Maternity Exam 3 Cumm. Questions

The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or younger. Which statement should the nurse include? A) "Your baby will respond to you the most if you look directly into his eyes and talk to him." B) "Each baby is different. Don't try to compare your infant's behavior with any other child's behavior." C) "If the sound level around your baby is high, the baby will wake up and be fussy or cry." D) "If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy."

A) "Your baby will respond to you the most if you look directly into his eyes and talk to him."

The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following? A) A normal position B) A possible chromosomal abnormality C) Facial paralysis D) Prematurity

A) A normal position

The student nurse notices that a newborn weighs less today compared with the newborn's birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following? A) A shift of intracellular water to extracellular spaces. B) Loss of meconium stool. C) A shift of extracellular water to intracellular spaces. D) The sleep-wake cycle.

A) A shift of intracellular water to extracellular spaces.

The client tells the nurse that she has come to the hospital so that her baby's position can be changed. The nurse would begin to organize the supplies needed to perform which procedure? A) A version B) An amniotomy C) Leopold maneuvers D) A ballottement

A) A version

In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? A) Allow extra time with feedings. B) Assign different personnel to the newborn each day. C) Place the newborn in a well-lit room. D) Monitor for hyperthermia.

A) Allow extra time with feedings

The nurse wishes to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use? A) Brazelton Neonatal Behavioral Assessment Scale B) New Ballard Score C) Dubowitz gestational age scale D) Ortolani maneuver

A) Brazelton Neonatal Behavioral Assessment Scale

Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn? A) Jitteriness B) Sucking on fingers C) Lusty cry D) Axillary temperature of 98°F

A) Jitteriness

The nurse has completed an initial physical assessment for a client admitted to the birthing unit. Which action should the nurse take next? A) Obtain the client's social history B) Document the physical assessment findings C) Report findings to the physician D) Perform interventions for pain management

A) Obtain the client's social history

Babies should sleep in what position every time they are put down for sleep? A) On their backs B) On their stomachs C) On their left sides D) On their right sides

A) On their backs

The nurse is performing an assessment on an infant whose mother states that she feeds the infant in a supine position by propping the bottle. Based on this information, what would the nurse include in the assessment? A) Otoscopic exam of the eardrum B) Bowel sounds C) Vital signs D) Skin assessment

A) Otoscopic exam of the eardrum

The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate? A) Place a gloved finger in the newborn's mouth. B) Take the vital signs. C) Wait until the newborn stops crying. D) Place a hot water bottle in the isolette.

A) Place a gloved finger in the newborn's mouth

The nurse understands that the classic symptom of endometritis in a postpartum client is which of the following? A) Purulent, foul-smelling lochia B) Decreased blood pressure C) Flank pain D) Breast is hot and swollen

A) Purulent, foul-smelling lochia

The nurse is preparing to administer postpartum neuraxial morphine to a client who is morbidly obese. For which side effect related to morbid obesity should the nurse monitor? A) Respiratory depression B) Confusion C) Constipation D) Hypotension

A) Respiratory depression

Which of the following behaviors noted in the postpartum client would require the nurse to assess further? A) Responds hesitantly to infant cries. B) Expresses satisfaction about the sex of the baby. C) Friends and family visit the client and give advice. D) Talks to and cuddles with the infant frequently

A) Responds hesitantly to infant cries

A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, what does the nursing instructor tell the student do? A) Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood. B) Use a previous puncture site. C) Cool the heel prior to obtaining blood. D) Use a sterile needle and aspirate.

A) Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood

The nurse is planning care for three newly delivered adolescents and their babies. What should the nurse keep in mind when planning their care? A) The baby's father should be encouraged to participate when the nurse is providing instruction. B) A class for all the adolescents would decrease teaching effectiveness. C) The schools that the adolescents attend will provide teaching on bathing. D) Adolescents understand the danger signals in newborns

A) The baby's father should be encouraged to participate when the nurse is providing instruction

The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? A) The infant's mother has group B streptococcal (GBS) disease. B) The infant's mother had an IV of lactated Ringer's solution. C) The infant's mother had a labor that lasted 12 hours. D) The infant's mother had a cesarean birth with her last child

A) The infant's mother has group B streptococcal (GBS) disease

The nurse is making an initial visit to a postpartum family's home. The mother states that she is having difficulty with breastfeeding. Which resource should the nurse tell the family about? A) The lactation consultant at the hospital B) Free immunizations through the county public health department clinics C) Sources of free formula at a local food pantry D) A support group for mothers who are experiencing postpartum depression

A) The lactation consultant at the hospital

The nurse is caring for a client who is about to receive an amnioinfusion. For which complication(s) should the nurse monitor the client? Select all that apply. A) Umbilical cord prolapse B) Amniotic fluid embolism C) Uterine rupture D) Amnionitis E) Abruptio placentae

A) Umbilical cord prolapse B) Amniotic fluid embolism C) Uterine rupture

In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include which of the following? Select all that apply. A) Volume of urine output B) Weight C) Blood pH D) Head circumference E) Bowel sounds

A, B

The nurse is cross-training maternal-child health unit nurses to provide home-based care for parents after discharge. Which statements indicate that additional teaching is required? Select all that apply. A) "The behavioral assessment should be done as soon after birth as possible." B) "The behavioral assessment can be performed without input from parents." C) "The behavioral assessment might be incomplete in a 1-hour home visit." D) "The behavioral assessment includes orientation and motor activity." E) "The behavioral assessment can detect neurological impairments."

A, B

The postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks whether there is something she can do to prevent mastitis this time. What would the best response of the nurse be? A) "Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple." B) "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." C) "Apply cabbage leaves to any areas that feel thickened or firm to relieve the swelling." D) "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe."

A) "Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple."

The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary? A) "Our baby was born with kidneys that are too small." B) "A baby's kidneys don't concentrate urine well for several months." C) "Feeding our baby frequently will help the kidneys function." D) "Kidney function in an infant is very different from that in an adult."

A) "Our baby was born with kidneys that are too small."

The client has experienced a hemorrhage at 6 hours postpartum. After controlling the hemorrhage, the client's partner asks what would cause a hemorrhage. How should the nurse respond? A) "Sometimes the uterus relaxes and excessive bleeding occurs." B) "The blood collected in the vagina and poured out when your partner stood up." C) "Bottle-feeding prevents the uterus from getting enough stimulation to contract." D) "The placenta had embedded in the uterine tissue abnormally."

A) "Sometimes the uterus relaxes and excessive bleeding occurs."

A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurse's best response? A) "Take your newborn to the pediatrician." B) "Cover the cord stump with gauze." C) "Apply Betadine around the cord stump." D) "This is normal during healing."

A) "Take your newborn to the pediatrician."

The nurse is performing discharge teaching for a newly delivered first-time mother and her infant on the 2nd postpartum day. Which statement by the mother indicates that teaching has been successful? A) "Taking baths will help my perineum feel less sore each day." B) "If I develop heavy bleeding, I should take my temperature." C) "My bowel movements should resume in a week." D) "I will go back to the doctor in 4 days for my RhoGAM shot."

A) "Taking baths will help my perineum feel less sore each day."

The nurse is completing the gestational age assessment on a newborn while in the mother's postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. What is the nurse's best response? A) "I'm checking to make sure the baby has all of its parts." B) "This assessment looks at both physical aspects and the nervous system." C) "This assessment checks the baby's brain and nerve function." D) "Don't worry. We perform this check on all the babies."

B) "This assessment looks at both physical aspects and the nervous system."

The nurse expects an initial weight loss for the average postpartum client to be which of the following? A) 5 to 8 pounds B) 10 to 12 pounds C) 12 to 15 pounds D) 15 to 20 pounds

B) 10 to 12 pounds

The nurse is assisting a mother to bottle-feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should do which of the following? A) Offer a pacifier B) Burp the newborn C) Unwrap the newborn D) Stroke the newborn's spine and feet

B) Burp the newborn

The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following? A) A history of obsessive-compulsive disorder (OCD) B) Chlamydia C) Delivered six other children by cesarean section D) A urinary tract infection (UTI)

B) Chlamydia

A new mother who is breastfeeding tells the nurse that her infant is spitting up frequently, has very loose stools and copious gas, and feeds for only short periods of time. The nurse suspects a feeding intolerance and, after questioning the mother about her diet, suggests that she do which of the following? A) Stop breastfeeding and switch to formula. B) Eliminate dairy products from her diet. C) Supplement breastfeeding with a soy-based formula. D) Offer the baby water between feedings.

B) Eliminate dairy products from her diet

While conducting a home visit, the nurse observes the father of a newborn hold the infant so that the following is observed. What should the nurse explain to the parents about this behavior? *baby puts feet down when parent holds them upright A) This is abnormal and should be reported. B) This will disappear between 4 and 8 weeks of age. C) It means the child will begin walking at an early age. D) The infant should be given more formula when this occurs

B) This will disappear between 4 and 8 weeks of age. This is the stepping reflex. When held upright with one foot touching a flat surface, the newborn puts one foot in front of the other and "walks." This reflex is more pronounced at birth and is lost in 4 to 8 weeks.

A woman has been admitted for an external version. She has completed an ultrasound exam and is attached to the fetal monitor. Prior to the procedure, why will terbutaline be administered? A) To provide analgesia B) To relax the uterus C) To induce labor D) To prevent hemorrhage

B) To relax the uterus

The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition? A) Meconium aspiration syndrome B) Transient tachypnea of the newborn C) Respiratory distress syndrome D) Prematurity of the neonate

B) Transient tachypnea of the newborn

Which of the following functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs? A) ABM B) WIC C) ILCA D) LLLI

B) WIC The Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Placing the baby at mother's breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated? A) 6 to 12 hours after birth B) Within 1 hour of birth C) 24 hours after birth D) 48 hours after birth

B) Within 1 hour of birth

At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborn's weight is which of the following? A) Excessive B) Within normal limits C) Less than expected D) Unusual

B) Within normal limits

The nurse has received the end-of-shift report on the postpartum unit. Which client should the nurse see first? A) Woman who is 2nd day post-cesarean, moderate lochia serosa B) Woman day of delivery, fundus firm 2 cm above umbilicus C) Woman who had a cesarean section, 1st postpartum day, 4 cm diastasis recti abdominis D) Woman who had a cesarean section, 1st postpartum day, hypoactive bowel sounds all quadrants

B) Woman day of delivery, fundus firm 2 cm above umbilicus

The nurse is caring for a client who delivered by cesarean birth. The client received a general anesthetic. To prevent or minimize abdominal distention, which of the following would the nurse encourage? Select all that apply. A) Increased intake of cold beverages B) Leg exercises every 2 hours C) Abdominal tightening D) Ambulation E) Using a straw when drinking fluids

B, C, D

Under which circumstances would the nurse remove prostaglandin from the client's cervix? Select all that apply. A) Contractions every 5 minutes B) Nausea and vomiting C) Uterine tachysystole D) Cardiac tachysystole E) Baseline fetal heart rate of 140-148

B, C, D

The nurse is caring for a client who plans to relinquish her baby for adoption. The nurse would implement which approach to care? Select all that apply. A) Encourage the client to see and hold her infant. B) Encourage the client to express her emotions. C) Respect any special requests for the birth. D) Acknowledge the grieving process in the client. E) Allow access to the infant, if the client requests it

B, C, D, E

The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Select all that apply. A) "We should keep our home air-conditioned so the baby doesn't overheat." B) "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." C) "When we change the baby's diaper, we should change any wet clothing or blankets, too." D) "If the baby's body temperature gets too low, he will warm himself up without any shivering." E) "Our baby will have a much faster rate of breathing if he is not dressed warmly enough."

B, C, D, E

A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU? Select all that apply. A) Schedule care throughout the day. B) Silence alarms quickly. C) Place a blanket over the top portion of the incubator. D) Do not offer a pacifier. E) Dim the lights.

B, C, E

Nursing interventions that foster the process of becoming a mother include which of the following? Select all that apply. A) Encouraging detachment from the nurse-patient relationship B) Promoting maternal-infant attachment C) Building awareness of and responsiveness to infant interactive capabilities D) Instruct about promoting newborn independence E) Preparing the woman for the maternal social role

B, C, E

Which of the following symptoms would be an indication of postpartum blues? Select all that apply. A) Overeating B) Anger C) Mood swings D) Constant sleepiness E) Crying

B, C, E

Which of the following would be considered normal newborn urinalysis values? Select all that apply. A) Color bright yellow B) Bacteria 0 C) Red blood cells (RBC) 0 D) White blood cells (WBC) more than 4-5/hpf E) Protein less than 5-10 mg/dL

B, C, E

Amniotomy as a method of labor induction has which of the following advantages? Select all that apply. A) The danger of a prolapsed cord is decreased. B) There is usually no risk of hypertonus or rupture of the uterus. C) The intervention can cause a decrease in pain. D) The color and composition of amniotic fluid can be evaluated. E) The contractions elicited are similar to those of spontaneous labor

B, D, E

Benefits of skin-to-skin care as a developmental intervention include which of the following? Select all that apply. A) Routine discharge B) Stabilization of vital signs C) Increased periods of awake-alert state D) Decline in episodes of apnea and bradycardia E) Increased growth parameters

B, D, E

During the first several postpartum weeks, the new mother must accomplish certain physical and developmental tasks, including which of the following? Select all that apply. A) Establish a therapeutic relationship with her physician B) Adapt to altered lifestyles and family structure resulting from the addition of a new member C) Restore her intellectual abilities D) Restore physical condition E) Develop competence in caring for and meeting the needs of her infant

B, D, E

The postpartum nurse is performing a home care visit to a first-time mother on her third day after delivery. She reports that her nipples are becoming sore. What statement indicates that further teaching is needed? A) "I can apply lanolin cream to help with the nipple pain." B) "Watching how much areola is visible will help me see whether my baby has a good mouthful of breast or not." C) "My nipples will heal if I switch to bottle feeding for about 3 days while I pump my breasts." D) "Rotating breastfeeding positions will allow the sore areas of my nipples to have less friction."

C) "My nipples will heal if I switch to bottle feeding for about 3 days while I pump my breasts."

The client delivered her second child 1 day ago. The client's temperature is 101.4° F, her pulse is 100, and her blood pressure is 110/70. Her lochia is moderate, serosanguinous, and malodorous. She is started on IV antibiotics. The nurse provides education for the client and her partner. Which statement indicates that teaching has been effective? A) "This condition is called parametritis." B) "Gonorrhea is the most common organism that causes this type of infection." C) "My positive Beta-strep culture might have contributed to this problem." D) "If I had walked more yesterday, this probably wouldn't have happened."

C) "My positive Beta-strep culture might have contributed to this problem."

The client requires vacuum extraction assistance. To provide easier access to the fetal head, the physician cuts a mediolateral episiotomy. After delivery, the client asks the nurse to describe the episiotomy. How does the nurse respond? A) "The episiotomy goes straight back toward your rectum." B) "The episiotomy is from your vagina toward the urethra." C) "The episiotomy is cut diagonally away from your vagina." D) "The episiotomy extends from your vagina into your rectum."

C) "The episiotomy is cut diagonally away from your vagina."

The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? A) "The white spots on my baby's nose are called milia, and are harmless." B) "The whitish cheeselike substance in the creases is vernix, and will be absorbed." C) "The red spots with a white center on my baby are abnormal acne." D) "Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician."

C) "The red spots with a white center on my baby are abnormal acne."

A client is consulting a certified nurse-midwife because she is hoping for a vaginal birth after cesarean (VBAC) with this pregnancy. Which statement indicates that the client requires more information about VBAC? A) "I can try a vaginal birth because my uterine incision is a low segment transverse incision." B) "The vertical scar on my skin doesn't mean that the scar on my uterus goes in the same direction." C) "There is about a 90% chance of giving birth vaginally after a cesarean." D) "Because my hospital has a surgery staff on call 24 hours a day, I can try a VBAC there."

C) "There is about a 90% chance of giving birth vaginally after a cesarean."

The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is which of the following? A) "Your newborn likes to be touched." B) "Stroking the newborn will help with stimulation." C) "Visits must be scheduled between feedings." D) "Your baby loves her pink blanket."

C) "Visits must be scheduled between feedings."

The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following? A) "My baby might open her arms wide and pull her legs up to her tummy if she is passing gas." B) "When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still." C) "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on." D) "I can get my baby to turn his head toward the right if I lift his right arm over his head."

C) "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on."

The client is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore. Ten minutes after an ice pack is applied, the client asks for another. What is the best response from the nurse? A) "I'll get you one right away." B) "You only need to use one ice pack." C) "You need to leave it off for at least 20 minutes and then reapply." D) "I'll bring you an extra so that you can change it when you are ready."

C) "You need to leave it off for at least 20 minutes and then reapply."

Approximately what percentage of the newborn's body weight is water? A) 5% to 10% B) 90% to 95% C) 70% to 75% D) 50% to 60%

C) 70% to 75%

The nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within how long? A) 2 days B) 10 days C) 8 days D) 14 days

C) 8 days

At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this infant's Apgar score? A) 7 B) 8 C) 9 D) 10

C) 9

The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding? A) A mother with a poorly balanced diet B) A mother who is overweight C) A mother who is HIV positive D) A mother who has twins

C) A mother who is HIV positive

On the 3rd day postpartum, a client who is not breastfeeding experiences engorgement. To relieve her discomfort, the nurse should encourage the client to do which of the following? A) Remove her bra B) Apply heat to the breasts C) Apply cold packs to the breasts D) Use a breast pump to release the milk

C) Apply cold packs to the breasts

The nurse teaches the parents of an infant who was recently circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur? A) Wrap the diaper tightly. B) Clean with warm water with each diaper change. C) Apply gentle pressure to the site with gauze. D) Apply a new petroleum ointment gauze dressing.

C) Apply gentle pressure to the site with gauze

The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following? A) Ortolani maneuver B) Palmar grasping reflex C) Clavicle D) Tonic neck reflex

C) Clavicle

The nurse is making an initial assessment of the newborn. The findings include a chest circumference of 32.5 cm and a head circumference of 33.5 cm. Based on these findings, which action should the nurse take first? A) Notify the physician. B) Elevate the newborn's head. C) Document the findings in the chart. D) Assess for hypothermia immediately.

C) Document the findings in the chart

The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss? A) Placing the newborn away from air currents B) Pre-warming the examination table C) Drying the newborn thoroughly D) Removing wet linens from the isolette

C) Drying the newborn thoroughly

Which relief measure would be most appropriate for a postpartum client with superficial thrombophlebitis? A) Urge ambulation B) Apply ice to the leg C) Elevate the affected limb D) Massage her calf

C) Elevate the affected limb

The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority? A) Tissue Integrity, Impaired B) Infection, Risk for C) Gas Exchange, Impaired D) Family Processes, Dysfunctional

C) Gas Exchange, Impaired

The nurse is performing a postpartum home care visit. Which teaching has the highest priority? A) Teaching or reviewing how to bathe the baby B) Teaching how to thoroughly childproof the house C) How many wet diapers the baby should have daily D) Prevention of plagiocephaly

C) How many wet diapers the baby should have daily

The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse? A) Occasional watery stools B) Spitting up after feeding C) Jitteriness and irritability D) Nasal stuffiness

C) Jitteriness and irritability

Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do? A) Enable T or B cells to respond to antigens B) Repress responses to specific B or T lymphocytes to antigens C) Kill foreign or virus-infected cells D) Remove pathogens and cell debris

C) Kill foreign or virus-infected cells

Which of the following is the primary carbohydrate in the breastfeeding newborn? A) Glucose B) Fructose C) Lactose D) Maltose

C) Lactose

During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following? A) Place the newborn in a prone position. B) Limit feedings to three a day to decrease diarrhea. C) Place the infant supine and operate a home apnea-monitoring system. D) Wean the newborn off the pacifier

C) Place the infant supine and operate a home apnea-monitoring system.

The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following? A) Increased blood pressure B) Hypoglycemia C) Postpartum hemorrhage D) Postpartum infection

C) Postpartum hemorrhage

During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. The nurse documents this finding as which of the following? A) Nevus vasculosus B) Nevus flammeus C) Telangiectatic nevi D) A Mongolian spot

C) Telangiectatic nevi

The postpartum client has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? A) The client reports she had this condition after her last pregnancy. B) The client develops pain and swelling in her left lower leg. C) The client appears anxious, and describes pressure in her chest. D) The client becomes upset that she cannot go home yet.

C) The client appears anxious, and describes pressure in her chest.

A nurse is caring for several postpartum clients. Which client is demonstrating a problem attaching to her newborn? A) The client who is discussing how the baby looks like her father B) The client who is singing softly to her baby C) The client who continues to touch her baby with only her fingertips D) The client who picks her baby up when the baby cries

C) The client who continues to touch her baby with only her fingertips

The charge nurse is assessing several postpartum clients. Which client has the greatest risk for postpartum hemorrhage? A) The client who was overdue and delivered vaginally B) The client who delivered by scheduled cesarean delivery C) The client who had oxytocin augmentation of labor D) The client who delivered vaginally at 36 weeks

C) The client who had oxytocin augmentation of labor

An abbreviated systematic physical assessment of the newborn is performed by the nurse in the birthing area to detect any abnormalities. Normal findings would include which of the following? Select all that apply. A) Skin color: Body blue with pinkish extremities B) Umbilical cord: two veins and one artery C) Respiration rate of 30-60 irregular D) Temperature of above 36.5°C (97.8°F) E) Sole creases that involve the heel

C, D, E

The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statement(s) by the parents indicate that additional teaching is needed? Select all that apply. A) "Our baby will be in an incubator to keep him warm." B) "Breathing might be harder for our baby because he is early." C) "The growth of our baby will be faster than if he were term." D) "Tube feedings will be required because his stomach is small." E) "Because he came early, he will not produce urine for 2 days."

C, D, E

What should the healthcare provider consider when prescribing a medication to a woman who is breastfeeding? Select all that apply. A) Drug's potential effect on hormone production B) Amount of drug excreted into the mother's blood C) Drug's potential adverse effects to the infant D) Infant's age and health E) Mother's need for the medication

C, D, E

The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock? Select all that apply. A) Increased pulse B) High blood pressure C) Tachycardia D) Bradycardia E) Capillary filling time greater than 3 seconds

C, E

A client at 20 weeks' gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the client indicate that the teaching was successful? A) "Formula-feeding gives the baby protection from infections." B) "Breast milk cannot be stored; it has to be thrown away after pumping." C) "Breastfeeding is more expensive than formula-feeding." D) "My baby will have a lower risk of food allergies if I breastfeed."

D) "My baby will have a lower risk of food allergies if I breastfeed."

The nurse is speaking to a community group about the controversy regarding the length of the hospital stay for postpartum clients. Which statement indicates that a participant needs additional information? A) "As of 1998, there's a law that requires insurance to pay for a 48-hour stay after an uncomplicated birth." B) "The length of stay was shortened by insurance companies to decrease healthcare costs." C) "Early discharge became more popular in the 1980s as an alternative to having a home birth." D) "With current length-of-stay laws, newborns have no problems at home, and get recommended follow-up care."

D) "With current length-of-stay laws, newborns have no problems at home, and get recommended follow-up care."

The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching? A) "Call your pediatrician if the baby's temperature is below 98.6°F axillary." B) "Your baby's stools will change to a greenish color when your milk comes in." C) "You can wipe away any eye drainage that might form." D) "Your infant should wet a diaper at least 6 times per day."

D) "Your infant should wet a diaper at least 6 times per day."

The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse? A) 60 breaths per minute B) 70 breaths per minute C) 64 breaths per minute D) 20 breaths per minute

D) 20 breaths per minute

The nurse is caring for a premature infant in the NICU, and is going to attempt a bottle feeding with thawed breast milk. How long can thawed breast milk be stored in the refrigerator before the nurse must discard it? A) 4 hours B) 8 hours C) 12 hours D) 24 hours

D) 24 hours

A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long? A) 2 months B) 2 weeks C) 1 year D) 4 months

D) 4 months

The nurse is preparing to receive a newly delivered client. The client is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important? A) Assign the client a room on the GYN surgical floor instead of on the postpartum floor. B) Prepare to complete teaching in time for discharge at 24 hours post-delivery. C) Make an effort not to bring up the topic of the baby, and discuss the mother's health instead. D) Ask the client how much contact she would like with the baby, and whether she wants to feed it

D) Ask the client how much contact she would like with the baby, and whether she wants to feed it

A newborn is receiving phototherapy. Which intervention by the nurse would be most important? A) Measurement of head circumference B) Encouraging the mother to stop breastfeeding C) Stool blood testing D) Assessment of hydration status

D) Assessment of hydration status

The nurse is beginning the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important? A) Describe the likely reaction of siblings to the new baby. B) Discuss adaptation to grandparenthood by her parents. C) Determine whether father-infant attachment is taking place. D) Assist the mother in identifying the baby's behavior cues

D) Assist the mother in identifying the baby's behavior cues

Which of the following is a sign of dehydration in the newborn? A) Slow, weak pulse B) Soft, loose stools C) Light colored, concentrated urine D) Depressed fontanelles

D) Depressed fontanelles

In the operating room, a client is being prepped for a cesarean delivery. The doctor is present. What is the last assessment the nurse should make just before the client is draped for surgery? A) Maternal temperature B) Maternal urine output C) Vaginal exam D) Fetal heart tones

D) Fetal heart tones

The postpartum client who is being discharged from the hospital experienced severe postpartum depression after her last birth. What should the nurse include in the plan of follow-up care for this client? A) One visit from a home care nurse, to take place in 2 days B) Two visits from a public health nurse over the next month C) An appointment with a mental health counselor D) Follow-up with the obstetrician in 6 weeks

D) Follow-up with the obstetrician in 6 weeks

Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following? A) Preeclampsia screening B) Congenital kidney disease screening C) Visual screening D) Hearing screening

D) Hearing screening

A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? A) Monitor for feeding difficulties. B) Assess for facial paralysis. C) Monitor for signs of hyperglycemia. D) Maintain a warm environment.

D) Maintain a warm environment

Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels? A) Monitor urine for amount and characteristics. B) Encourage late feedings to promote intestinal elimination. C) All infants should be routinely monitored for iron intake. D) Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above

D) Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above

The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with which of the following? A) Omphalocele B) Gastroschisis C) Diaphragmatic hernia D) Myelomeningocele

D) Myelomeningocele

Which of the following is a risk factor for urinary retention after childbirth? A) Multiparity B) Precipitous labor C) Unassisted childbirth D) Not sufficiently recovering from the effects of anesthesia

D) Not sufficiently recovering from the effects of anesthesia

The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate? A) Encourage the new mother, saying, "It will happen soon." B) Instruct the client to eat a low-fiber diet. C) Decrease fluid intake. D) Obtain an order for a stool softener.

D) Obtain an order for a stool softener.

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? A) Respiratory rate 60 and irregular in depth and rhythm B) Pulse rate 145, cardiac murmur heard C) Mean blood pressure 55 mmHg D) Pauses in respiration lasting 30 seconds

D) Pauses in respiration lasting 30 seconds

After inserting prostaglandin gel for cervical ripening, what should the nurse do? A) Apply an internal fetal monitor. B) Insert an indwelling catheter. C) Withhold oral intake and start intravenous fluids. D) Place the client in a supine position with a right hip wedge

D) Place the client in a supine position with a right hip wedge

The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about? A) Neonatal jaundice B) Neonatal hypothermia C) Neonatal hyperthermia D) Respiratory distress

D) Respiratory distress

The nurse is analyzing various strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? A) Select videos on various topics of newborn care. B) Organize a class that includes first-time mothers only. C) Have mothers return in 1 week, when they feel more rested. D) Schedule time for one-to-one teaching in the mother's room.

D) Schedule time for one-to-one teaching in the mother's room

During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up? A) Firm fundus B) Fundus at the umbilical level C) Moderate lochia rubra D) Steady trickle of blood

D) Steady trickle of blood

A client had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action? A) That the client would be encouraged to ambulate freely B) That the client would be given aspirin 650 mg by mouth C) That the client would be given Methergine IM D) That the client would be placed on bed rest

D) That the client would be placed on bed rest

A postpartum client with endometritis is being discharged home on antibiotic therapy. The new mother plans to breastfeed her baby. What should the nurse's discharge instruction include? A) The client can douche every other day. B) Sexual intercourse can be resumed when the client feels up to it. C) Light housework will provide needed exercise. D) The baby's mouth should be examined for thrush.

D) The baby's mouth should be examined for thrush

The nurse is caring for a client who recently emigrated from a Southeast Asian country. The mother has been resting since the birth, while her sister has changed the diapers and fed the infant. What is the most likely explanation for this behavior? A) The client is not attaching to her infant appropriately. B) The client is not going to be a good mother, and the baby is at risk. C) The client has no mother present to role-model behaviors. D) The client is exhibiting normal behavior for her culture.

D) The client is exhibiting normal behavior for her culture

The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? A) The new nurse holds the infant after giving a gavage feeding. B) The new nurse provides skin-to-skin care. C) The new nurse provides care when the baby is awake. D) The new nurse gives the feeding with room-temperature formula

D) The new nurse gives the feeding with room-temperature formula

The nurse is caring for a new breastfeeding mother who is from Pakistan. The nurse plans her care so that the newborn is offered the breast on which of the following? A) Day of birth B) First day after birth C) Second day after birth D) Third to fourth day after birth

D) Third to fourth day after birth

The client delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an IV of lactated Ringer's solution running at 100 mL/hr. Her fundus is firm and to the right of midline. What is the best nursing action? A) To massage the fundus vigorously B) To assess the client's pain level C) To increase the rate of the IV D) To assist the client to the bathroom

D) To assist the client to the bathroom

To assess the healing of the uterus at the placental site, what does the nurse assess? A) Lab values B) Blood pressure C) Uterine size D) Type, amount, and consistency of lochia

D) Type, amount, and consistency of lochia

The client is having fetal heart rate decelerations. An amnioinfusion has been ordered to alleviate the decelerations. The nurse understands that the type of decelerations that will be alleviated by amnioinfusion is which of the following? A) Early decelerations B) Moderate decelerations C) Late decelerations D) Variable decelerations

D) Variable decelerations

The nurse is assessing the emotional state of a client following the delivery of her newborn. Which response by the client requires further follow up by the nurse? A) Excitability B) Crying C) Quiet D) Withdrawn

D) Withdrawn Being withdrawn is not considered a normal emotional response to delivery of a newborn, and requires further follow up by the nurse

At birth a newborn's head circumference is 13 inches. What should the nurse expect the chest circumference to be in cm? (Round to the nearest whole number.)

31 cm The circumference of the newborn's head is approximately 2 cm greater than the circumference of the newborn's chest at birth. First determine the infant's head circumference in cm by multiplying 13 inches by 2.54 cm or 13 x 2.54 = 33.02 or 33 cm. If the chest circumference is 2 cm smaller than the head circumference, the nurse should expect the infant's chest to measure 31 cm

A newborn weighs 7 lbs. 10 ounces at birth. What is the maximum number of calories that the nurse should instruct the mother that the baby needs to consume each day? (Calculate to the nearest whole number.)

400 calories Caloric intake for a newborn is 45.5 to 52.5 kcal/lb/day or 100 to 115 kcal/kg/day

A neonate weighing 5.5 lb is prescribed to receive intravenous cefotaxime (Claforan) 50 mg/kg/dose every 6 hours for treatment of sepsis. How many mg of the medication should the nurse anticipate the patient will need for 24 hours? (Calculate to the nearest whole number.)

500 mg Convert the patient's weight in lb to kg by dividing by 2.2, or 5.5/2.2 = 2.5 kg. Then calculate the amount of medication needed for each dose by multiplying 50 mg x 2.5 kg = 125 mg. Then multiply the amount of medication for each dose by 4 (one dose every 6 hours) or 125 mg x 4 = 500 mg

At birth a newborn measured 20 inches. What length should the nurse instruct the mother to expect the baby to be at 4 months? (Calculate the anticipated length in cm and round to the nearest whole number.)

61 cm The conversion 2.54 cm = 1 inch will be used. If the initial length was 20 inches, convert this to cm by multiplying 20 x 2.54 = 50.8 cm. If the average growth is approximately one inch per month for the first 6 months, then multiply 2.54 x 4 = 10.16 cm and add this amount to the birth length of 50.8 cm or 10.16 cm + 50.8 cm = 60.96. With rounding, the mother can expect the infant to be 61 cm in length

The nurse is reviewing the contents of breastmilk with a new mother. What amount of water should the nurse explain is in 8 ounces of breastmilk? Record your answer rounding to the nearest whole number

7 oz Breastmilk contains 87% water. The nurse should multiply 8 ounces by 87% to determine that 6.96 ounces out of 8 ounces of breast milk is water. With rounding, the volume of water in 8 ounces of breastmilk is 7 ounces

The nurse is instructing a new mother on the amount and frequency of bottle-feeding for her newborn. The mother plans to use formula that is available in 6-ounce cans. If the infant ingests 25 mL for each of 8 feedings per day, how many cans of formula should the mother have available for a week? (Round to the nearest whole number.)

8 cans One ounce is equal to 30 mL. For a 6-ounce can, the amount of formula is 30 x 6 or 180 mL. For one day, the infant will ingest 25 mL x 8 feedings or 200 mL. For 7 days the infant will ingest 200 mL x 7 = 1400 mL. To determine the number of cans of formula needed divide the weekly total of 1400 mL by 180 mL or 1400/180 = 7.78 or 8 cans

The nurse is preparing teaching material for a new mother. What should the nurse include when instructing on areas to include when observing the infant? Select all that apply. 1. Touch 2. Vision 3. Hearing 4. Diaper care 5. General appearance

1, 2, 3, 5

A new mother is planning to bottle feed her infant and wants helps with suppressing lactation. What should the nurse suggest to help this new mother? Select all that apply. 1. Wear a 24-hour support bra 2. Apply cabbage leaves to the breast tissue 3. Apply warm compresses every 4 to 6 hours 4. Massage lotion on the breasts 3 times a day 5. Avoid all nipple stimulation for 7 to 10 days

1, 2, 5

A postpartum patient who received epidural morphine prior to a cesarean birth is concerned about a severe headache that has persisted for several days. What should the nurse suggest to this patient? Select all that apply. 1. Ingest fluids with caffeine 2. Engage in moderate exercise 3. Increase the intake of all fluids 4. Lie in bed in a quiet dark room 5. Restrict the intake of warm fluids

1, 3, 4

A postpartum patient weighing 165 lb is prescribed a subcutaneous injection of Enoxaparin 1 mg/kg twice daily. The medication available is 50 mg/mL. How many mL of medication should the nurse provide for each injection? (Calculate to the nearest tenth decimal point.)

1.5 mL First determine the patient's weight in kg by dividing 165 lb by 2.2 or 165/2.2 = 75 kg. Next determine the prescribed dose by multiplying the amount of 1 mg by kg of body weight or 1 mg x 75 kg = 75 mg. Next calculate the amount of medication to provide by using the equation Dosage Required/Dosage Available x mL; 75 mg/50 mg x 1 mL = 75/50 x 1 = 1.5 mL

During a home visit the mother of a 2 week old newborn is concerned that the baby always seems to be "wet" and wonders if this is normal. The newborn weighs 4 kg. How many mL of fluid should the nurse explain that the infant makes each day? (Round to the nearest whole number.)

100 mL The newborn voids 5 to 25 times every 24 hours, with a volume of 25 mL/kg/day. If the newborn weighs 4 kg then the amount of urine produced every day is 25 mL x 4 = 100 mL.

The nurse is caring for a newborn with a cleft lip. What actions should the nurse take when caring for this infant? Select all that apply. 1. Burp frequently 2. Assess patency of nares 3. Assist with parental coping 4. Clean the area with sterile water 5. Feed with a special nipple and bottle

1, 3, 4, 5

A patient experiencing postpartum hemorrhage is prescribed to receive 741 mL of a crystalloid solution. How many mL of blood did this patient lose from the hemorrhage? (Calculate to the nearest whole number.)

247 mL Lost intravascular volume is replaced initially with rapid administration of warmed crystalloid solutions, in a 3 mL solution per 1 mL of estimated blood lost ratio. To determine blood loss, divide the volume of fluid by 3 or 741/3 = 247 mL

The nurse is calling clients at 4 weeks postpartum. Which of the following clients should be seen immediately? A) The client who describes feeling sad all the time B) The client who reports hearing voices talking about the baby C) The client who states she has no appetite and wants to sleep all day D) The client who says she needs a refill on her sertraline (Zoloft) next week

B) The client who reports hearing voices talking about the baby

The physician/CNM opts to use a vacuum extractor for a delivery. What does the nurse understand? A) There is little risk with vacuum extraction devices. B) There should be further fetal descent with the first two "pop-offs." C) Traction is applied between contractions. D) The woman often feels increased discomfort during the procedure.

B) There should be further fetal descent with the first two "pop-offs."

The nurse is supervising a student nurse who is working with a 14-year-old client who delivered her first child yesterday. Which statement indicates that the nursing student understands the particular needs of an adolescent client? A) "This client will need less teaching, because she will have gotten the right information in school." B) "Because of her age, this client will require less frequent fundal checks to assess for postpartal hemorrhage." C) "Because of her age, this client will probably need extra teaching about the terminology for her anatomy." D) "This client will need to have her grandmother provide day care and help raise the baby."

C) "Because of her age, this client will probably need extra teaching about the terminology for her anatomy."

The nurse is monitoring a postpartum patient receiving methylergonovine maleate (Methergine). Which assessment findings should the nurse identify as being expected adverse effects of this medication? Select all that apply. 1. Nausea 2. Leg pain 3. Headache 4. Hypertension 5. Uterine cramping

1, 3, 4, 5

A patient who is hemorrhaging after a vaginal delivery is being considered for a uterine tamponade. What should the nurse instruct the patient about this process? Select all that apply. 1. A balloon is inserted into the uterus 2. The balloon is kept in place for 12 hours 3. The balloon is inflated with 300 to 500 mL of saline 4. After removal, the uterus is packed with sterile gauze 5. The tube has an open tip to permit bleeding to be visualized

1, 3, 5

At 3 weeks a newborn weighs 8 lbs. 1 ounce. What percent of this body weight should the nurse explain to the mother as being water? (Calculate the average weight in ounces to the first decimal point.)

93.5 oz Approximately 70% to 75% of the newborn's body weight is water. First determine the infant's weight in ounces by multiplying 8 x 16 ounces = 128 ounces + 1 ounce = 129 ounces. Then multiply the weight in ounces by 70% and then by 75%: 129 ounces x 70% = 90.3 ounces; 129 ounces x 75% = 96.75. Then add the values of 70% and 75% and divide by 2 to determine the average: 90.3 + 96.75 = 187.05/2 = 93.525 ounces. To determine this weight in pounds divide by 16, or 93.525/16 = 5.84 of the infant's weight is water. To determine the weight in pounds and ounces: .84/100 = x/16; 1344 = 100x; 1344/100 = 13.44 ounces. The percentage of the infant's weight that is water is 5 pounds, 13.44 ounces

The home care nurse is visiting a newborn-and-mother couplet. Which nursing action has the highest priority? A) Establish rapport with the family members. B) Review the hospital medical records. C) Determine the newborn's sleeping arrangements. D) Examine the umbilical cord stump.

A) Establish rapport with the family members

To prevent the spread of infection, the nurse teaches the postpartum client to do which of the following? A) Address pain early B) Change peri-pads frequently C) Avoid overhydration D) Report symptoms of uterine cramping

B) Change peri-pads frequently

In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? A) Eye prophylaxis medication B) Drying the newborn C) Vital signs D) Vitamin K injection

A) Eye prophylaxis medication

The postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this client's chart? A) "Cesarean birth after extended labor with ruptured membranes." B) "Unassisted childbirth and afterbirth." C) "External fetal monitoring used throughout labor." D) "The client has history of pregnancy-induced hypertension."

A) "Cesarean birth after extended labor with ruptured membranes."

The nurse knows that the Bishop scoring system for cervical readiness includes which of the following? Select all that apply. A) Fetal station B) Fetal lie C) Fetal presenting part D) Cervical effacement E) Cervical softness

A) Fetal station D) Cervical effacement E) Cervical softness

A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following? A) "A quick cool bath will help wake up my son for feedings." B) "I can check my son's temperature under his arm." C) "My baby should be dressed warmly, with a hat." D) "Cuddling my son will help to keep him warm."

A) "A quick cool bath will help wake up my son for feedings."

The nurse is preparing a class on breastfeeding for pregnant women in their first trimester. The women are from a variety of cultural backgrounds, and all speak English well. Which statement should the nurse include in this presentation? A) "Although some cultures believe colostrum is not good for the baby, it provides protection from infections and helps the digestive system to function." B) "Some women are uncomfortable with exposing their breasts to nurse their infant, but it really isn't a big deal. You will get used to it." C) "No religion prescribes a feeding method, so you all can choose whatever method makes the most sense to you." D) "In most cultures, it is culturally acceptable to speak about intimate matters in front of their families."

A) "Although some cultures believe colostrum is not good for the baby, it provides protection from infections and helps the digestive system to function."

The pregnant client at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best? A) "Babies can develop postmaturity syndrome, which refers to a number of complications that can occur after 42 weeks of pregnancy." B) "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." C) "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." D) "The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger."

A) "Babies can develop postmaturity syndrome, which refers to a number of complications that can occur after 42 weeks of pregnancy."

The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which statement by a participant indicates that additional information is needed? A) "Because the scar on my belly goes down from my navel, I am not a candidate for a VBAC." B) "My first baby was in a breech position, so for this pregnancy, I can try a VBAC if the baby is head-down." C) "Because my hospital is so small and in a rural area, they won't let me attempt a VBAC." D) "The rate of complications from VBAC is lower than the rate of complications from a cesarean."

A) "Because the scar on my belly goes down from my navel, I am not a candidate for a VBAC."

The nurse is at the home of a postpartum client for an initial assessment. The client gave birth by cesarean section 1 week earlier. Which statements should the nurse include? Select all that apply. A) "Because you had a cesarean, I'd like to assess your incision." B) "You aren't having any problems nursing, right?" C) "How rested do you feel since you came home?" D) "Because you are bottle-feeding, I won't assess your breasts." E) "You should remain at home for the first 3 weeks after delivery."

A) "Because you had a cesarean, I'd like to assess your incision." C) "How rested do you feel since you came home?"

A client who delivered 2 hours ago tells the nurse that she is exhausted and feels guilty because her friends told her how euphoric they felt after giving birth. How should the nurse respond? A) "Everyone is different, and both responses are normal." B) "Most mothers do feel euphoria; I don't know why you don't." C) "It's good for me to know that because it might indicate a problem." D) "Let me bring your baby to the nursery so that you can rest."

A) "Everyone is different, and both responses are normal."

The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. What is the best response by the nurse? A) "His head is molded from fitting through the birth canal. It will become more round." B) "We refer to that as 'cone head,' which is a temporary condition that goes away." C) "It might mean that your baby sustained brain damage during birth, and could have delays." D) "I think he looks just like you. Your head is much the same shape as your baby's."

A) "His head is molded from fitting through the birth canal. It will become more round."

The nurse is completing the discharge teaching of a young first-time mother. Which statement by the mother requires immediate intervention? A) "I will put my baby to bed with his bottle so he doesn't get hungry during the night." B) "My baby will probably have a bowel movement each breastfeeding, and will wet often." C) "Nursing every 2 to 3 hours is normal, for a total of 8 to 12 feedings every day." D) "I will drink fenugreek tea from my grandmother to prevent my milk from coming in."

A) "I will put my baby to bed with his bottle so he doesn't get hungry during the night."

The client delivered by cesarean birth 3 days ago and is being discharged. Which statement should the nurse include in the discharge teaching? A) "If your incision becomes increasingly painful, call the doctor." B) "It is normal for the incision to ooze greenish discharge in a few days." C) "Increasing redness around the incision is a part of the healing process." D) "A fever is to be expected because you had a surgical delivery."

A) "If your incision becomes increasingly painful, call the doctor."

The nurse is teaching a prenatal class about feeding methods. A father-to-be asks the nurse which method, breast or formula, leads to the fastest infant growth and weight gain. Which response by the nurse is best? A) "In the first 3 to 4 months breastfed babies tend to gain weight faster." B) "In the first 3 to 4 months there is no difference in weight gain." C) "In the first 3 to 4 months bottle-fed babies grow faster." D) "In the first 3 to 4 months growth isn't as important as your comfort with the method."

A) "In the first 3 to 4 months breastfed babies tend to gain weight faster."

The mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? A) "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth." B) "Bring your infant to the clinic immediately." C) "This is due to overriding of the cranial bones during labor." D) "Your baby must be dehydrated."

A) "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth."

The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurse's best response? A) "Most newborns are nose breathers." B) "The tube will elicit the sucking reflex." C) "A smaller catheter is preferred for feedings." D) "Most newborns are mouth breathers."

A) "Most newborns are nose breathers."

The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching? A) "My baby isn't getting enough iron from my breast milk." B) "Babies undergo physiologic anemia of infancy." C) "This results from dilution because of the increased plasma volume." D) "Delaying the cord clamping did not cause this to happen."

A) "My baby isn't getting enough iron from my breast milk."

The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didn't I see that he was so sick?" What is the nurse's best reply? A) "Newborns have immature immune function at birth, and illness is very hard to detect." B) "Your mothering skills will improve with time. You should take the newborn class." C) "Your baby didn't get enough active acquired immunity from you during the pregnancy." D) "The immunity your baby gets in utero doesn't start to function until he is 4 to 8 weeks old."

A) "Newborns have immature immune function at birth, and illness is very hard to detect."

The nurse has completed a community education session on growth patterns of infants. Which statement by a participant indicates that additional teaching is needed? A) "Newborns should regain their birth weight by 1 week of age." B) "Breastfed and formula-fed babies have different growth rates." C) "Formula-fed infants regain their birth weight earlier than breastfed infants." D) "Healthcare providers consider breastfeeding to be the 'gold standard' for neonatal nutrition."

A) "Newborns should regain their birth weight by 1 week of age."

A laboring client's obstetrician has suggested amniotomy as a method for creating stronger contractions and facilitating birth. The client asks, "What are the advantages of doing this?" What should the nurse cite in response? A) Contractions elicited are similar to those of spontaneous labor. B) Amniotomy decreases the chances of a prolapsed cord. C) Amniotomy reduces the pain of labor and makes it easier to manage. D) The client will not need an episiotomy

A) Contractions elicited are similar to those of spontaneous labor

The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse? A) "The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion." B) "The infant received too many red blood cells after delivery because the cord was not clamped immediately." C) "The yellow color of your baby's skin indicates that you are breastfeeding too often." D) "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should."

A) "The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion."

The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents do not seem to understand the explanation given by the physician. What statement by the nurse is best? A) "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." B) "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder." C) "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart." D) "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal."

A) "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body."

The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? A) 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory B) 23-year-old of low socioeconomic status, unmarried C) 16-year-old who began prenatal care at 30 weeks D) 28-year-old with a history of gestational diabetes

A) 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory

A client delivered 30 minutes ago. Which postpartal assessment finding would require close nursing attention? A) A soaked perineal pad since the last 15-minute check B) An edematous perineum C) The client experiencing tremors D) A fundus located at the umbilicus

A) A soaked perineal pad since the last 15-minute check

What condition is due to poor peripheral circulation? A) Acrocyanosis B) Mottling C) Harlequin sign D) Jaundice

A) Acrocyanosis

Before drying off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool? A) Amount and area of vernix coverage B) Creases on the sole C) Size of the areola D) Body surface temperature

A) Amount and area of vernix coverage

A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth? A) Arm recoil B) Square window sign C) Scarf sign D) Popliteal angle

A) Arm recoil

During a postpartum home visit, which step should the nurse take to establish a caring relationship? A) Ask family members how they want to be addressed. B) Do a portion of what the nurse agrees to do for the family, to avoid overwhelming them. C) Speak directly to the father when asking questions. D) Present information to the family instead of asking questions

A) Ask family members how they want to be addressed.

The nurse assesses the postpartum client to have moderate lochia rubra with clots. Which nursing intervention would be appropriate? A) Assess fundus and bladder status. B) Catheterize the client. C) Administer Methergine IM per order. D) Contact the physician immediately

A) Assess fundus and bladder status

The client delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration. Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this client? A) Assist the client to the bathroom in 2 hours to void. B) Place a Foley catheter now. C) Apply warm packs to the perineum three times a day. D) Allow the client to rest for the next 8 hours

A) Assist the client to the bathroom in 2 hours to void

The postpartum home care nurse has performed home visits to four breastfeeding mothers. Which mother is experiencing an expected outcome? A) Breasts are engorged; placing fresh cabbage leaves inside her bra B) Sore and cracked nipples; using hydrogel dressings to facilitate healing C) Breast engorgement; accompanied by erythema D) Concerns about milk supply; supplementing with formula

A) Breasts are engorged; placing fresh cabbage leaves inside her bra

Which of the following is a localized, easily identifiable soft area of the infant's scalp, generally resulting from a long and difficult labor or vacuum extraction? A) Caput succedaneum B) Cephalohematoma C) Molding D) Depressed fontanelles

A) Caput succedaneum

The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? A) Cephalohematoma B) Mongolian spots C) Telangiectatic nevi D) Molding

A) Cephalohematoma

The laboring client presses the call light and reports that her water has just broken. What would the nurse's first action be? A) Check fetal heart tones. B) Encourage the mother to go for a walk. C) Change bed linens. D) Call the physician

A) Check fetal heart tones

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? A) Chest circumference 31.5 cm, head circumference 33.5 cm B) Chest circumference 30 cm, head circumference 29 cm C) Chest circumference 38 cm, head circumference 31.5 cm D) Chest circumference 32.5 cm, head circumference 36 cm

A) Chest circumference 31.5 cm, head circumference 33.5 cm

Which nonspecific immune mechanism helps the ability of antibodies and phagocytic cells to clear pathogens from an organism? A) Complement B) Coagulation C) Inflammatory response D) Phagocytosis

A) Complement

A postpartum client has inflamed hemorrhoids. Which nursing intervention would be appropriate? A) Encourage sitz baths. B) Position the client in the supine position. C) Avoid stool softeners. D) Decrease fluid intake.

A) Encourage sitz baths

Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant? A) Fewer infants require blood transfusion for anemia B) Fewer infants require blood transfusion for high blood pressure C) Increase in the incidence of intraventricular hemorrhage D) Increase in incidence of infant breastfeeding

A) Fewer infants require blood transfusion for anemia

The community nurse is working with a client from Southeast Asia who has delivered her first child. Her mother has come to live with the family for several months. The nurse understands that the main role of the grandmother while visiting is to do which of the following? A) Help the new mother by allowing her to focus on resting and caring for the baby. B) Teach her son-in-law the right way to be a father because this is his first child. C) Make sure that her daughter does not become abusive towards the infant. D) Pass on cultural values and beliefs to the newborn grandchild

A) Help the new mother by allowing her to focus on resting and caring for the baby

The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of which of the following? A) Hyperventilation B) Seizure auras C) Imminent birth D) Anxiety

A) Hyperventilation

The nurse is reviewing charts of clients who underwent cesarean births by request in the last two years. The hospital is attempting to decrease costs of maternity care. What findings contribute to increased healthcare costs in clients undergoing cesarean birth by request? A) Increased abnormal placenta implantation in subsequent pregnancies B) Decreased use of general anesthesia with greater use of epidural anesthesia C) Prolonged anemia, requiring blood transfusions every few months D) Coordination of career projects of both partners leading to increased income

A) Increased abnormal placenta implantation in subsequent pregnancies

A breastfeeding postpartum client reports sore nipples to the nurse during a home visit. What intervention would be the highest priority? A) Infant positioning B) Use of the breast shield C) Use of breast pads D) Type of soap used

A) Infant positioning

The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require which of the following? A) Initial resuscitation B) Vigorous stimulation at birth C) Phototherapy immediately D) An initial feeding of iron-enriched formula

A) Initial resuscitation

A newborn has the following applied to the umbilical cord? *pic on back* What should the nurse instruct the new parents about regarding this device? A) It has to stay intact for at least one week B) It is removed in 24 hours if the cord has dried C) It eliminates the need to wash the infant's abdomen D) It is removed by cutting the tissue beneath the clamp

A) It has to stay intact for at least one week

The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern? A) Large amounts of uric acid crystals in the first days of life B) At least 6 to 10 wet diapers a day after the first few days of life C) 1 to 2 stools a day for a formula-fed baby D) Urine that is straw to amber color without foul smell

A) Large amounts of uric acid crystals in the first days of life

Two hours after delivery, a client's fundus is boggy and has risen to above the umbilicus. What is the first action the nurse would take? A) Massage the fundus until firm B) Express retained clots C) Increase the intravenous solution D) Call the physician

A) Massage the fundus until firm

The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus? A) Methylergonovine maleate (Methergine) B) Rh immune globulin (RhoGAM) C) Terbutaline (Brethine) D) Docusate (Colace)

A) Methylergonovine maleate (Methergine)

The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first? A) Mother of a 2-week-old infant who doesn't make eye contact when talked to B) Father of a 1-week-old infant who sleeps through the noise of an older sibling C) Father of a 6-day-old infant who responds more to mother's voice than to father's voice D) Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand

A) Mother of a 2-week-old infant who doesn't make eye contact when talked to

A variety of drugs are used either alone or in combination to provide relief of postpartum pain. Which of the following would be an option for pain relief? A) Nonsteroidal anti-inflammatory agents B) Proquad C) Methergine D) Intravenous oxytocin

A) Nonsteroidal anti-inflammatory agents

The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority? A) Obtain a blood calcium level. B) Take the newborn's temperature. C) Obtain a bilirubin level. D) Place a pulse oximeter on the newborn

A) Obtain a blood calcium level

The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurse's plan of care for this newborn? A) Offer early feedings. B) Administer an intravenous infusion of glucose. C) Assess for hypercalcemia. D) Assess for hyperbilirubinemia immediately after birth.

A) Offer early feedings

The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn? A) Offer early feedings with formula or breast milk. B) Provide glucose water exclusively. C) Evaluate blood glucose levels at 12 hours after birth. D) Assess for hyperthermia

A) Offer early feedings with formula or breast milk

The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother? A) Physiologic jaundice is normal, and peaks at this age. B) The newborn's liver is not working as well as it should. C) The baby is yellow because the bowels are not excreting bilirubin. D) The yellow color indicates that brain damage might be occurring

A) Physiologic jaundice is normal, and peaks at this age

The nurse knows that a contraindication to the induction of labor is which of the following? A) Placenta previa B) Isoimmunization C) Diabetes mellitus D) Premature rupture of membranes

A) Placenta previa

The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the client's chart requires immediate intervention? A) Previous birth by cesarean B) Frank breech ballotable C) 37 weeks, complete breech D) Failed ECV last week

A) Previous birth by cesarean

By inquiring about the expectations and plans that a laboring woman and her partner have for the labor and birth, the nurse is primarily doing which of the following? A) Recognizing the client as an active participant in her own care. B) Attempting to correct any misinformation the client might have received. C) Acting as an advocate for the client. D) Establishing rapport with the client.

A) Recognizing the client as an active participant in her own care

Which of the following conditions would predispose a client for thrombophlebitis? A) Severe anemia B) Cesarean delivery C) Anorexia D) Hypocoagulabilit

A) Severe anemia

The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. What information does teaching include? A) Specially prepared formulas B) Cataract problems C) Low glucose concentrations D) Administration of thyroid medication

A) Specially prepared formulas

The nurse is assessing the comfort of the parents during the third stage of labor. Which finding(s) indicate that the parents feel comfortable during this stage? Select all that apply. A) Talking to the newborn B) Verbally expressing feelings of pride C) Requesting to dim the lights D) Preferring limited contact with the newborn initially E) Immediately placing phone calls

A) Talking to the newborn B) Verbally expressing feelings of pride

The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? A) The newborn maintains a normal temperature B) An increase of serum bilirubin levels C) Weight loss D) Skin blanching yellow

A) The newborn maintains a normal temperature

A new mother at 36 hours post-delivery has asked to be discharged to home. The nurse explains that criteria for discharge before the newborn is 48 hours old include which of the following? A) The newborn's respiratory rate is less than 60/min. B) Singleton birth at a minimum 35 weeks' gestation. C) The newborn has passed at least three spontaneous stools. D) The newborn has normal and stable vital signs for 24 hours before discharge.

A) The newborn's respiratory rate is less than 60/min.

During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations? A) The rise and fall of the chest B) Sudden wakefulness C) Urinary output D) Adequate thermoregulation

A) The rise and fall of the chest

At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight? A) This weight loss is excessive. B) This weight loss is within normal limits. C) This weight gain is excessive. D) This weight gain is within normal limits.

A) This weight loss is excessive

The nurse administered oxytocin 20 units at the time of placental delivery. Why was this primarily done? A) To contract the uterus and minimize bleeding B) To decrease breast milk production C) To decrease maternal blood pressure D) To increase maternal blood pressure

A) To contract the uterus and minimize bleeding

After being in labor for several hours with no progress, a client is diagnosed with CPD (cephalopelvic disproportion), and must have a cesarean section. The client is worried that she will not be able to have any future children vaginally. After sharing this information with her care provider, the nurse would anticipate that the client would receive what type of incision? A) Transverse B) Infraumbilical midline C) Classic D) Vertical

A) Transverse

The nurse is observing a student nurse who is caring for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? A) Urine specific gravity is assessed at each voiding. B) Eye coverings are left off to help keep the baby calm. C) Temperature is checked every 6 hours. D) The infant is taken out of the isolette for diaper changes

A) Urine specific gravity is assessed at each voiding

A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. The nurse explains to the parents that due to oxygen therapy, their infant is at a greater risk for which of the following? A) Visual impairment B) Hyperthermia C) Central cyanosis D) Sensitive gag reflex

A) Visual impairment

The nurse is assessing a new mother 2 days after a normal vaginal delivery. The mother has chosen not to breastfeed. What would an abnormal finding be? A) Weight loss of 3 pounds B) Small amount of breast milk expressed C) Pink striae on the abdomen D) Lochia serosa

A) Weight loss of 3 pounds

The nurse is assessing clients after delivery. For which client is early discharge at 24 hours after delivery appropriate? A) Woman and baby who have had two successful breastfeedings B) Woman who is bottle-feeding her infant and has not voided since delivery C) Twins delivered at 35 weeks, bottle-feeding D) Cesarean birth performed for fetal distress

A) Woman and baby who have had two successful breastfeedings

The nurse has taken a detailed social history from a client admitted to the birthing unit. Which insights may the nurse gain as a result of this assessment? Select all that apply. A) Social habits B) Psychologic factors C) Presence of HIV D) Readiness for discharge E) Need for bed rest

A, B

A nurse suspects that a postpartum client has mastitis. Which data support this assessment? Select all that apply. A) Shooting pain between breastfeedings B) Late onset of nipple pain C) Pink, flaking, pruritic skin of the affected nipple D) Nipple soreness when the infant latches on E) Pain radiating to the underarm area from the breast

A, B, C

A postpartal client recovering from deep vein thrombosis is being discharged. What areas of teaching on self-care and anticipatory guidance should the nurse discuss with the client? Select all that apply. A) Avoid crossing the legs. B) Avoid prolonged standing or sitting. C) Take frequent walks. D) Take a daily aspirin dose of 650 mg. E) Avoid long car trips

A, B, C

The nurse is reviewing the contents of the birthing unit's emergency pack for use in case of a precipitous birth. Which item(s) should the nurse ensure is (are) included in the pack? Select all that apply. A) Sterile drape B) Bulb syringe C) Two sterile clamps D) Sterile gloves E) Forceps

A, B, C, D

A newborn who has not voided by 48 hours after birth should be assessed for which of the following? Select all that apply. A) Restlessness B) Pain C) Kidney distention D) Adequacy of fluid intake E) Lethargy

A, B, D

Marked changes that occur in the cardiopulmonary system at birth include which of the following? Select all that apply. A) Closure of the foramen ovale B) Closure of the ductus venosus C) Mean blood pressure of 31 to 61 mmHg in full-term resting newborns D) Increased systemic vascular resistance and decreased pulmonary vascular resistance E) Opening of the ductus arteriosus

A, B, D

The client is undergoing an emergency cesarean birth for fetal bradycardia. The client's partner has not been allowed into the operating room. What can the nurse do to alleviate the partner's emotional distress? Select all that apply. A) Allow the partner to wheel the baby's crib to the newborn nursery. B) Allow the partner to be near the operating room where the newborn's first cry can be heard. C) Have the partner wait in the client's postpartum room. D) Encourage the partner to be in the nursery for the initial assessment. E) Teach the partner how to take the client's blood pressure

A, B, D

The nurse tells a mother that the doctor is preparing to circumcise her newborn. The mother expresses concern that the infant will be uncomfortable during the procedure. The nurse explains that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure include which of the following? Select all that apply. A) Providing a pacifier B) Stroking the head C) Restraining both arms and legs D) Talking to the infant E) Giving the infant a sedative before the procedure

A, B, D

A client is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications? Select all that apply. A) Methergine B) Coumadin C) Misoprostol D) Serotonin reuptake inhibitors (SSRIs) E) Nonsteroidal anti-inflammatory drugs

A, C

A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Select all that apply. A) Gently massage the site after injection. B) Use a 22-gauge, 1-inch needle. C) Inject in the vastus lateralis muscle. D) Cleanse the site with alcohol prior to injection. E) Inject at a 45-degree angle.

A, C, D

The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following? Select all that apply. A) Lights can stay on all the time. B) The eyes do not need to be covered. C) The lights will need to be removed for feedings. D) Newborns do not get overheated. E) Weight loss is not a complication of this system

A, B, D, E

Which findings would indicate the presence of a perineal wound infection? Select all that apply. A) Redness B) Tender at the margins C) Vaginal bleeding D) Hardened tissue E) Purulent drainage

A, B, D, E

Risk factors associated with increased risk of thromboembolic disease include which of the following? Select all that apply. A) Diabetes mellitus B) Varicose veins C) Hypertension D) Adolescent pregnancy E) Malignancy

A, B, E

The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Indicators of normal labor include which of the following? Select all that apply. A) Fetal heart rate of 130 with average variability B) Blood pressure of 130/80 C) Maternal pulse of 160 D) Protein of +1 in urine E) Odorless, clear fluid on underwear

A, B, E

The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Select all that apply. A) The medication should be instilled in the lower conjunctival sac of each eye. B) The eyelids should be massaged gently to distribute the ointment. C) The medication must be given immediately after delivery. D) The medication does not cause any discomfort to the infant. E) The medication can interfere with the baby's ability to focus.

A, B, E

To maintain a healthy temperature in the newborn, which of the following actions should be taken? Select all that apply. A) Keep the newborn's clothing and bedding dry. B) Reduce the newborn's exposure to drafts. C) Do not use the radiant warmer during procedures. D) Do not wrap the newborn. E) Encourage the mother to snuggle with the newborn under blankets

A, B, E

Which of the following are potential disadvantages to breastfeeding? Select all that apply. A) Pain with breastfeeding B) Leaking milk C) Equal feeding responsibilities with fathers D) Vaginal wetness E) Embarrassment

A, B, E

Which statements by a breastfeeding class participant indicate that teaching by the nurse was effective? Select all that apply. A) "Breastfed infants get more skin-to-skin contact and sleep better." B) "Breastfeeding raises the level of a hormone that makes me feel good." C) "Breastfeeding is complex and difficult, and I probably won't succeed." D) "Breastfeeding is worthwhile, even if it costs more overall." E) "Breastfed infants have fewer digestive and respiratory illnesses."

A, B, E

A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability? Select all that apply. A) Newborns have less subcutaneous fat than do adults. B) Infants have a thick epidermis layer. C) Newborns have a large body surface to weight ratio. D) Infants have increased total body water. E) Newborns have more subcutaneous fat than do adults.

A, C, D

The nurse encourages a new mother to feed the newborn as soon as the newborn shows interest. The nurse bases this recommendation on which benefits of early feedings? Select all that apply. A) Early feedings stimulate peristalsis. B) Colostrum is thinner than mature milk. C) Early feedings enhance maternal-infant bonding. D) Early feedings promote the passage of meconium. E) Colostrum contains a high number of calories

A, C, D

The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing which of the following? Select all that apply. A) Respiratory rate B) Skin texture C) Airway clearance D) Ability to feed E) Head weight

A, C, D

The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for the newborn at home. Which instructions should the nurse emphasize? Select all that apply. A) Use proper hand-washing technique. B) Provide three feedings per day. C) Place soiled diapers in a sealed plastic bag. D) Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. E) Take the temperature rectally.

A, C, D

Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Select all that apply. A) Obtain skin cultures. B) Restrict parental visits. C) Evaluate bilirubin levels. D) Administer oxygen as ordered. E) Observe for signs of hypoglycemia

A, C, D, E

The incidence of complications and discomforts in the first year postpartum is common and women may experience which of the following? Select all that apply. A) Pain B) Excess energy C) Urinary incontinence D) Changes in mental health status E) Sleep deprivation

A, C, D, E

The nurse is caring for a client and her spouse during the third stage of labor. Which action(s) support initial parental-newborn attachment at this time? Select all that apply. A) Minimizing assessments B) Delaying ophthalmic antibiotics for 2 hours C) Dimming the room lights D) Talking quietly E) Providing privacy

A, C, D, E

The nurse is caring for a client who had a cesarean birth 4 hours ago. Which interventions would the nurse implement at this time? Select all that apply. A) Administer analgesics as needed. B) Encourage the client to ambulate to the bathroom to void. C) Encourage leg exercises every 2 hours. D) Encourage the client to cough and deep-breathe every 2 to 4 hours. E) Encourage the use of breathing, relaxation, and distraction

A, C, D, E

The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs? Select all that apply. A) Continual rise in temperature B) Decreased frequency of stools C) Absence of breathing longer than 20 seconds D) Lethargy E) Refusal of two feedings in a row

A, C, D, E

Which of the following are important behaviors to assess in the neurologic assessment? Select all that apply. A) State of alertness B) Active posture C) Quality of muscle tone D) Cry E) Motor activity

A, C, D, E

A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following? Select all that apply. A) The fontanelles can swell with crying. B) The fontanelles might be depressed. C) The fontanelles can pulsate with the heartbeat. D) The fontanelles might bulge. E) The fontanelles can swell when stool is passed.

A, C, E

Clinical features of posttraumatic stress disorder (PTSD) include which of the following? A) Difficulty sleeping B) Acute awareness C) Flashbacks D) The need to be constantly around others E) Irritability

A, C, E

The newborn's cry should have which of the following characteristics? Select all that apply. A) Medium pitch B) Shrillness C) Strength D) High pitch E) Lusty

A, C, E

The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? Select all that apply. A) Hyperirritability B) Decreased muscle tone C) Exaggerated reflexes D) Low pitched cry E) Transient tachypnea

A, C, E

The nurse is teaching experienced postpartum nurses about home care visits. Which statements indicate that teaching was effective? Select all that apply A) "I should tell the family to put any guns or knives away." B) "It is best to blend in with the community and not bring attention to myself on visits." C) "If I encounter a crime in progress, I should leave the area." D) "Wearing jewelry is a good way to demonstrate my professionalism." E) "Ignoring my 'gut' feelings might lead to an unsafe situation."

A, C, E

A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on which characteristics? Select all that apply. A) The mass appeared on the second day after birth. B) The mass appears larger when the newborn cries. C) The head appears asymmetrical. D) The mass appears on only one side of the head. E) The mass overrides the suture line.

A, D

Many newborns exposed to HIV/AIDS show signs and symptoms of disease within days of birth that include which of the following? Select all that apply. A) Swollen glands B) Hard stools C) Smaller than average spleen and liver D) Rhinorrhea E) Interstitial pneumonia

A, D, E

The nurse is caring for a postpartum client who is experiencing afterpains following the birth of her third child. Which comfort measure should the nurse implement to decrease her pain? Select all that apply. A) Offer a warm water bottle for her abdomen. B) Call the physician to report this finding. C) Inform her that this is not normal, and she will need an oxytocic agent. D) Administer a mild analgesic to help with breastfeeding. E) Administer a mild analgesic at bedtime to ensure rest

A, D, E

The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? Select all that apply. A) Physiologic jaundice occurs after 24 hours of age. B) Pathologic jaundice occurs after 24 hours of age. C) Phototherapy increases serum bilirubin levels. D) The need for phototherapy depends on the bilirubin level and age of the infant. E) Kernicterus causes irreversible neurological damage

A, E

To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following? A) Keep the baby in the room at all times. B) Check the identification of all personnel who transport the newborn. C) Place a "No Visitors" sign on the door. D) Keep the baby in the nursery at all times.

B) Check the identification of all personnel who transport the newborn

The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? A) Keep the infant NPO for 4 hours following the procedure. B) Observe for urine output. C) Wrap dry gauze tightly around the penis. D) Clean with cool water with each diaper change.

B) Observe for urine output

The student nurse notices that the newborn seems to focus on the mother's eyes. The nursing instructor explains that this newborn behavior is which of the following? A) Habituation B) Orientation C) Self-quieting D) Reactivity

B) Orientation

A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first? A) Stool characteristics B) Fluid intake C) Skin color D) Bilirubin level

C) Skin color

The home care nurse is seeing a client at 6 weeks postpartum. Which statement by the client indicates the need for immediate intervention? A) "The baby sleeps 7 hours each night now." B) "My flow is red, and I need to wear a pad." C) "My breasts no longer leak between feedings." D) "I started back on the pill 2 weeks ago."

B) "My flow is red, and I need to wear a pad."

A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant? A) Test with an HIV serologic test at 8 months. B) Begin prophylactic AZT (Zidovudine) administration. C) Provide 4 to 5 large feedings throughout the day. D) Encourage the mother to breastfeed the child

B) Begin prophylactic AZT (Zidovudine) administration

A new grandmother comments that when her children were born, they stayed in the nursery. The grandmother asks the nurse why her daughter's baby stays mostly in the room instead of the nursery. How should the nurse respond? A) "Babies like to be with their mothers more than they like to be in the nursery." B) "Contact between parents and babies increases attachment." C) "Budget cuts have decreased the number of nurses in the nursery." D) "Why do you ask? Do you have concerns about your daughter's parenting?"

B) "Contact between parents and babies increases attachment."

The client has been pushing for two hours, and is exhausted. The fetal head is visible between contractions. The physician informs the client that a vacuum extractor could be used to facilitate the delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance? A) "A small cup will be put onto the baby's head, and a gentle suction will be applied." B) "I can stop pushing and just rest if the vacuum extractor is used." C) "The baby's head might have some swelling from the vacuum cup." D) "The vacuum will be applied for a total of ten minutes or less."

B) "I can stop pushing and just rest if the vacuum extractor is used."

A postpartum client has just received a rubella vaccination. The client demonstrates understanding of the teaching associated with administration of this vaccine when she states which of the following? A) "I will need another vaccination in 3 months." B) "I must avoid getting pregnant for 1 month." C) "This will prevent me from getting chickenpox." D) "This will protect my newborn from getting the measles."

B) "I must avoid getting pregnant for 1 month."

The community nurse is working with poor women who are formula-feeding their infants. Which statement indicates that the nurse's education session was effective? A) "I should use only soy-based formula for the first year." B) "I should follow the instructions for mixing the powdered formula exactly." C) "It is okay to add more water to the formula to make it last longer." D) "The mixed formula can be left on the counter for a day."

B) "I should follow the instructions for mixing the powdered formula exactly."

The postpartum client expresses concern about getting back to her prepregnant shape, and asks the nurse when she will be able to run again. Which statement by the client indicates that teaching was effective? A) "I can start running in 2 weeks, and can breastfeed as soon as I am done." B) "I should see how my energy level is at home, and increase my activity slowly." C) "Running is not recommended for breastfeeding women." D) "If I am getting 8 hours of sleep per day, I can start running."

B) "I should see how my energy level is at home, and increase my activity slowly."

Which statement by a nursing student preparing to care for a postpartum lesbian mother would indicate that the student is prepared for the teaching? A) "I can't let the client know I've never worked with lesbian mothers." B) "I will have to adjust some of my discharge instruction for this mother." C) "I don't need to include the partner when I provide care and instruction." D) "Discharge teaching is exactly the same for lesbian mothers as for all others."

B) "I will have to adjust some of my discharge instruction for this mother."

Before applying a cord clamp, the nurse assesses the umbilical cord. The mother asks why the nurse is doing this. What should the nurse reply? A) "I'm checking the blood vessels in the cord to see whether it has one artery and one vein." B) "I'm checking the blood vessels in the cord to see whether it has two arteries and one vein." C) "I'm checking the blood vessels in the cord to see whether it has two veins and one artery." D) "I'm checking the blood vessels in the cord to see whether it has two arteries and two veins."

B) "I'm checking the blood vessels in the cord to see whether it has two arteries and one vein."

A multiparous client delivered her first child vaginally 2 years ago, and delivered an infant by cesarean yesterday due to breech presentation. Which statement would the nurse expect the client to make? A) "I can't believe how much more tired I was with the first baby." B) "I'm having significantly more pain this time than with my last birth." C) "It is disappointing that I can't breastfeed because of the cesarean." D) "Getting in and out of bed feels more comfortable than last time."

B) "I'm having significantly more pain this time than with my last birth."

The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected? A) "If I had taken better care of myself, this wouldn't have happened." B) "I've been sleeping very well since I had the baby." C) "This is probably the doctor's fault." D) "If I hadn't seen our baby's birth, I wouldn't believe she is ours."

B) "I've been sleeping very well since I had the baby."

The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction? A) "The en face position promotes bonding and attachment." B) "Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed." C) "In reciprocity, the interaction of mother and infant is mutually satisfying and synchronous." D) "The needs of the mother and of her infant are balanced during the phase of mutual regulation."

B) "Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed."

The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement by a parent indicates that teaching was effective? A) "My baby will be able to focus on my face when she is about a month old." B) "My baby might startle a little if a loud noise happens near him." C) "Newborns prefer sour tastes." D) "Our baby won't have a sense of smell until she is older."

B) "My baby might startle a little if a loud noise happens near him."

The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues? A) "I am so happy and blessed to have my new baby." B) "One minute I'm laughing and the next I'm crying." C) "My husband is helping out by changing the baby at night." D) "Breastfeeding is going quite well now that the engorgement is gone."

B) "One minute I'm laughing and the next I'm crying."

A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurse's best response? A) "I will call your pediatrician immediately." B) "Passage of the first stool within 48 hours is normal." C) "Your newborn might not have a stool until the third day." D) "Your newborn must be dehydrated."

B) "Passage of the first stool within 48 hours is normal."

The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them? A) "Jaundice is uncommon in newborns." B) "Some newborns require phototherapy." C) "Jaundice is a medical emergency." D) "Jaundice is always a sign of liver disease."

B) "Some newborns require phototherapy."

The nurse is working with a mother who has just delivered her third child at 33 weeks' gestation. The mother says to the nurse, "This baby doesn't turn her head and suck like the older two children did. Why?" What is the best response by the nurse? A) "Every baby is different. This is just one variation of normal that we see on a regular basis." B) "This baby might not have a rooting or sucking reflex because she is premature." C) "When she is wide awake and alert, she will probably root and suck even if she is early." D) "She might be too tired from the birthing process and need a couple of days to recover."

B) "This baby might not have a rooting or sucking reflex because she is premature."

The postpartum home care client asks the nurse why the visit is taking place. Which response is best? A) "We make home care visits to reinforce any teaching that you didn't quite grasp in the hospital." B) "We make home care visits to verify that both you and the baby are safe and doing well." C) "We make home care visits to ensure you are breastfeeding correctly." D) "We make home care visits to thoroughly assess your baby to make sure he is growing."

B) "We make home care visits to verify that both you and the baby are safe and doing well."

The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parent indicates that teaching was effective? A) "This condition occurs more frequently among Japanese people." B) "We must be very careful to avoid most proteins to prevent brain damage." C) "Carbohydrates can cause our baby to develop cataracts and liver damage." D) "Our baby's thyroid gland isn't functioning properly."

B) "We must be very careful to avoid most proteins to prevent brain damage."

The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." What response is best? A) "We'll take good care of you and your baby. You'll be home before you know it." B) "You'll be wearing a sequential compression device until you start walking." C) "You will have a lot of pain, but there are medications that we give when it gets really bad." D) "You won't be able to nurse until the baby is 12 hours old, because of your epidural."

B) "You'll be wearing a sequential compression device until you start walking."

The client with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse? A) "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." B) "Your body has made antibodies against the baby's blood that are destroying her red blood cells." C) "The red blood cells of your baby are breaking down because you both have type O blood." D) "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."

B) "Your body has made antibodies against the baby's blood that are destroying her red blood cells."

A new mother is holding her 2-hour-old son. The delivery occurred on the due date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurse's best response? A) "Don't worry. Babies go through a lot of these little phases." B) "Your son is in the sleep phase. He'll wake up soon." C) "Your son is exhausted from being born, and will sleep 6 more hours." D) "Your breastfeeding efforts have caused excessive fatigue in your son

B) "Your son is in the sleep phase. He'll wake up soon."

The neonate was born 5 minutes ago. The body is bluish. The heart rate is 150. The infant is crying strongly. The infant cries when the sole of the foot is stimulated. The arms and legs are flexed, and resist straightening. What should the nurse record as this infant's Apgar score? A) 7 B) 8 C) 9 D) 10

B) 8

The laboring client participated in childbirth preparation classes that strongly discouraged the use of medications and intervention during labor. The client has been pushing for two hours, and is exhausted. The physician requests that a vacuum extractor be used to facilitate the birth. The client first states that she wants the birth to be normal, then allows the vacuum extraction. Following this, what should the nurse assess the client for after the birth? A) Elation, euphoria, and talkativeness B) A sense of failure and loss C) Questions about whether or not to circumcise D) Uncertainty surrounding the baby's name

B) A sense of failure and loss

The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? A) Eyes are covered, no clothing on, diaper in place B) Axillary temperature 99.7°F C) Infant removed from the isolette for breastfeeding D) Loose bowel movement

B) Axillary temperature 99.7°F

The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dL to 16.6 mg/dL in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn? A) Continue to observe B) Begin phototherapy C) Begin blood exchange transfusion D) Stop breastfeeding

B) Begin phototherapy

A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse anticipate? A) Delivery of the neonate on its side with head up, to facilitate drainage of secretions. B) Direct tracheal suctioning by specially trained personnel. C) Preparation for the immediate use of positive pressure to expand the lungs. D) Suctioning of the oropharynx when the newborn's head is delivered

B) Direct tracheal suctioning by specially trained personnel

Forceps are being used to deliver the fetus of a laboring patient, as identified in the diagram. In which direction should the healthcare provider use the forceps to guide the fetus for delivery? A) Upward and outward B) Downward and outward C) Midline and towards the left D) Midline and toward the right

B) Downward and outward

The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this client? Select all that apply. A) Make sure she gets a kosher diet. B) Expect that most visitors will be women. C) Uncover only the necessary skin when assessing. D) The father will take an active role in infant care. E) She will prefer a male physician

B) Expect that most visitors will be women C) Uncover only the necessary skin when assessing

The postpartum client is suspected of having acute cystitis. Which symptoms would the nurse expect to see in this client? Select all that apply. A) High fever B) Frequency C) Suprapubic pain D) Chills E) Nausea and vomiting

B) Frequency C) Suprapubic pain

The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. What would be the first action of the nurse? A) Assist the client to empty her bladder B) Help the client back to bed to check the fundus C) Assess her blood pressure and pulse D) Begin an IV of lactated Ringer's solution

B) Help the client back to bed to check the fundus

Which of the following would be considered a clinical sign of hemorrhage? A) Increased blood pressure B) Increasing pulse C) Increased urinary output D) Hunger

B) Increasing pulse

A postpartum woman is at increased risk for developing urinary tract problems because of which of the following? A) Decreased bladder capacity B) Inhibited neural control of the bladder following the use of anesthetic agents C) Increased bladder sensitivity D) Abnormal postpartum diuresis

B) Inhibited neural control of the bladder following the use of anesthetic agents

One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate? A) Meticulous hand washing and antibiotic eye ointment administration. B) Intravenous acyclovir (Zovirax) and contact precautions. C) Cultures of blood and CSF and serial chest x-rays every 12 hours. D) Parental rooming-in and four intramuscular injections of penicillin

B) Intravenous acyclovir (Zovirax) and contact precautions

Mild or chronic anemia in an infant may be treated adequately by which of the following? A) Transfusions with O-negative or typed and cross-matched packed red cells B) Iron supplements or iron-fortified formulas C) Steroid therapy D) Antibiotics or antivirals

B) Iron supplements or iron-fortified formulas

Late preterm infants have higher infant morbidity and mortality rates than term infants. Which of the following complications can they experience? A) Hyperglycemia B) Jaundice C) Motor difficulties D) Sensory complications

B) Jaundice

The laboring client is having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a -2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? A) Encourage the husband to remain in the room. B) Keep the client on bed rest at this time. C) Apply an internal fetal scalp electrode. D) Obtain a clean-catch urine specimen.

B) Keep the client on bed rest at this time.

The nurse is making a postpartum home visit in the summer. The new father asks about taking the baby to a family outing this weekend. The nurse should encourage the father to do which of the following? A) Cover the infant with dark blankets to block the sun. B) Keep the infant in the shade. C) Uncover the infant's head to prevent hyperthermia. D) Avoid taking the infant outdoors for 6 months

B) Keep the infant in the shade

What is the primary carbohydrate in mammalian milk that plays a crucial role in the nourishment of the newborn? A) Colostrum B) Lactose C) Lactoferrin D) Secretory IgA

B) Lactose

The need for forceps has been determined. The client's cervix is dilated to 10 cm, and the fetus is at +2 station. What category of forceps application would the nurse anticipate? A) Input B) Low C) Mid D) Outlet

B) Low

A new mother is concerned about spoiling her newborn. The home care nurse teaches the mother which of the following? A) Newborns can be manipulative, so caution is advised. B) Meeting the infant's needs develops a trusting relationship. C) An infant who is rocked to sleep every night is being spoiled. D) Crying is good for babies, and letting them cry it out is advised.

B) Meeting the infant's needs develops a trusting relationship

A nurse is evaluating the diet plan of a breastfeeding mother. Which beverage is most likely to cause intolerance in the infant? A) Orange juice B) Milk C) Decaffeinated tea D) Water

B) Milk

The client presents for cervical ripening in anticipation of labor induction tomorrow. What should the nurse include in her plan of care for this client? A) Apply an internal fetal monitor. B) Monitor the client using electronic fetal monitoring. C) Withhold oral intake and start intravenous fluids. D) Place the client in an upright, sitting position

B) Monitor the client using electronic fetal monitoring

The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following? A) Adducting the foot and listening for a click. B) Moving the foot to midline and determining resistance. C) Extending the foot and observing for pain. D) Stimulating the sole of the foot.

B) Moving the foot to midline and determining resistance

The laboring client is at 7 cm, with the vertex at a +1 station. Her birth plan indicates that she and her partner took Lamaze prenatal classes, and they have planned on a natural, unmedicated birth. Her contractions are every 3 minutes and last 60 seconds. She has used relaxation and breathing techniques very successfully in her labor until the last 15 minutes. Now, during contractions, she is writhing on the bed and screaming. Her labor partner is rubbing the client's back and speaking to her quietly. Which nursing diagnosis should the nurse incorporate into the plan of care for this client? A) Fear/Anxiety related to discomfort of labor and unknown labor outcome B) Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent C) Coping: Family, Compromised, related to labor process D) Knowledge, Deficient, related to lack of information about normal labor process and comfort measures

B) Pain, Acute, related to uterine contractions, cervical dilatation, and fetal descent

What type of forceps are designed to be used with a breech presentation? A) Midforceps B) Piper C) Low D) High

B) Piper

An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care for the newborn at home. Which instructions should the nurse include? A) Do not add food supplements to the baby's diet. B) Place soiled diapers in a sealed plastic bag. C) Wash soiled linens in cool water with bleach. D) Shield the baby's eyes from bright lights

B) Place soiled diapers in a sealed plastic bag

In utero, what is the organ responsible for gas exchange? A) Umbilical vein B) Placenta C) Inferior vena cava D) Right atrium

B) Placenta

Upon delivery of the newborn, what nursing intervention most promotes parental attachment? A) Placing the newborn under the radiant warmer. B) Placing the newborn on the mother's abdomen. C) Allowing the mother a chance to rest immediately after delivery. D) Taking the newborn to the nursery for the initial assessment.

B) Placing the newborn on the mother's abdomen.

The physician has determined the need for forceps. The nurse should explain to the client that the use of forceps is indicated because of which of the following? A) Her support person is exhausted B) Premature placental separation C) To shorten the first stage of labor D) To prevent fetal distress

B) Premature placental separation

The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment? A) Lanugo mainly gone, little vernix across the body B) Prominent clitoris, enlarging minora, anus patent C) Full areola, 5 to 10 mm bud, pinkish-brown in color D) Skin opaque, cracking at wrists and ankles, no vessels visible

B) Prominent clitoris, enlarging minora, anus patent

A nurse is evaluating the diet plan of a breastfeeding mother, and determines that her intake of fruits and vegetables is inadequate. The nurse explains that the nutritional composition of the mother's breast milk can be adversely affected by this nutritional inadequacy. Which strategy should the nurse recommend to the mother? A) Stop breastfeeding B) Provide newborn supplements to the newborn C) Offer whole milk D) Supplement with skim milk

B) Provide newborn supplements to the newborn

The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be which of the following? A) Temperature 97.9°F B) Respirations 68 breaths/minute C) Stable vital signs 45 minutes ago D) Heart rate 156 beats/min

B) Respirations 68 breaths/minute

Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. What action should the nurse take? A) Answer questions quickly and try to divert her attention to other subjects. B) Review the documentation of the birth experience and discuss it with her. C) Contact the physician to warn him the client might want to file a lawsuit, based on her preoccupation with the birth experience. D) Submit a referral to Social Services because of possible obsessive behavior.

B) Review the documentation of the birth experience and discuss it with her

The nurse is working with a new mother who delivered yesterday. The mother has chosen to breastfeed her infant. Which demonstration of skill is the best indicator that the client understands breastfeeding? A) She puts the infant to breast when he is asleep to help wake him up. B) She takes off her gown to achieve skin-to-skin contact. C) She leans toward the infant so that he turns his head to access the nipple. D) The infant is crying when he is brought to the breast

B) She takes off her gown to achieve skin-to-skin contact

The nurse determines that a newborn has the following findings: Heart rate: 88 beats per minute Respirations: 24 per minute and irregular Muscle tone: Minor movement of lower extremities Reflex response: Grimace Skin color: Pink body, blue extremities Using APGAR, which action should the nurse take at this time? A) Begin resuscitation B) Stimulate the infant C) Document the findings D) Nasopharyngeal suctioning

B) Stimulate the infant The infant's Apgar score is 5. An Apgar score between 4 and 7 indicates the need for stimulation

The nurse is teaching a new mother how to encourage a sleepy baby to breastfeed. Which of the following instructions would not be included in that teaching? A) Providing skin-to-skin contact B) Swaddling the newborn in a blanket C) Unwrapping the newborn D) Allowing the newborn to feel and smell the mother's breast

B) Swaddling the newborn in a blanket

The home care nurse is examining a newborn who is sleeping on a pillow in a basket, covered with a fluffy blanket. There is also a stuffed animal in the basket. The most important nursing action to do is which of the following? A) Remove the stuffed animal from the basket and place it on the floor. B) Teach the parents the risk of SIDS from soft items in the infant's bed. C) Make certain that the blanket is firmly tucked under the baby. D) Ask whether the color of the blanket has cultural significance.

B) Teach the parents the risk of SIDS from soft items in the infant's bed.

The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data? A) Heart rate 120 B) Temperature 96.8°F C) Respiratory rate 50 D) Temperature 99.6°F

B) Temperature 96.8°F

What indications would lead the nurse to suspect sepsis in a newborn? A) Respiratory distress syndrome developing 48 hours after birth B) Temperature drops from 97.4°F to 97.0 2°F hours after 2 hours of warming. C) Irritability and flushing of the skin at 8 hours of age D) Bradycardia and tachypnea developing when the infant is 36 hours old

B) Temperature drops from 97.4°F to 97.0 2°F hours after 2 hours of warming

The nurse is training a nurse new to the labor and delivery unit. They are caring for a laboring client who will have a forceps delivery. Which action or assessment finding requires intervention? A) Regional anesthesia is administered via pudendal block. B) The client is instructed to push between contractions. C) Fetal heart tones are consistently between 110 and 115. D) The client's bladder is emptied using a straight catheter.

B) The client is instructed to push between contractions

The laboring client and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first? A) The sterile vaginal exam B) Welcoming the couple C) Auscultation of the fetal heart rate D) Checking for ruptured membranes

B) Welcoming the couple It is important to establish rapport and to create an environment in which the family feels free to ask questions. The support and encouragement of the nurse in maintaining a caring environment begins with the initial admission

The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal? Select all that apply. A) Respiratory rate of 66 breaths per minute B) Periodic breathing with pauses of 25 seconds C) Synchronous chest and abdomen movements D) Grunting on expiration E) Nasal flaring

B, D, E

Which of the following are considered risk factors for development of severe hyperbilirubinemia? Select all that apply. A) Northern European descent B) Previous sibling received phototherapy C) Gestational age 27 to 30 weeks D) Exclusive breastfeeding E) Infection

B, D, E

The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Select all that apply. A) Lanugo abundant over shoulders and back B) Plantar creases over entire sole C) Pinna of ear springs back slowly when folded. D) Vernix well distributed over entire body E) Testes are pendulous, and the scrotum has deep rugae

B, E

The client demonstrates understanding of the implications for future pregnancies secondary to her classic uterine incision when she states which of the following? A) "The next time I have a baby, I can try to deliver vaginally." B) "The risk of rupturing my uterus is too high for me to have any more babies." C) "Every time I have a baby, I will have to have a cesarean delivery." D) "I can only have one more baby."

C) "Every time I have a baby, I will have to have a cesarean delivery."

The nurse is providing education to the new family. Which question by the nurse is best? A) "Do you know how to give the baby a bath?" B) "You have diapers and supplies at home, right?" C) "How have your breastfeedings been going?" D) "How much formal education do you have?"

C) "How have your breastfeedings been going?"

The community nurse is working with a client whose only child is 8 months old. Which statement does the nurse expect the mother to make? A) "I have a lot more time to myself than I thought I would have." B) "My confidence level in my parenting is higher than I anticipated." C) "I am constantly tired. I feel like I could sleep for a week." D) "My baby likes everyone, and never fusses when she's held by a stranger."

C) "I am constantly tired. I feel like I could sleep for a week."

A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? A) "I can't believe he can already digest fats, carbohydrates, and proteins." B) "It is amazing that his whole digestive tract can move things along at birth." C) "Incredibly, his stomach capacity was already a cupful when he was born." D) "He will lose some weight but then miraculously regain it by about 10 days."

C) "Incredibly, his stomach capacity was already a cupful when he was born."

The labor and birth nurse is admitting a client. The nurse's assessment includes asking the client whom she would like to have present for the labor and birth, and what the client would prefer to wear. The client's partner asks the nurse the reason for these questions. What would the nurse's best response be? Select all that apply. A) "These questions are asked of all women. It's no big deal." B) "I'd prefer that your partner ask me all the questions, not you." C) "A client's preferences for her birth are important for me to understand." D) "Many women have beliefs about childbearing that affect these choices." E) "I'm gathering information that the nurses will use after the birth."

C) "A client's preferences for her birth are important for me to understand." D) "Many women have beliefs about childbearing that affect these choices."

The client is being admitted to the birthing unit. As the nurse begins the assessment, the client's partner asks why the fetus's heart rate will be monitored. After the nurse explains, which statement by the partner indicates a need for further teaching? A) "The fetus's heart rate will vary between 110 and 160." B) "The heart rate is monitored to see whether the fetus is tolerating labor." C) "By listening to the heart, we can tell the gender of the fetus." D) "After listening to the heart rate, you will contact the midwife."

C) "By listening to the heart, we can tell the gender of the fetus."

The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse? A) "Circumcision should be undertaken to prevent problems in the future." B) "Circumcision might decrease the child's risk of developing a urinary tract infection." C) "Circumcision can sometimes cause complications. What questions do you have?" D) "Circumcision is painful, and should be avoided unless you are Jewish."

C) "Circumcision can sometimes cause complications. What questions do you have?"

Which statement by a new mother 1 week postpartum indicates maternal role attainment? A) "I don't think I'll ever know what I'm doing." B) "This baby feels like a real stranger to me." C) "It works better for me to undress the baby and to nurse in the chair rather than the bed." D) "My sister took to mothering in no time. Why can't I?"

C) "It works better for me to undress the baby and to nurse in the chair rather than the bed."

The breastfeeding client asks the nurse about appropriate contraception. What is the nurse's best response? A) "Breastfeeding has many effects on sexual intercourse." B) "IUDs are easy to use and easy to insert prior to sexual intercourse." C) "It's possible to get pregnant before your menstrual period returns. Let's talk about some different options for contraception." D) "Breastfeeding hampers ovulation, so no contraception is needed."

C) "It's possible to get pregnant before your menstrual period returns. Let's talk about some different options for contraception."

The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement? A) "I should expect a lighter flow next week." B) "The flow will increase if I am too active." C) "My bleeding will remain red for about a month." D) "I will be able to use a pantiliner in a day or two."

C) "My bleeding will remain red for about a month."

A new father asks the nurse to describe what his baby will experience while sleeping and awake. What is the best response? A) "Babies have several sleep and alert states. Keep watching and you'll notice them." B) "You might have noticed that your child was in an alert awake state for an hour after birth." C) "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." D) "Birth is hard work for babies. It takes them a week or two to recover and become more awake."

C) "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep."

The nurse is preparing a class for mothers who have just recently delivered and their partners. One topic of the class is infant attachment. Which statement by a participant indicates an understanding of this concept? Select all that apply. A) "We should avoid holding the baby too much." B) "Looking directly into the baby's eyes might frighten him." C) "Talking to the baby is good because he'll recognize our voices." D) "Holding the baby so we have direct face-to-face contact is good." E) "We should only touch the baby with our fingertips for the first month."

C) "Talking to the baby is good because he'll recognize our voices." D) "Holding the baby so we have direct face-to-face contact is good."

A young adolescent is transferred to the labor and delivery unit from the emergency department. The client is in active labor, but did not know she was pregnant. What is the most important nursing action? A) Determine who might be the father of the baby for paternity testing. B) Ask the client what kind of birthing experience she would like to have. C) Assess blood pressure and check for proteinuria. D) Obtain a Social Services referral to discuss adoption.

C) Assess blood pressure and check for proteinuria

New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant? A) The foreskin will be retractable at 2 months. B) Retract the foreskin and clean thoroughly. C) Avoid retracting the foreskin. D) Use soap and Betadine to cleanse the penis daily

C) Avoid retracting the foreskin

Induction of labor is planned for a 31-year-old client at 39 weeks due to insulin-dependent diabetes. Which nursing action is most important? A) Administer 100 mcg of misoprostol (Cytotec) vaginally every 2 hours. B) Place dinoprostone (Prepidil) vaginal gel and ambulate client for 1 hour. C) Begin Pitocin (oxytocin) 4 hours after 50 mcg misoprostol (Cytotec). D) Prepare to induce labor after administering a tap water enema.

C) Begin Pitocin (oxytocin) 4 hours after 50 mcg misoprostol (Cytotec)

A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best? A) Begin chest compressions. B) Begin direct tracheal suctioning. C) Begin bag-and-mask ventilation. D) Obtain a blood pressure reading

C) Begin bag-and-mask ventilation.

A client from Mexico has just delivered a son, and the nurse offers to assist in putting the baby to breast. Although the client indicated before the birth that she wanted to breastfeed, she is very hesitant, and says she would like to bottle-feed for the first few days. After talking to her, the nurse understands that her primary reason for wanting to delay breastfeeding is based on what cultural belief? A) Breast milk causes skin rashes. B) It is harmful to breastfeed immediately. C) Colostrum is bad for the baby. D) Thin milk causes diarrhea.

C) Colostrum is bad for the baby

The nurse is observed performing the following with a patient: *one hand on top of fundus, other underneath* What information will this assessment technique provide to the nurse? A) Assesses for bladder distention B) Estimates the weight of the uterus C) Determines the height of the fundus D) Evaluates the remaining placenta contents

C) Determines the height of the fundus

The postpartum client is about to go home. The nurse includes which subject in the teaching plan? A) Replacement of fluids B) Striae C) Diastasis of the recti muscles D) REEDA scale

C) Diastasis of the recti muscles

A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding? A) Call the physician. B) Administer oxygen. C) Document the finding. D) Place the newborn under the radiant warmer

C) Document the finding

The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following? A) Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline B) Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body C) Ear cartilage folded over, lanugo present over much of the body, slow recoil time D) 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

C) Ear cartilage folded over, lanugo present over much of the body, slow recoil time

A laboring client's obstetrician has suggested amniotomy as a method for inducing labor. Which assessment(s) must be made just before the amniotomy is performed? A) Maternal temperature, BP, and pulse B) Estimation of fetal birth weight C) Fetal presentation, position, station, and heart rate D) Biparietal diameter

C) Fetal presentation, position, station, and heart rate

The postpartum client is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse can teach include which of the following? A) Wearing a tight-fitting bra B) Limiting breastfeedings C) Frequent breastfeedings D) Restricting fluid intake

C) Frequent breastfeedings

The postpartum client has chosen to bottle-feed her infant. Nursing actions that aid in lactation suppression include which of the following? A) Warm showers B) Pumping milk C) Ice packs to each breast D) Avoiding wearing a bra for 5 to 7 days

C) Ice packs to each breast

The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do? A) Document the findings. B) Catheterize the client. C) Massage the uterine fundus until it is firm. D) Call the physician immediatel

C) Massage the uterine fundus until it is firm.

A postpartum client reports sharp, shooting pains in her nipple during breastfeeding and flaky, itchy skin on her breasts. Which of the following does the nurse suspect? A) Nipple soreness B) Engorgement C) Mastitis D) Letdown reflex

C) Mastitis

Major perineal trauma (extension to or through the anal sphincter) is more likely to occur if what type of episiotomy is performed? A) Mediolateral B) Episiorrhaphy C) Midline D) Medical

C) Midline

When is breastfeeding contraindicated? A) Infant has hypertension B) Mother has a history of treated tuberculosis C) Mother is HIV positive or has AIDS D) Mother has a history of treated herpes

C) Mother is HIV positive or has AIDS

An expectant father has been at the bedside of his laboring partner for more than 12 hours. An appropriate nursing intervention would be which of the following? A) Insist that he leave the room for at least the next hour. B) Tell him he is not being as effective as he was, and that he needs to let someone else take over. C) Offer to remain with his partner while he takes a break. D) Suggest that the client's mother might be of more help.

C) Offer to remain with his partner while he takes a break

The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse? A) Asking the client to void and donning clean gloves B) Listening to bowel sounds and then asking when her last bowel movement occurred C) Offering the patient pre-medication 2 hours before the assessment D) Completing the assessment and explaining the results to the client

C) Offering the patient pre-medication 2 hours before the assessment

To prevent sudden infant death syndrome (SIDS), the nurse encourages the parents of a term infant to place the infant in which position when the infant is sleeping? A) On the parents' waterbed B) Swaddled in the infant swing C) On the back D) On the sides

C) On the back

The nurse should explain to new parents that their infant's position should be changed periodically during the early months of life to prevent which of the following? A) Muscle contractures B) Respiratory distress C) Permanently flattened areas of the skull D) Esophageal reflux

C) Permanently flattened areas of the skull

When a breastfeeding mother complains that her breasts are leaking milk, the nurse can offer which effective intervention? A) Decrease the number of minutes the newborn is at the breast per feeding. B) Decrease the mother's fluid intake. C) Place absorbent pads in the bra. D) Administer oxytocin.

C) Place absorbent pads in the bra.

The postpartum client states that she doesn't understand why she can't enjoy being with her baby. What would the nurse be concerned about? A) Postpartum psychosis B) Postpartum infection C) Postpartum depression D) Postpartum blues

C) Postpartum depression

The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart? A) Preterm appropriate for gestational age, symmetrical IUGR B) Term small for gestational age, symmetrical IUGR C) Preterm small for gestational age, asymmetrical IUGR D) Preterm appropriate for gestational age, asymmetrical IUGR

C) Preterm small for gestational age, asymmetrical IUGR

The nurse is planning a home care visit to a mother who just recently delivered. The neighborhood is known to have a significant crime rate. What should the nurse do when planning this visit to facilitate personal safety? A) Be friendly to all pets encountered on the visit to build client rapport. B) Wait to find the exact location until arrival in the neighborhood. C) Put personal possessions in the trunk when leaving the office. D) Wear flashy jewelry to garner respect.

C) Put personal possessions in the trunk when leaving the office

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following signs and symptoms would not be characteristic of RDS? A) Grunting respirations B) Nasal flaring C) Respiratory rate of 40 during sleep D) Chest retractions

C) Respiratory rate of 40 during sleep

The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention? A) Increased skin temperature and respirations B) Blood glucose level of 45 C) Room-temperature IV running D) Positioned under radiant warmer

C) Room-temperature IV running

A client who wishes to have an unmedicated birth is in the transition stage. She is very uncomfortable and turns frequently in the bed. Her partner has stepped out momentarily. How can the nurse be most helpful? A) Talk to the client the entire time. B) Turn on the television to distract the client. C) Stand next to the bed with hands on the railing next to the client. D) Sit silently in the room away from the bed.

C) Stand next to the bed with hands on the railing next to the client

A client's labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse do? A) Go to the nurse's station and immediately call the physician. B) Run to the delivery room for an emergency birth pack. C) Stay with the client and ask auxiliary personnel for assistance. D) Hold back the infant's head forcibly until the physician arrives for the delivery.

C) Stay with the client and ask auxiliary personnel for assistance

The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. Which of the following assessment findings is not congruent with prematurity? A) Cry is weak and feeble B) Clitoris and labia minora are prominent C) Strong sucking reflex D) Lanugo is plentiful

C) Strong sucking reflex

The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what? A) Hold the newborn in an upright position. B) Massage the hands and feet. C) Swaddle the newborn in a blanket. D) Make eye contact while talking to the newborn

C) Swaddle the newborn in a blanket

The nurse suspects that a client has developed a perineal hematoma. What assessment findings would lead the nurse to this conclusion? A) Facial petechiae B) Large, soft hemorrhoids C) Tense tissues with severe pain D) Elevated temperature

C) Tense tissues with severe pain

The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? A) 37-week male, respiratory rate 45 B) 8 pound 1 ounce female, pulse 150 C) Term male, nasal flaring D) 4-hour-old female who has not voided

C) Term male, nasal flaring

What is the advantage of a client using a patient-controlled analgesia (PCA) following a cesarean birth? A) The client receives a bolus of the analgesia when pressing the button. B) The client experiences pain relief within 30 minutes. C) The client feels a greater sense of control, and is less dependent on the nursing staff. D) The client can deliver as many doses of the medication as needed.

C) The client feels a greater sense of control, and is less dependent on the nursing staff

The client has been pushing for 2 hours and is exhausted. The physician is performing a vacuum extraction to assist the birth. Which finding is expected and normal? A) The head is delivered after eight "pop-offs" during contractions. B) A cephalohematoma is present on the fetal scalp. C) The location of the vacuum is apparent on the fetal scalp after birth. D) Positive pressure is applied by the vacuum extraction during contractions

C) The location of the vacuum is apparent on the fetal scalp after birth

A mother states that her breasts leak between feedings. Which of the following can contribute to the letdown reflex in breastfeeding mothers? A) Pain with breastfeeding B) Number of hours passed since last feeding C) The newborn's cry D) Maternal fluid intake

C) The newborn's cry

The nurse is caring for a 15-year-old client who gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent? A) The client's mother is included in all discussions and demonstrations. B) The father of the baby is encouraged to change a diaper and give a bottle. C) The nurse explains the characteristics and cues of the baby when assessing him. D) A discussion on contraceptive methods is the first topic of teaching.

C) The nurse explains the characteristics and cues of the baby when assessing him.

The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? A) The student nurse listens to bowel sounds, then assesses the head for skull consistency and size and tension of fontanelles. B) The student nurse checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate. C) The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. D) The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

C) The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet

On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to which of the following? A) The taking-hold phase B) Postpartum hemorrhage C) The taking-in period D) Epidural anesthesia

C) The taking-in period

Before a newborn and mother are discharged from the hospital, the nurse informs the parents about routine screening tests for newborns. What is a good reason for having the screening tests done? A) The tests prevent infants from developing phenylketonuria. B) The tests detect such disorders as hypertension and diabetes. C) The tests detect disorders that cause physical, intellectual, and developmental complications or death if left undiscovered. D) The tests prevent sickle-cell anemia, galactosemia, and homocystinuria.

C) The tests detect disorders that cause physical, intellectual, and developmental complications or death if left undiscovered

The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? A) Conjugated bilirubin is eliminated in the conjugated state. B) Unconjugated bilirubin is neurotoxic, and cannot cross the placenta. C) Total bilirubin is the sum of the direct and indirect levels. D) Hyperbilirubinemia is a decreased total serum bilirubin level.

C) Total bilirubin is the sum of the direct and indirect levels

A client is admitted to the labor and delivery unit with contractions that are regular, are 2 minutes apart, and last 60 seconds. She reports that her labor began about 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presenting, with the cervix 100% effaced and 8 cm dilated. The client asks what part of labor she is in. The nurse should inform the client that she is in what phase of labor? A) Latent phase B) Active phase C) Transition phase D) Fourth stage

C) Transition phase The transition phase begins with 8 cm of dilatation, and is characterized by contractions that are closer and more intense

The nurse is preparing a teaching brochure for Spanish-speaking postpartum clients. Which topics are critical for this population? A) Baby baths and birth certificates B) Hygiene practices C) When and how to contact their healthcare provider D) Pain-relief options in labor and after birth

C) When and how to contact their healthcare provider

Clinical risk factors for severe hyperbilirubinemia include which of the following? Select all that apply. A) African American ethnicity B) Female gender C) Cephalohematoma D) Bruising E) Assisted delivery with vacuum or forceps

C, D, E

The nurse is meeting with a new mother for the first time during a home visit. The client delivered her first child 3 days ago. She had a normal pregnancy and a vaginal delivery. The infant is breastfeeding. Which statements by the mother indicate that she needs more information about the home visit? Select all that apply. A) "You are going to check my baby's weight." B) "You are going to watch me nurse the baby and give me tips." C) "You are going to teach my mother about the baby." D) "You are checking for safety issues when my son starts crawling." E) "You are going to take blood samples from me and my son."

C, D, E

The nurse is planning discharge teaching for a postpartum woman. What recommendations should the woman receive before being discharged? Select all that apply. A) To abstain from sexual intercourse for 6 months B) To avoid showers for 4 weeks C) To avoid overexertion D) To practice postpartum exercises E) To obtain adequate rest

C, D, E

A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurse's best response? A) "Take your newborn to the pediatrician." B) "There might be a possible food allergy." C) "Your newborn has diarrhea." D) "This is a normal occurrence."

D) "This is a normal occurrence."

The nurse is explaining the nutritional differences between breast milk and formula to an expectant couple. The mother-to-be asks whether breast milk is nutritionally superior to formula. What should the nurse reply? A) The vitamins and minerals in formula are more bioavailable to the infant. B) There is no cholesterol in breast milk. C) The only carbohydrate in breast milk is lactose. D) The ratio of whey to casein proteins in breast milk changes to meet the nutritional needs of the growing infant

D) The ratio of whey to casein proteins in breast milk changes to meet the nutritional needs of the growing infant

The nurse is working with a client from Southeast Asia. The client tells the nurse that she should not put the baby to breast until her milk comes in and her breasts are warm, because "cold milk" (colostrum) is bad for the baby. After the nurse explains the benefits of colostrum, the client still insists that "cold milk" is bad. Which response by the nurse is best? A) "What kind of formula would you like to use?" B) "That idea is folklore. Colostrum is good for the baby." C) "Now that you are here, you need to feed your baby the right way." D) "Let's give the baby formula after you breastfeed."

D) "Let's give the baby formula after you breastfeed."

The nurse is teaching a group of new parents about newborn behavior. Which statement made by a parent would indicate a need for additional information? A) "Sleep and alert states cycle throughout the day." B) "We can best bond with our child during an alert state." C) "About half of the baby's sleep time is in active sleep." D) "Babies sleep during the night right from birth."

D) "Babies sleep during the night right from birth."

The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. What is the nurse's best response? A) "We see this from time to time. It's not a big deal." B) "The gush is an indication that your fundus isn't contracting." C) "Don't worry. I'll make sure everything is fine." D) "Blood pooled in the vagina while you were in bed."

D) "Blood pooled in the vagina while you were in bed."

The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn? A) "You appear to be Muslim. Do you want your son circumcised?" B) "Let me explain newborn care here in the United States." C) "Your baby is a United States citizen. You must be very happy about that." D) "Could you explain your preferences regarding childrearing?"

D) "Could you explain your preferences regarding childrearing?"

The parents of a newborn comment to the nurse that their infant seems to enjoy being held, and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents' learning. Which statement indicates that teaching was effective? A) "Some babies are easier to deal with than others." B) "We are lucky to have a baby with a calm disposition." C) "Our baby spends more time in the active alert phase." D) "Cuddliness is a social behavior that some babies have."

D) "Cuddliness is a social behavior that some babies have."

Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? A) "Our baby's heart murmur is from this syndrome." B) "He might be a fussy baby because of this." C) "His face looks like it does due to this problem." D) "Cuddling and rocking will help him stay calm."

D) "Cuddling and rocking will help him stay calm."

The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? A) "I should avoid looking directly into the baby's eyes to prevent frightening the baby." B) "My baby will be very sleepy immediately after birth and should go to the nursery." C) "Newborns cannot focus their eyes, so it doesn't matter how I hold my new baby." D) "Giving my baby his first bath can really give me a chance to get to know him."

D) "Giving my baby his first bath can really give me a chance to get to know him."

The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement by the client indicates that further information is required? A) "Because I have a midline episiotomy, I should keep my perineum clean." B) "I can use an ice pack to relieve some the pain from the episiotomy." C) "I can take ibuprofen (Motrin) when my perineum starts to hurt." D) "The tear I have through my rectum is unrelated to my episiotomy."

D) "The tear I have through my rectum is unrelated to my episiotomy."

The client delivered her second child yesterday, and is preparing to be discharged. She expresses concern to the nurse because she developed an upper urinary tract infection (UTI) after the birth of her first child. Which statement indicates that the client needs additional teaching about this issue? A) "If I start to have burning with urination, I need to call the doctor." B) "Drinking 8 glasses of water each day will help prevent another UTI." C) "I will remember to wipe from front to back after I move my bowels." D) "Voiding 2 or 3 times per day will help prevent a recurrence."

D) "Voiding 2 or 3 times per day will help prevent a recurrence."

The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information? A) "The baby should be in the back seat." B) "Newborns must be in rear-facing car seats." C) "We need instruction on how to use the car seat before installing it." D) "We can bring the baby home from the hospital without a car seat, as it is only a short drive."

D) "We can bring the baby home from the hospital without a car seat, as it is only a short drive."

The nurse is working with an adolescent mother who tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." What is the best response by the nurse? A) "You are very young, and parenting will be a challenge for you." B) "Your mother was probably right. Be very careful with your baby." C) "Mothers have instincts that kick in when they get their babies home." D) "We can give the baby a bath together. I'll help you learn how to do it."

D) "We can give the baby a bath together. I'll help you learn how to do it."

The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best? A) "I'll bring you to your baby and then leave so you can have some privacy." B) "Your baby is on a ventilator with 50% oxygen, and has an umbilical line." C) "I am so sorry this has all happened. I know how stressful this can be." D) "Your baby is working hard to breathe and lying quite still, and has an IV."

D) "Your baby is working hard to breathe and lying quite still, and has an IV."

The nurse is planning visits to the homes of new parents and their newborns. Which client should the nurse see first? A) 3-day-old male who received hepatitis B vaccine prior to discharge B) 4-day-old female whose parents are both hearing-impaired C) 5-day-old male with light, sticky, yellow drainage on the circumcision site D) 6-day-old female with greenish discharge from the umbilical cord site

D) 6-day-old female with greenish discharge from the umbilical cord site

Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void frequently? A) A full bladder impedes oxygen flow to the fetus. B) Frequent voiding prevents bruising of the bladder. C) Frequent voiding encourages sphincter control. D) A full bladder can impede fetal descent.

D) A full bladder can impede fetal descent

The hospital is developing a new maternity unit. What aspects should be included in the planning of the new unit to best promote family wellness? A) Normal newborn nursery centrally located to all client rooms B) A kitchen with a refrigerator stocked with juice and sandwiches C) Small, cozy rooms with a client bed and rocking chair D) A nursing care model based on providing couplet care

D) A nursing care model based on providing couplet care

The postpartum home care nurse is assessing a new mother, and finds her temperature to be 101.6°F. What is the most important nursing action? A) Ask the mother how often and how well the baby is nursing. B) Determine the frequency of the mother's voiding and stooling. C) Verify how many hours of sleep she is getting per day. D) Assess the odor and color of the lochia and perineum

D) Assess the odor and color of the lochia and perineum

Nurses should educate parents about which of the following AAP recommendations to promote a safe sleep environment and decrease the risk of SIDS and SUID in infants less than 12 months of age? A) Babies should not be offered a pacifier while falling asleep. B) Babies should be bottle-fed unless contraindicated. C) Babies should be under many covers when sleeping to keep them warm. D) Babies should have "tummy time" when they are awake.

D) Babies should have "tummy time" when they are awake.

As compared with admission considerations for an adult woman in labor, the nurse's priority for an adolescent in labor would be which of the following? A) Cultural background B) Plans for keeping the infant C) Support persons D) Developmental level

D) Developmental level

How does the nurse assess for Homans' sign? A) Extending the foot and inquiring about calf pain. B) Extending the leg and inquiring about foot pain. C) Flexing the knee and inquiring about thigh pain. D) Dorsiflexing the foot and inquiring about calf pain

D) Dorsiflexing the foot and inquiring about calf pain

A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment? A) Decreased urine output B) Pulmonary vascular resistance increases C) Increased PCO2 D) Increased urination

D) Increased urination

To actively involve the postpartal client during discharge teaching, the postpartum nurse applies which learning principle? A) Reprints of magazine articles B) Classroom lectures C) Audiotapes D) Interactive nurse-patient relationships

D) Interactive nurse-patient relationships

The client has stated that she wants to avoid an epidural and would like an unmedicated birth. Which nursing action is most important for this client? A) Encourage the client to vocalize during contractions. B) Perform vaginal exams only between contractions. C) Provide a CD of soft music with sounds of nature. D) Offer to teach the partner how to massage tense muscles

D) Offer to teach the partner how to massage tense muscles

The nurse caring for a postterm newborn would not perform what intervention? A) Providing warmth B) Frequently monitoring blood glucose C) Observing respiratory status D) Restricting breastfeeding

D) Restricting breastfeeding

The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention? A) At rest, the infant has partially flexed arms and the legs drawn up to the abdomen. B) When the corner of the mouth is touched, the infant turns the head that direction. C) The infant blinks when the exam light is turned on over the face and body. D) The right arm is flaccid while the infant brings the left arm and fist upward to the head

D) The right arm is flaccid while the infant brings the left arm and fist upward to the head

A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dL. What is the best nursing action? A) To recheck the blood sugar in 6 hours B) To begin an IV of 10% dextrose C) To feed the baby 1 ounce of formula D) To document the findings in the chart

D) To document the findings in the chart

The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect? A) Apical heart rate of 140 beats per minute B) Respiratory rate of 40 C) Temperature of 36.5°C D) Visible, blue discoloration of the skin

D) Visible, blue discoloration of the skin