor for amniotic fluid embolism. Select one: True False
True Risk factors for amniotic fluid embolism include induction of labor, maternal age over 35, operative delivery, placenta previa, abruptio placenta, polyhydramnios, eclampsia, and cervical or uterine laceration
The perinatal nurse teaches the postpartum woman that the most critical time to achieve effectiveness from the application of ice packs to the perineum is during the first 24 hours following birth. Select one: True False
True To reduce perineal swelling and pain that result from bruising, ice packs may be applied every 2 to 4 hours. Patients obtain the most relief when ice packs are applied within the first 24 hours after childbirth.
Eye movements are an example of newborn/infant style of communication. Select one: True False
True
It is a common custom for traditional Chinese women to bottle feed their infants until their milk comes in. Select one: True False
True
Lesbian women are at a higher risk for heart disease than heterosexual women. Select one: True False
True
Metritis is an infection that usually starts at the placental site. Select one: True False
True
A woman is 2 days postpartum from a normal vaginal delivery over an intact perineum of a 3000-gram baby. Where would the nurse expect to palpate the client's fundus? Select one: a. At the umbilicus b. 2 cm below the umbilicus c. 2 cm above the symphysis d. At the symphysis
b. 2 cm below the umbilicus After birth, the uterine fundus is palpated midway between the umbilicus and the symphysis pubis. Within 12 hours after birth of the placenta, the fundus is located at the level of the umbilicus. 24 hours after birth of the placenta, the fundus is located at 1 cm below the umbilicus. The uterus descends 1 cm per day; by postpartum day #2, the uterine fundus would be palpated 2 cm below the umbilicus.
A 35 year old G1 P1 postpartum woman is Rh negative and has given birth to an Rh positive infant. Rh (D) immune globulin is to be administered. The most appropriate dose that the perinatal nurse would expect to be ordered would be: Select one: a. 120 mcg b. 250 mcg c. 300 mcg d. 350 mcg
c. 300 mcg Nonsensitized women who are Rh negative and have given birth to an Rh positive infant should receive 300 mcg of Rh(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations, depending on the extent of hemorrhage and exchange of maternal-fetal blood, a larger dose of RhoGAM may be indicated.
