Newborn

A nurse is to care for a client during the postpartum period. The client reports pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? Select all that apply. A. Breasts are hard. B. Breasts are tender. C. Nipples are fissured. D. Nipples are cracked. E. Breasts are soft.

A. Breasts are hard. B. Breasts are tender.

At what point should the nurse expect a healthy newborn to pass meconium? A. before birth B. within 1 to 2 hours of birth C. by 12 to 18 hours of life D. within 24 hours after birth

D. within 24 hours after birth

A newborn develops physiologic jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate? A. "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed." B. "There is some type of blood incompatibility between you and your baby that's causing the problem." C. "Your baby must have a blocked duct near his liver that's preventing the bilirubin from being excreted." D. "We really don't know why jaundice develops in some babies and not in others. We just know how to treat it."

A. "Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed."

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention? A. 30 mg/dL (1.67 mmol/L) B. 53 mg/dL (2.94 mmol/L) C. 70 mg/dL (3.89 mmol/L) D. 90 mg/dL (5.00 mmol/L)

A. 30 mg/dL (1.67 mmol/L)

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

A. Document the finding, as it is a normal finding at this time.

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery? A. To monitor the mother's blood pressure to note any elevations B. To check for postpartum hemorrhage C. To determine if the mother's milk is coming in D. To answer questions the new parents may have

B. To check for postpartum hemorrhage

A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on which information? Select all that apply. A. Labor of 1 1/2 hours B. Labor induction with oxytocin C. Forceps birth D. Third stage of labor of 10 minutes E. Hemoglobin 8.0 g/dL (80.0 g/L)

A. Labor of 1 1/2 hours B. Labor induction with oxytocin C. Forceps birth

What is the best way for the nurse to assess the newborn's heartbeat? A. auscultating the apical pulse for 60 seconds B. auscultating the apical pulse for 30 seconds and multiplying by 2 C. palpating the brachial pulse for 60 seconds D. palpating the femoral pulse for 30 seconds and multiplying by 2

A. auscultating the apical pulse for 60 seconds

A nursing student observes that the babies in the nursery are wrapped up warmly and are wearing knit caps. Which explanation by the nursery staff would be correct? A. "The caps and blankets simulate the temperature of the mother's womb that they are used to." B. "Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes." C. "Studies show that newborns like the extra warmth." D. "That's how we have always done it, and it seems to work out well."

B. "Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes."

A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action? A. Avoid getting out of bed for another 2 days. B. Walk with the nurse the length of her room. C. Walk the length of the hallway to regain her strength. D. Avoid elevating her feet when she rests in a chair.

B. Walk with the nurse the length of her room.

A postpartum woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give? A. Avoid using soap for any perineal care. B. Wash her perineum with her daily shower. C. Use an alcohol wipe to wash her episiotomy line. D. Refrain from washing lochia from the suture line.

B. Wash her perineum with her daily shower.

The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time? A. Within 12 hours B. Within one hour C. Any time prior to discharge D. Within 72 hours

B. Within one hour

A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? A. "Expect to see your 2-year-old become more independent when the baby gets home." B. "Talk to your 2-year-old about the baby when you're driving him to day care." C. "Ask your 2-year-old to pick out a special toy for his sister." D. "Have your 2-year-old stay at home while you're here in the hospital."

C. "Ask your 2-year-old to pick out a special toy for his sister."

The nurse is questioning the effective bonding of a client and her 2-day-old infant after noting signs of impaired bonding and attachment. Which actions does the nurse find concerning? A. Making eye contact with the baby B. Breastfeeding the infant on demand C. Calling the baby "it" or "they" D. Asking for assistance changing a diaper

C. Calling the baby "it" or "they"

A 17-year-old woman is living with a 21-year-old man. The man often comes home drunk and then becomes jealous. He refers to the woman as lazy, stupid, and useless and makes accusations about her talking with people while he is working to support her. He rarely hits her. Given this history, the nurse recognizes this client is at risk for which condition associated with pregnancy? A. Gestational diabetes B. Molar pregnancy C. Postpartum depression E Postterm pregnancy

C. Postpartum depression

A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client? A. Actively stimulate the infant to cry. B. Offer blow-by oxygen. C. Wrap the infant in a blanket and hand to the mother for bonding. D. Place the infant in a warmer bed and heat the newborn up.

C. Wrap the infant in a blanket and hand to the mother for bonding.

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel? A. fundus height 4 cm below umbilicus and midline B. fundus two fingerbreadths above symphysis pubis and hard C. fundus 4 cm above symphysis pubis and firm D. fundus two fingerbreadths below umbilicus and firm

D. fundus two fingerbreadths below umbilicus and firm

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? A. thick skin with deep lying blood vessels B. enhanced shivering ability C. expanded stores of glucose and glycogen D. limited voluntary muscle activity

D. limited voluntary muscle activity

A nurse has been handed a newborn term infant who is not crying and has decreased tone. In which order should the following actions be accomplished? All options must be used.

Transfer the newborn to a preheated radiant warmer. Dry the newborn. Clear the airway. Stimulate the newborn by rubbing the back. Check the heart rate.

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

A. "Make sure to use an iron-fortified formula until your baby is about 1 year old." D. "Your baby gets enough fluid with formula, so you do not need to give extra water." E. "It is important to give your baby vitamin D each day."

A mother is concerned because her 2-day-old newborn's birth weight was 8 lb (3584 g) and his current weight is 7 lb 8 oz (3360 g). What would be the nurse's response to the mother's concern? A. "The weight loss is a normal finding, since newborns lose 5% to10% of their birth weight in the first few days after birth." B. "The newborn needs to be fed more frequently to stop this weight loss pattern." C. "The weight loss may be indicative of some underlying health problem. I need to notify the doctor." D. "Although newborns lose some weight after birth due to poor nutrition, this amount is concerning."

A. "The weight loss is a normal finding, since newborns lose 5% to 10% of their birth weight in the first few days after birth."

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem? A. Inspect the clamp to insure that it is tightly closed and applied correctly. B. Clean the cord with soap and water, as oozing of blood is a common finding. C. Remove the clamp and replace with another one just above the old one. D. Notify the doctor to come suture the site of the bleeding.

A. Inspect the clamp to insure that it is tightly closed and applied correctly.

During a postbirth home visit, the nurse asks the client to complete the Edinburgh Depression Scale. What information will the nurse learn from this scale? Select all that apply. A. To identify client at risk for perinatal depressions B. To identify clients at risk for suicide C. To identify the client's attachment to the newborn D. To identify the need for additional support in the home E. To identify the client's need for antidepressant medications

A. To identify client at risk for perinatal depressions B. To identify clients at risk for suicide

A mother asks the nurse why her newborn is getting a Vitamin K injection in the birth room. The nurse explains that the injection is necessary because: A. Vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth. B. Vitamin K aids in protein metabolism. Newborns have defective protein metabolism until 24 hours of life. C. Newborns are prone to hypoglycemia, and vitamin K helps maintain a steady blood glucose level. D. The mother was febrile at the time of birth and prophylactic vitamin K is necessary.

A. Vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth.

The Ballard scoring system evaluates newborns on which two factors? A. physical maturity and neuromuscular maturity B. skin maturity and reflex maturity C. tone maturity and extremities maturity D. body maturity and cranial nerve maturity

A. physical maturity and neuromuscular maturity

The nurse is concerned that the parents are having difficulties relating to their newborn. In an effort to assist with and encourage attachment, which activity should the nurse suggest? A. promoting skin-to-skin contact (kangaroo care) on the chest B. sleeping with the infant C. keeping the baby in the same room at all times D. playing a recording of their voices at all times

A. promoting skin-to-skin contact (kangaroo care) on the chest

The mother has given birth to a premature infant at 30 weeks. To ensure the alveoli can function properly, the infant needs to be evaluated for: A. surfactant. B. oxygen. C. hematocrit. D. blood flow.

A. surfactant.

A new mother who is breastfeeding her son asks the nurse, "How do I know if my son is getting enough fluids?" Which response by the nurse would be most appropriate? A. "Don't worry. He has a natural instinct that tells him when he needs to eat and drink." B. "The best way is to check the number of diapers he wets. If he wets 6 to 8 times a day, he's getting enough." C. "The amount of fluids is not important. It's the amount of calories he takes in that we watch." D. "If you think he's not taking enough, give him 4 to 8 ounces of water each day in addition to what he breastfeeds."

B. "The best way is to check the number of diapers he wets. If he wets 6 to 8 times a day, he's getting enough."

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life? A. 10% to 15% of their birth weight B. 5% to 10% of their birth weight C. 15% to 18% of their birth weight D. 20% of their birth weight

B. 5% to 10% of their birth weight

The nurse is preparing discharge teaching for a client who is 2 days postpartum. Which action should the nurse prioritize to encourage prevention of constipation? A. Use a stimulant laxative. B. Encourage fiber-rich foods. C. Increase coffee intake. D. Get plenty of rest.

B. Encourage fiber-rich foods.

A client gives birth to a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home? A. Ensure cool air is circulating over the newborn to prevent overheating. B. Keep the newborn wrapped in a blanket, with a cap on its head. C. Encourage the mother to keep the infant in her bed to ensure that the infant stays warm. D. Keep the infant's room temperature at least 80°F (27°C).

B. Keep the newborn wrapped in a blanket, with a cap on its head.

What measure(s) will the nurse implement to help ensure that a newborn is not misidentified in the hospital? Select all that apply. A. Obtain the newborn and the mother's thumbprint on the mother's chart. B. Place an identification band on both the mother and the newborn immediately after birth, before separating them. C. Have identifying data on the newborn's chart and compare information to that in the mother's chart. D. Ask the parents to look at the newborn each time the newborn is brought to the room to be sure that the newborn is theirs. E. Keep the newborn with the parent 24 hours per day until discharge.

B. Place an identification band on both the mother and the newborn immediately after birth, before separating them.

What treatments would the nurse perform in caring for a newly circumcised newborn? Select all that apply. A. Apply talc powder to the diaper area with each diaper change. B. Wash the penis with warm water at each diaper change. C. Fasten the diaper loosely to prevent unnecessary friction as irritation. D. Report if there is a bleeding spot the size of a dime on the diaper. E. Notify the doctor if the newborn does not void after 4 hours.

B. Wash the penis with warm water at each diaper change. C. Fasten the diaper loosely to prevent unnecessary friction as irritation.

A newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which substance in response to cold exposure? A. white fat B. brown fat C. muscles D. nerves

B. brown fat

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that clients empty their bladders. A full bladder can lead to which complication? A. permanent urinary incontinence B. increased lochia drainage C. fluid volume overload D. ruptured bladder

B. increased lochia drainage

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

B. light

A nursing student is aware that fetal gas exchange takes place in which area? A. uterus B. placenta C. lungs D. bronchioles

B. placenta

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding? A. The infant requires immediate and aggressive interventions for survival. B. The infant is adjusting well to extrauterine life. C. The infant is experiencing moderate difficulty in adjusting to extrauterine life. D. The infant probably has either a congenital heart defect or an immature respiratory system.

C. The infant is experiencing moderate difficulty in adjusting to extrauterine life.

The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform pelvic floor muscle training or Kegel exercises. The nurse includes this information for which reason? A. reduce lochia B. promote uterine involution C. improve pelvic floor tone D. alleviate perineal pain

C. improve pelvic floor tone

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? A. labor less than 3 hours B. hemoglobin of 11.5 mg/dl (115 g/L) C. placenta removed via manual extraction D. multiparity

C. placenta removed via manual extraction