OB Final Questions

The nurse determines that a newborn is hypoglycemic based on which of the following fi ndings? Select all that apply. ■ 1. Glucometer reading of 40 mg/dL. ■ 2. Family history of insulin-dependent diabetes. ■ 3. Internal fetal monitor tracing. ■ 4. Irregular respirations, tremors, and hypothermia. ■ 5. Large for gestational age.

1, 4

After the delivery of a neonate, a quick assessment is completed. The neonate is found to be apneic. After quickly drying the neonate, what should the nurse do next? ■ 1. Assign the fi rst Apgar score. ■ 2. Place the head in a "sniff" position. ■ 3. Administer oxygen. ■ 4. Start cardiac compressions.

2. Place the head in a "sniff" position.

At a postpartum check up 11 days after delivery, the nurse asks the client about the color of her lochia. Which of the following colors is expected? ■ 1. Dark red. ■ 2. Pink. ■ 3. Brown. ■ 4. White.

4. White.

The nurse explains to the mother of a neonate diagnosed with erythroblastosis fetalis that the exchange transfusion is necessary to prevent damage primarily to which of the following organs in the neonate? ■ 1. Kidneys. ■ 2. Brain. ■ 3. Lungs. ■ 4. Liver.

■ 2. Brain.

Which of the following would be most important for the nurse to encourage in a primiparous client diagnosed with endometritis who is receiving intravenous antibiotic therapy? ■ 1. Ambulate to the bathroom frequently. ■ 2. Discontinue breast-feeding temporarily. ■ 3. Maintain bed rest in Fowler's position. ■ 4. Restrict visitors to prevent contamination.

■ 3. Maintain bed rest in Fowler's position.

After explaining to a primiparous client about the causes of her neonate's cranial molding, which of the following statements by the mother indicates the need for further instruction? ■ 1. "The molding was caused by an overlapping of the baby's cranial bones during my labor." ■ 2. "The amount of molding is related to the amount and length of pressure on the head." ■ 3. "The molding will usually disappear in a couple of days." ■ 4. "Brain damage may occur if the molding doesn't resolve quickly."

■ 4. "Brain damage may occur if the molding doesn't resolve quickly."

Which of the following client statements indicates effective teaching about burping a breastfed neonate? ■ 1. "Breast-fed babies who are burped frequently will take more on each breast." ■ 2. "If I supplement the baby with formula, I will rarely have to burp him." ■ 3. "I'll breast-feed my baby every 3 hours so I won't have to burp him." ■ 4. "When I switch to the other breast, I'll burp the baby."

■ 4. "When I switch to the other breast, I'll burp the baby."

The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal delivery. The nurse should next: ■ 1. Apply an ice pack to the perineal area. ■ 2. Assess the client's temperature. ■ 3. Have the client take a warm sitz bath. ■ 4. Contact the physician for orders for an antibiotic.

■ 1. Apply an ice pack to the perineal area.

When reviewing the prenatal history for a newly delivered neonate, the nurse notes that the mother has neurofi bromatosis. The nurse should further assess the neonate for: ■ 1. Acrocyanosis. ■ 2. Café au lait spots. ■ 3. Port wine nevus. ■ 4. Strawberry hemangiomas.

■ 2. Café au lait spots

After instructing a primiparous client who is bottle-feeding about burping, which of the following client statements indicates that the client needs further teaching? ■ 1. "I'll burp him after 15 minutes of feeding him formula." ■ 2. "After he takes one-half ounce of formula, I'll burp him." ■ 3. "I'll burp him while he is in an upright position." ■ 4. "I'll gently pat his back to get him to burp."

■ 1. "I'll burp him after 15 minutes of feeding him formula."

Which of the following actions should the nurse take when performing external cardiac massage on a neonate born at 28 weeks' gestation? ■ 1. Alternate cardiac massage with ventilation. ■ 2. Compress the sternum with the palm of the hand. ■ 3. Compress the chest 70 to 80 times per minute. ■ 4. Displace the chest wall half the depth of the anterior-posterior diameter of the chest.

■ 1. Alternate cardiac massage with ventilation.

Four hours after cesarean delivery of a neonate weighing 4,000 g (8 lb, 13 oz), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean delivery (VBAC) on which of the following? ■ 1. VBAC may be possible if the client has not had a classic uterine incision. ■ 2. A history of rapid labor is a necessary criterion for VBAC. ■ 3. A low transverse incision contraindicates the possibility for VBAC. ■ 4. VBAC is not possible because the neonate was large for gestational age.

■ 1. VBAC may be possible if the client has not had a classic uterine incision.

A primiparous client who delivered 12 hours ago under epidural anesthesia with a midline episiotomy tells the nurse that she is experiencing a great deal of discomfort when she sits in a chair with the baby. Which of the following instructions would be most appropriate? ■ 1. "Ask for some pain medication before you sit down." ■ 2. "Squeeze your buttock muscles together before sitting down." ■ 3. "Keep a relaxed posture before sitting down with your full weight." ■ 4. "Ask the physician for some analgesic cream or spray."

■ 2. "Squeeze your buttock muscles together before sitting down."

A 6-lb, 8-oz neonate was delivered vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, fl accid tone, no response to stimulus, overall pale white in color. The Apgar score is: ■ 1. 2. ■ 2. 3. ■ 3. 4. ■ 4. 6.

■ 3. 4.

A breast-feeding primiparous client with a midline episiotomy is prescribed ibuprofen 200 mg orally. The nurse instructs the client to take the medication: ■ 1. Before going to bed. ■ 2. Midway between feedings. ■ 3. Immediately after a feeding. ■ 4. When providing supplemental formula

■ 3. Immediately after a feeding.

A preterm neonate is unable to breast- or bottle-feed. The physician writes an order to feed the neonate via nasogastric (NG) tube. When choosing an NG feeding tube for a neonate, the nurse should base the tube size on the neonate's: ■ 1. Disease process. ■ 2. Gestational age. ■ 3. Length. ■ 4. Weight.

■ 4. Weight.

Which of the following would lead the nurse to suspect retinopathy of prematurity (ROP) when assessing a neonate at 32 weeks' gestation who weighs 2,000 g? ■ 1. Sunken orbital sockets. ■ 2. Strabismus. ■ 3. Reaction to bright light. ■ 4. Constricted retinal vessels.

■ 4. Constricted retinal vessels.

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean delivery. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which of the following? ■ 1. Trauma during labor and delivery. ■ 2. Moderate fundal massage after delivery. ■ 3. Lengthy and prolonged second stage of labor. ■ 4. Overdistention of the uterus from hydramnios.

■ 4. Overdistention of the uterus from hydramnios

Twelve hours after a vaginal delivery with epidural anesthesia, the nurse palpates the fundus of a primiparous client and fi nds it to be fi rm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next? ■ 1. Document this as a normal fi nding in the client's record. ■ 2. Contact the physician for an order for methylergonovine. ■ 3. Encourage the client to ambulate to the bathroom and void. ■ 4. Gently massage the fundus to expel the clots

■ 3. Encourage the client to ambulate to the bathroom and void.

Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, fi nding it distended. The nurse interprets this fi nding based on the understanding that the client's bladder distention is most likely caused by which of the following? ■ 1. Prolonged fi rst stage of labor. ■ 2. Urinary tract infection. ■ 3. Pressure of the uterus on the bladder. ■ 4. Edema in the lower urinary tract area.

■ 4. Edema in the lower urinary tract area.

Which of the following subjects should the nurse include when teaching the mother of a neonate diagnosed with retinopathy of prematurity (ROP) about possible treatment for complications? ■ 1. Laser therapy. ■ 2. Cromolyn sodium (Intal) eye drops. ■ 3. Frequent testing for glaucoma. ■ 4. Corneal transplants.

■ 1. Laser therapy.

While assessing the fundus of a multiparous client 36 hours after delivery of a term neonate, the nurse notes a separation of the abdominal muscles. What action should the nurse take based on this assessment? ■ 1. Notify the health care provider of the separation. ■ 2. Discuss with the client that no further action is needed. ■ 3. Demonstrate exercises involving head and shoulder lifting. ■ 4. Refer the client to a surgeon for surgical repair after 6 weeks postpartum.

■ 2. Discuss with the client that no further action is needed.

A client is in the fourth stage of labor. Which set of assessments is the highest priority at this time? ■ 1. Assessment of the ability to push with contractions, hydration, and emotional stability. ■ 2. Assessment of maternal vital signs, fetal heart tones, and the contraction pattern. ■ 3. Assessment of maternal vital signs, the fundus, the bladder, and lochia. ■ 4. Assessment of maternal emotional status, infant bonding, and feeding preferences.

■ 3. Assessment of maternal vital signs, the fundus, the bladder, and lochia.

The nurse is assessing a cesarean section client who delivered 12 hours ago. Findings include a distended abdomen with faint bowel sounds × 1 quadrant, fundus fi rm at umbilicus, lochia scant, rubra, and pain rated 2 on a scale of 1 to 10. The I.V. and Foley catheter have been discontinued and the client received medication 3 hours ago for pain. The client can have pain medication every 3 to 4 hours. The nurse should fi rst: ■ 1. Give the client pain medication. ■ 2. Have the client use the incentive spirometry. ■ 3. Ambulate the client from the bed to the hallway and back. ■ 4. Encourage the client to begin caring for her baby.

■ 3. Ambulate the client from the bed to the hallway and back.

Two hours ago, a neonate at 38 weeks' gestation and weighing 3,175 g (7 lb) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which of the following would alert the nurse to notify the pediatrician? ■ 1. Alkalosis. ■ 2. Increased muscle tone. ■ 3. Temperature instability. ■ 4. Positive Babinski's refl ex.

■ 3. Temperature instability.

Which of the following best identifi es the reason for assessing a neonate weighing 1,500 g at 32 weeks' gestation for retinopathy of prematurity (ROP)? ■ 1. The neonate is at risk because of multiple factors. ■ 2. Oxygen is being administered at a level of 21%. ■ 3. The neonate was alkalotic immediately after birth. ■ 4. Phototherapy is likely to be ordered by the pediatrician.

1. The neonate is at risk because of multiple factors.

The nurse in the newborn nursery has just received shift report about a group of newborns and is to receive another admission in 30 minutes. In order to provide the safest care and plan for the new admission, the nurse should do which of the following in order of fi rst to last? 1. Move quickly from room to room and assess all clients. 2. Check the room to which the new client will be admitted to be sure all supplies and equipment are available. 3. Log on to the clinical information system and determine if there are new orders. 4. Review notes from shift report and prioritize all clients; make rounds on the most critical fi rst.

4, 1, 3, 2

A primiparous client who delivered a viable term neonate vaginally 48 hours ago has a midline episiotomy and repair of a third-degree laceration. When preparing the client for discharge, which of the following assessments would be most important? ■ 1. Constipation. ■ 2. Diarrhea. ■ 3. Excessive bleeding. ■ 4. Rectal fi stulas.

■ 1. Constipation.

The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains? ■ 1. G 4, P 1 client who is breast-feeding her infant. ■ 2. G 3, P 3 client who is breast-feeding her infant. ■ 3. G 2, P 2 cesarean client who is bottle-feeding her infant. ■ 4. G 3, P 3 client who is bottle-feeding her infant.

■ 2. G 3, P 3 client who is breast-feeding her infant.

A primiparous client who underwent a cesarean delivery 30 minutes ago is to receive Rho(D) immune globulin (RhoGAM). The nurse should administer the medication within which of the following time frames after delivery? ■ 1. 8 hours. ■ 2. 24 hours. ■ 3. 72 hours. ■ 4. 96 hours.

■ 3. 72 hours.

After instructing a mother about normal refl exes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck refl ex as occurring when the neonate does which of the following? ■ 1. Steps briskly when held upright near a fi rm, hard surface. ■ 2. Pulls both arms and does not move the chin beyond the point of the elbows. ■ 3. Turns head to the left, extends left extremities, and fl exes right extremities. ■ 4. Extends and abducts the arms and legs with the toes fanning open.

■ 3. Turns head to the left, extends left extremities, and fl exes right extremities.

Assessment of a 2-day-old neonate delivered at 34 weeks' gestation reveals absent apical pulse left of the midclavicular line, cyanosis, grunting, and diminished breath sounds. The nurse should fi rst: ■ 1. Consult with health care provider to obtain a chest x-ray. ■ 2. Reposition the neonate and then assess if the grunting and cyanosis resolve. ■ 3. Begin oxygen administration at 6-8 L via mask. ■ 4. Obtain a complete blood count to determine infection.

■ 1. Consult with health care provider to obtain a chest x-ray.

While caring for a multiparous client 4 hours after vaginal delivery of a term neonate, the nurse notes that the mother's temperature is 99.8° F (37.2° C), the pulse is 66 bpm, and the respirations are 18 breaths/minute. Her fundus is fi rm, midline, and at the level of the umbilicus. The nurse should: ■ 1. Continue to monitor the client's vital signs. ■ 2. Assess the client's lochia for large clots. ■ 3. Notify the client's physician about the fi ndings. ■ 4. Offer the mother an ice pack for her forehead.

■ 1. Continue to monitor the client's vital signs.

Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who delivered 24 hours ago and is receiving intravenous antibiotic therapy for cystitis? ■ 1. Limiting fl uid intake to 1 L daily to prevent overload. ■ 2. Emptying the bladder every 2 to 4 hours while awake. ■ 3. Washing the perineum with povidone iodine (Betadine) after voiding. ■ 4. Avoiding the intake of acidic fruit juices until the treatment is discontinued.

■ 2. Emptying the bladder every 2 to 4 hours while awake.

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client fi nding indicates a problem at this time? ■ 1. Firm fundus at the symphysis. ■ 2. White, thick vaginal discharge. ■ 3. Striae that are silver in color. ■ 4. Soft breasts without milk.

■ 1. Firm fundus at the symphysis.

While making a home visit to a primiparous client and her 3-day-old son, the nurse observes the mother changing the baby's disposable diaper. Before putting the clean diaper on the neonate, the mother begins to apply baby powder to the neonate's buttocks. Which of the following statements about baby powder should the nurse relate to the mother? ■ 1. It may cause pneumonia to develop. ■ 2. It helps prevent diaper rash. ■ 3. It keeps the diaper from adhering to the skin. ■ 4. It can result in allergies later in life.

■ 1. It may cause pneumonia to develop.

A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which of the following responses by the nurse would be most appropriate? ■ 1. "Your menstrual cycle will return in 3 to 4 weeks." ■ 2. "It will probably be 6 to 10 weeks before it starts again." ■ 3. "You can expect your menses to start in 12 to 14 weeks." ■ 4. "Your menses will return in 16 to 18 weeks

■ 2. "It will probably be 6 to 10 weeks before it starts again."

At which of the following locations would the nurse expect to palpate the fundus of a primiparous client immediately after delivery of a neonate? ■ 1. Halfway between the umbilicus and the symphysis pubis. ■ 2. At the level of the umbilicus. ■ 3. Just below the level of the umbilicus. ■ 4. Above the level of the umbilicus.

■ 1. Halfway between the umbilicus and the symphysis pubis.

While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidifi ed. The nurse should tell the mother? ■ 1. "The humidity promotes expansion of the neonate's immature lungs." ■ 2. "The humidity helps to prevent viral or bacterial pneumonia." ■ 3. "Oxygen is drying to the mucous membranes unless it is humidifi ed." ■ 4. "Circulation to the baby's heart is improved with humidifi ed oxygen."

■ 3. "Oxygen is drying to the mucous membranes unless it is humidifi ed."

A newly delivered primiparous client asks the nurse, "Can my baby see?" Which of the following statements about neonatal vision should the nurse include in the explanation? ■ 1. Neonates primarily focus on moving objects. ■ 2. They can see objects up to 12 inches away. ■ 3. Usually they see clearly by about 2 days after birth. ■ 4. Neonates primarily distinguish light from dark.

■ 2. They can see objects up to 12 inches away.

A 24-year-old primipara who has delivered a healthy neonate in the hospital's birthing center plans to bottle-feed her neonate. When developing the nutritional teaching plan for the mother about the neonate's daily calorie allotment, the nurse should determine that the number of calories required by the neonate each day per pound of body weight is which of the following? ■ 1. 30 to 35. ■ 2. 40 to 45. ■ 3. 50 to 55. ■ 4. 60 to 65.

■ 3. 50 to 55.

The physician orders an intramuscular injection of phytonadione (AquaMEPHYTON) for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following? ■ 1. Hypoglycemia. ■ 2. Hyperbilirubinemia. ■ 3. Hemorrhage. ■ 4. Polycythemia.

■ 3. Hemorrhage.

At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/minute. The nurse interprets these fi ndings as indicating that this neonate is most likely experiencing which of the following? ■ 1. Drug withdrawal. ■ 2. First period of reactivity. ■ 3. A state of deep sleep. ■ 4. Respiratory distress.

■ 3. A state of deep sleep.

After a vaginal delivery, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which of the following positions? ■ 1. Left side, with the neck slightly fl exed. ■ 2. Back, with the head turned to the left side. ■ 3. Abdomen, with the head down. ■ 4. Back, with the neck slightly extended.

■ 4. Back, with the neck slightly extended.

A 30-year-old woman, G 4, P 4, has delivered a healthy term female neonate by cesarean delivery due to a nonreassuring fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's retention catheter and observes that the client's urine is slightly red tinged. Which of the following should the nurse do next? ■ 1. Continue to monitor the client's input and output. ■ 2. Palpate the client's fundus gently every 15 minutes. ■ 3. Assess the placement of the retention catheter. ■ 4. Contact the client's physician for further orders

■ 4. Contact the client's physician for further orders

A newborn who is 20 hours old has a respiratory rate of 66, is grunting when exhaling, and has occasional nasal fl aring. The newborn's temperature is 98; he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before delivery. Based on these data, the nurse should include which of the following in the management of the infant's care? ■ 1. Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours for 24 hours, infant at bedside. ■ 2. With a health care provider (HCP) order, draw blood cultures, monitor vital signs every 2 hours as well as feeding and elimination patterns every 4 hours, newborn at bedside. ■ 3. Transfer the newborn to the neonatal intensive care unit with diagnosis of possible sepsis, parents at bedside. ■ 4. Request CBC with differential from the health care provider, keep the newborn under the radiant warmer, and monitor vital signs every 4 hours, parents at bedside.

2. With a health care provider (HCP) order, draw blood cultures, monitor vital signs every 2 hours as well as feeding and elimination patterns every 4 hours, newborn at bedside.

After explaining the procedure for using a portable sitz bath to a primiparous client who delivered 30 hours ago, which of the following would the nurse do next? ■ 1. Fill the collecting bag with water at a temperature of 107° F (41.25° C). ■ 2. Spray the perineal area with the ordered analgesic spray. ■ 3. Wash hands and don clean gloves for the procedure. ■ 4. Assess the client's perineum for swelling and redness.

■ 3. Wash hands and don clean gloves for the procedure.

The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)? ■ 1. A neonate born at 36 weeks' gestation. ■ 2. A neonate born by Cesarean section. ■ 3. A neonate experiencing apneic episodes. ■ 4. A neonate who is 42 weeks' gestation

■ 1. A neonate born at 36 weeks' gestation.

While caring for a neonate of a diabetic mother soon after delivery, the nurse has fed the newborn formula to prevent hypoglycemia. The nurse checks the neonate's blood glucose level and it is 60 mg/dL, but the neonate continues to exhibit jitteriness and tremors. The nurse should fi rst: ■ 1. Inform the physician of the neonate's glucose levels and tremors and request an order for blood calcium levels. ■ 2. Administer glucose intravenously based on infant glucose level. ■ 3. Take the neonate's temperature and place him in the radiant warmer. ■ 4. Refeed the infant to continue to increase the blood glucose level.

■ 1. Inform the physician of the neonate's glucose levels and tremors and request an order for blood calcium levels.

An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold her baby without "spoiling" him. Which of the following responses would be most appropriate? ■ 1. "Hold him when he is fussy or crying." ■ 2. "Hold him as much as you want to hold him." ■ 3. "Try to hold him infrequently to avoid overstimulation." ■ 4. "You can hold him periodically throughout the day."

■ 2. "Hold him as much as you want to hold him."

After instructing a primiparous client about episiotomy care, which of the following client statements indicates successful teaching? ■ 1. "I'll use hot, sudsy water to clean the episiotomy area." ■ 2. "I wipe the area from front to back using a blotting motion." ■ 3. "Before bedtime, I'll use a cold water sitz bath." ■ 4. "I can use ice packs for 3 to 4 days after delivery."

■ 2. "I wipe the area from front to back using a blotting motion."

A primiparous client who delivered a viable neonate 8 hours ago tells the nurse that she gained 26 lb during pregnancy and asks how long it will take to return to her normal prepregnant weight. The nurse should tell the client that the usual time frame for returning to prepregnant weight is: ■ 1. 4 weeks. ■ 2. 6 weeks. ■ 3. 8 weeks. ■ 4. 12 weeks.

■ 2. 6 weeks.

While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which of the following stages of grief? ■ 1. Denial. ■ 2. Shock. ■ 3. Bargaining. ■ 4. Anger.

■ 2. Shock.

A multiparous client who has a neonate diagnosed with hemolytic disease of the newborn asks the nurse why the neonate has developed this problem. Which of the following responses by the nurse would be most appropriate? ■ 1. "You are Rh-positive and the neonate's father is Rh-negative." ■ 2. "You and the neonate's father are both Rhnegative." ■ 3. "You are Rh-negative and the neonate's father is Rh-positive." ■ 4. "The fetus is Rh-negative and you are Rhpositive."

■ 3. "You are Rh-negative and the neonate's father is Rh-positive."

A female neonate delivered vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which of the following actions should the nurse do the fi rst time that the parents visit the neonate in the nursery? ■ 1. Explain the surgical interventions that will be performed. ■ 2. Stress that this defect is not life-threatening. ■ 3. Emphasize the neonate's normal characteristics. ■ 4. Reassure the parents about the success rate of the surgery.

■ 3. Emphasize the neonate's normal characteristics.

Which of the following characteristics should the nurse teach the mother about her neonate diagnosed with fetal alcohol syndrome (FAS)? ■ 1. Neonates are commonly listless and lethargic. ■ 2. The IQ scores are usually average. ■ 3. Hyperactivity and speech disorders are common. ■ 4. The mortality rate is 70% unless treated.

■ 3. Hyperactivity and speech disorders are common.

The nurse is caring for a term neonate who is diagnosed with patent ductus arteriosus. While performing a physical assessment of the neonate, the nurse anticipates that the neonate will exhibit which of the following? ■ 1. Decreased cardiac output with faint peripheral pulses. ■ 2. Profound cyanosis over most of the body. ■ 3. Loud cardiac murmurs through systole and diastole. ■ 4. Harsh systolic murmurs with a palpable thrill.

■ 3. Loud cardiac murmurs through systole and diastole.

After teaching a new mother about the care of her neonate after circumcision with a Gomco clamp, which of the following statements by the mother indicates to the nurse that the mother needs additional instructions? ■ 1. "The petroleum gauze may fall off into the diaper." ■ 2. "A few drops of blood oozing from the site is normal." ■ 3. "I'll leave the gauze in place for 24 hours." ■ 4. "I'll remove any yellowish crusting gently with water."

■ 4. "I'll remove any yellowish crusting gently with water."

While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted? ■ 1. Bronze-colored skin. ■ 2. Maculopapular chest rash. ■ 3. Urine specifi c gravity of 1.018. ■ 4. Absent Moro refl ex.

■ 4. Absent Moro refl ex.

The nurse is caring for a 2-day-old neonate in the recovery room 30 minutes after surgical correction for the cardiac defect, transposition of the great vessels. Which of the following would alert the nurse to notify the physician? ■ 1. Oxygen saturation of 90%. ■ 2. Pale pink extremities. ■ 3. Warm, dry skin. ■ 4. Femoral pulse of 90 bpm.

■ 4. Femoral pulse of 90 bpm.

106. The nurse is developing a plan of care for a neonate who is to undergo gastroschisis surgery. What should be included? Select all that apply. ■ 1. Prevention of hypothermia. ■ 2. Maintenance of fl uid and electrolyte balance. ■ 3. Provision of time for parental bonding. ■ 4. Prevention of infection. ■ 5. Providing developmental care.

1, 2, 4

Which of the following instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy? ■ 1. Keep the neonate's eyes completely covered. ■ 2. Use a regular diaper on the neonate. ■ 3. Offer feedings every 4 hours. ■ 4. Check the oral temperature every 8 hours.

1. Keep the neonate's eyes completely covered.

Approximately 90 minutes after birth, the nurse should encourage the mother of a term neonate to do which of the following? ■ 1. Feed the neonate. ■ 2. Allow the neonate to sleep. ■ 3. Get to know the neonate. ■ 4. Change the neonate's diaper

■ 2. Allow the neonate to sleep.

The nurse has received shift report on a group of newborns. The nurse should make rounds on which of the following clients fi rst? ■ 1. A newborn who is large for gestational age (LGA) who needs a repeat blood glucose prior to the next feeding in 15 minutes. ■ 2. A newborn delivered at 36-weeks' gestation weighing 5 lb who is due to breast-feed for the fi rst time in 15 minutes. ■ 3. A newborn who was delivered 24 hours ago by Cesarean section and had a respiratory rate of 62 30 minutes ago. ■ 4. A newborn who had a borderline low temperature and was double-wrapped with a hat on ½ hour ago to bring up the temperature.

■ 3. A newborn who was delivered 24 hours ago by Cesarean section and had a respiratory rate of 62 30 minutes ago.

Which of the following would the nurse include in the teaching plan for a primiparous client about the frequency of breast-feeding the neonate during the fi rst few days? ■ 1. Feeding the neonate whenever he or she cries. ■ 2. Restricting feedings to 1 to 2 minutes per side. ■ 3. Feeding the neonate for at least 10 minutes per side. ■ 4. Maintaining feeding for 20 to 30 minutes per side

■ 3. Feeding the neonate for at least 10 minutes per side.

While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following? ■ 1. Effects of the anesthetic during labor. ■ 2. Hemorrhage during the delivery process. ■ 3. Effects of analgesics used during labor. ■ 4. Decreased blood volume in the vascular system.

■ 4. Decreased blood volume in the vascular system.

During the home visit, a breast-feeding client asks the nurse what contraception method she and her husband should use until she has her 6-week postpartal examination. Which of the following would be most appropriate for the nurse to suggest? ■ 1. Condom with spermicide. ■ 2. Oral contraceptives. ■ 3. Rhythm method. ■ 4. Abstinence.

1. Condom with spermicide.

Which of the following would the nurse include in the primiparous client's discharge teaching plan about measures to provide visual stimulation for the neonate? ■ 1. Maintain eye contact while talking to the baby. ■ 2. Paint the baby's room in bright colors accented with teddy bears. ■ 3. Use brightly colored animals and cartoon fi gures on the wall. ■ 4. Move a brightly colored rattle in front of the baby's eyes.

■ 1. Maintain eye contact while talking to the baby.

The nurse is catheterizing a client who cannot void after a normal delivery 8 hours ago. The nurse begins the catheterization process and the client asks the nurse if Betadine was used to clean the meatus for the catheterization. The nurse realizes that the client is allergic to Betadine and the client is reacting to the cleansing agent. The nurse should take the following steps in order of priority from fi rst to last. 1. document the incident 2. Clean Betadine from client's vaginal area. 3. Notify physician ordering catheterization. 4. Ask client what her reaction is when exposed to Betadine. 5. File an incident report.

4,2,3,1,5

A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breast-feed my baby?" The nurse should tell the client: ■ 1. "You can continue to breast-feed as long as you want to do so." ■ 2. "Alternate your breast-feeding with formula feeding to help you rest." ■ 3. "You'll need to discontinue breast-feeding until the antibiotic therapy is stopped." ■ 4. "You'll need to modify your technique by manually pumping your breasts."

■ 1. "You can continue to breast-feed as long as you want to do so."

During a home visit to a breast-feeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do? ■ 1. Wipe off any lanolin creams from the nipple before each feeding. ■ 2. Position the baby with the entire areola in the baby's mouth. ■ 3. Feed the baby less often for the next several days. ■ 4. Use a mild soap while in the shower to prevent an infection.

■ 2. Position the baby with the entire areola in the baby's mouth.

Which of the following assessment fi ndings in a term neonate would cause the nurse to notify the pediatrician? ■ 1. Absence of tears. ■ 2. Unequally sized corneas. ■ 3. Pupillary constriction to bright light. ■ 4. Red circle on pupils with ophthalmoscopic examination.

■ 2. Unequally sized corneas.

In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal delivery with a midline episiotomy. The nurse should instruct the client that she can resume sexual intercourse: ■ 1. In 6 weeks when the episiotomy is completely healed. ■ 2. After a postpartum check by the health care provider. ■ 3. Whenever the client is feeling amorous and desirable. ■ 4. When lochia fl ow and episiotomy pain have stopped.

■ 4. When lochia fl ow and episiotomy pain have stopped.

A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result? ■ 1. Bradycardia. ■ 2. Rapid eye movement. ■ 3. Seizures. ■ 4. Tachycardia.

■ 1. Bradycardia.

When preparing for discharge a 15-year-old primipara who is bottle-feeding her neonate, the nurse instructs the client not to "prop" the bottle while feeding the neonate because this can lead to which of the following? ■ 1. Overfeeding and obesity. ■ 2. Aspiration of the formula. ■ 3. Tooth decay in the formative months. ■ 4. Sudden infant death syndrome (SIDS).

■ 2. Aspiration of the formula.

A preterm infant delivered 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following? ■ 1. Placement of the neonate on a ventilator. ■ 2. Administration of bronchodilators through the nares. ■ 3. Suctioning of the neonate's nares with wall suction. ■ 4. Insertion of a chest tube into the neonate.

■ 4. Insertion of a chest tube into the neonate.

Thirty-six hours after a vaginal delivery, a multiparous client is diagnosed with endometritis due to b-hemolytic streptococcus. When assessing the client, which of the following would the nurse expect to fi nd? ■ 1. Profuse amounts of lochia. ■ 2. Abdominal distention. ■ 3. Nausea and vomiting. ■ 4. Odorless vaginal discharge.

■ 4. Odorless vaginal discharge.

The nurse is caring for a G 3, T 3, P 0, Ab 0, L 3 woman who is one day postpartum following a vaginal delivery. Which of the following indicates a need for further assessment? ■ 1. Increased hematocrit and hemoglobin. ■ 2. White blood cell (WBC) count of 15,000. ■ 3. Pulse of 60. ■ 4. Temperature of 100.8° F.

■ 4. Temperature of 100.8° F.

The nurse is caring for a primipara who delivered her baby yesterday and has chosen to breast-feed her neonate. Which assessment fi nding is considered unusual for the client at this point postpartum? ■ 1. Milk production. ■ 2. Diaphoresis. ■ 3. Constipation. ■ 4. Diuresis.

1. Milk production.

A 15-year-old unmarried primiparous client is being cared for in the hospital's birthing center after vaginal delivery of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which of the following responses would be most appropriate? ■ 1. "I'll bring the baby to you for feeding." ■ 2. "I think we should ask your physician if this is a good idea." ■ 3. "It's not a good idea for you to have any contact with the baby." ■ 4. "I'll check with the social worker to see if the adopting parents will permit this."

■ 1. "I'll bring the baby to you for feeding."

After the nurse explains to the mother of a male neonate scheduled to receive an injection of vitamin K soon after birth about the rationale for the medication, which of the following statements by the mother indicates successful teaching? ■ 1. "My baby doesn't have the normal bacteria in his intestines to produce this vitamin." ■ 2. "My baby is at a high risk for a problem involving his blood's ability to clot." ■ 3. "The red blood cells my baby formed during pregnancy are destroying the vitamin K." ■ 4. "My baby's liver is not able to produce enough of this vitamin so soon after birth."

■ 1. "My baby doesn't have the normal bacteria in his intestines to produce this vitamin."

A 26-year-old primiparous client is seen in the urgent care clinic 2 weeks after delivering a viable female neonate. The client, who is breast-feeding, is diagnosed with infectious mastitis of the right breast. The client asks the nurse, "Can I continue breastfeeding?" The nurse should tell the client: ■ 1. "You can continue to breast-feed, feeding your baby more frequently." ■ 2. "You can continue once your symptoms begin to decrease." ■ 3. "You must discontinue breast-feeding until antibiotic therapy is completed." ■ 4. "You must stop breast-feeding because the breast is contaminated."

■ 1. "You can continue to breast-feed, feeding your baby more frequently."

The nurse assigns an individual who is an unlicensed assistive personnel to care for a client who is one day postpartum. Which of the following would be appropriate to delegate to this person? Select all that apply. ■ 1. Changing the perineal pad and reporting the drainage. ■ 2. Assisting the mother to latch the infant onto the breast. ■ 3. Checking the location of the fundus prior to ambulating the client. ■ 4. Reinforcing good hygiene while assisting the client with washing the perineum. ■ 5. Discussing postpartum depression with the client who is found crying. ■ 6. Assisting the client with ambulation shortly after delivery.

■ 1. Changing the perineal pad and reporting the drainage. ■ 4. Reinforcing good hygiene while assisting the client with washing the perineum. ■ 6. Assisting the client with ambulation shortly after delivery.

A breast-feeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which of the following? ■ 1. Fat. ■ 2. Iron. ■ 3. Sodium. ■ 4. Calcium.

■ 1. Fat.

The nurse instructs a primiparous client about bottle-feeding her neonate. Which of the following demonstrates that the mother has understood the nurse's instructions? ■ 1. Placing the neonate on his back after the feeding. ■ 2. Bubbling the baby after 1 oz of formula. ■ 3. Putting three-fourths of the bottle nipple into the baby's mouth. ■ 4. Pointing the nipple toward the neonate's palate

■ 1. Placing the neonate on his back after the feeding

A primiparous client who will be bottlefeeding her neonate asks, "What is the best position for the baby after feeding?" Which of the following positions should the nurse recommend to aid digestion? ■ 1. Supine position. ■ 2. On the left side. ■ 3. Prone without a pillow. ■ 4. Sitting on the caregiver's lap for 20 minutes

■ 1. Supine position.

A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which of the following actions in the infant's plan of care? ■ 1. Urine toxicology screening. ■ 2. Notifying hospital security. ■ 3. Limiting contact with visitors. ■ 4. Contacting local law enforcement.

■ 1. Urine toxicology screening.

When teaching a primiparous client about the growth and development of the neonate, which of the following should the nurse include as the usual age at which most babies are able to drink from a cup independently? ■ 1. 5 to 7 months. ■ 2. 8 to 10 months. ■ 3. 12 to 14 months. ■ 4. 15 to 16 months.

■ 2. 8 to 10 months.

A neonate is delivered by primary cesarean section at 36 weeks' gestation. The temperature in the delivery room is 70° F. To prevent heat loss from convection, which action should the nurse take? ■ 1. Dry the neonate quickly after delivery. ■ 2. Keep the neonate away from air conditioning vents. ■ 3. Place the neonate away from outside windows. ■ 4. Prewarm the bed.

■ 2. Keep the neonate away from air conditioning vents.

At a home visit, the nurse assesses a neonate delivered vaginally at 41 weeks' gestation 5 days ago, noting the following fi ndings: frequent hiccups; loose, watery stool in diaper; red rash on face; and dry, peeling skin. Which of these fi ndings warrants further assessment? ■ 1. Frequent hiccups. ■ 2. Loose, watery stool in diaper. ■ 3. Pink papular vesicles on the face. ■ 4. Dry, peeling skin.

■ 2. Loose, watery stool in diaper.

A nurse is reviewing a client's maternal prenatal record and notes that the mother used narcotics during her pregnancy. A primary nursing intervention when caring for a drug-exposed neonate is to: ■ 1. Assess vital signs including blood pressure every hour. ■ 2. Minimize environmental stimuli. ■ 3. Place the infant in a well-lighted area for observation. ■ 4. Provide stimulation to increase adaptation to the environment.

■ 2. Minimize environmental stimuli.

Carboprost (Hemabate) was injected into the uterus of a client to treat uterine atony during a cesarean section. In preparing to care for this client postpartum, the nurse should assess the client for which of the following common adverse effects of the medication? ■ 1. Vertigo and confusion. ■ 2. Nausea and diarrhea. ■ 3. Restlessness and increased vaginal bleeding. ■ 4. Headache and hypertension.

■ 2. Nausea and diarrhea.

A viable male neonate delivered to a 28-year-old multiparous client by cesarean delivery because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which of the following would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome? ■ 1. Mother's development of placenta previa. ■ 2. Neonate delivered preterm. ■ 3. Mother receiving analgesia 4 hours before delivery. ■ 4. Neonate with sluggish respiratory efforts after delivery.

■ 2. Neonate delivered preterm.

When performing an initial assessment of a post-term male neonate weighing 4,000 g (9 lb) who was admitted to the observation nursery after a vaginal delivery with low forceps, the nurse detects Ortolani's sign. Which of the following actions should the nurse do next? ■ 1. Determine the length of the mother's labor. ■ 2. Notify the pediatrician immediately. ■ 3. Keep the neonate under the radiant warmer for 2 hours. ■ 4. Obtain a blood sample to check for hypoglycemia.

■ 2. Notify the pediatrician immediately.

A multiparous client whose fundus is fi rm and midline at the umbilicus 8 hours after a vaginal delivery tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which of the following would the nurse include when explaining to the client about the increased lochia on ambulation? ■ 1. Her bleeding needs to be reported to the physician immediately. ■ 2. The increased lochia occurs from lochia pooling in the vaginal vault. ■ 3. The increase in lochia may be an early sign of postpartum hemorrhage. ■ 4. This increase in lochia usually indicates retained placental fragments.

■ 2. The increased lochia occurs from lochia pooling in the vaginal vault.

After the nurse teaches a primiparous client planning to return to work in 6 weeks about storing breast milk, which of the following client statements indicates the need for further teaching? ■ 1. "I can let the milk sit out in a bottle for up to 10 hours." ■ 2. "I'll be sure to label the milk with the date, time, and amount." ■ 3. "I can safely store the milk for 3 days in the refrigerator." ■ 4. "I can keep the milk in a deep-freeze in clean glass bottles for up to 1 year."

■ 3. "I can safely store the milk for 3 days in the refrigerator."

Which of the following would the nurse expect to assess in a neonate delivered at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? ■ 1. Increased muscle tone. ■ 2. Hyperbilirubinemia. ■ 3. Bulging fontanels. ■ 4. Hyperactivity.

■ 3. Bulging fontanels.

A primiparous client, 20 hours after delivery, asks the nurse about starting postpartum exercises. Which of the following would be most appropriate to include in the nurse's instructions? ■ 1. Start in a sitting position, then lie back, and return to a sitting position, repeating this fi ve times. ■ 2. Assume a prone position, then do push-ups by using the arms to lift the upper body. ■ 3. Flex the knees while supine, then inhale deeply and exhale while contracting the abdominal muscles. ■ 4. Flex the knees while supine, then bring chin to chest while exhaling and reach for the knees by

■ 3. Flex the knees while supine, then inhale deeply and exhale while contracting the abdominal muscles.

A septic preterm neonate's I.V. was removed due to infi ltration. While restarting the I.V., the nurse should carefully assess the neonate for: ■ 1. Fever. ■ 2. Hyperkalemia. ■ 3. Hypoglycemia. ■ 4. Tachycardia.

■ 3. Hypoglycemia.

Which of the following should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate? ■ 1. "Wait until you have breast-fed for at least 4 months." ■ 2. "Eliminate the baby's favorite feeding times fi rst." ■ 3. "Plan to omit the daytime feedings last." ■ 4. "Gradually eliminate one feeding at a time."

■ 4. "Gradually eliminate one feeding at a time."

A postpartum client delivered 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus 2 fi ngerbreadths above the umbilicus and off to the right side. What should the nurse do fi rst? ■ 1. Administer ibuprofen (Motrin). ■ 2. Reassess in 1 hour. ■ 3. Catheterize the client. ■ 4. Administer an I.V. bolus of 500 mL to rehydrate per policy.

■ 4. Administer an I.V. bolus of 500 mL to rehydrate per policy.

The nurse on the night shift fi nds a multiparous client, 8 hours postpartum, drenched in perspiration. The client's temperature is 99° F (36.8° C), the pulse is 68 bpm, and the blood pressure is 120/80 mm Hg. Which of the following nursing diagnoses is a priority? ■ 1. Risk for infection (postpartum) related to birth trauma. ■ 2. Ineffective thermoregulation related to hormonal changes. ■ 3. Ineffective tissue perfusion: Renal related to the status of multiparity. ■ 4. Excess fl uid volume related to normal postpartal diuresis.

■ 4. Excess fl uid volume related to normal postpartal diuresis.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breast-feed the neonate. Which of the following instructions about breast-feeding would be most appropriate? ■ 1. Breast-feeding is not recommended because the neonate needs increased fat in the diet. ■ 2. Once the neonate no longer needs oxygen and continuous monitoring, breast-feeding can be done. ■ 3. Breast-feeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. ■ 4. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

■ 4. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

A multiparous client visits the urgent care center 5 days after a vaginal delivery experiencing persistent lochia rubra in a moderate to heavy amount. The client asks the nurse, "Why am I continuing to bleed like this?" The nurse should instruct the client that this type of postpartum bleeding is usually caused by which of the following? ■ 1. Uterine atony. ■ 2. Cervical lacerations. ■ 3. Vaginal lacerations. ■ 4. Retained placental fragments.

■ 4. Retained placental fragments.

The nurse is evaluating the client who delivered vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a G 4, P 4, breast-feeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the orders sheet would be the most appropriate for this client? ■ 1. Aspirin 1,000 mg P.O. q 4 to 6 hour p.r.n. ■ 2. Ibuprofen 800 mg P.O. q 6 to 8 hour p.r.n. ■ 3. Colace 100 mg P.O. b.i.d. ■ 4. Vicodin 1 to 2 tabs P.O. q 4 to 6 hour p.r.n.

■ 4. Vicodin 1 to 2 tabs P.O. q 4 to 6 hour p.r.n.

The nurse is caring for a multiparous client after vaginal delivery of a set of male twins 2 hours ago. The nurse should encourage the mother and husband to: ■ 1. Bottle-feed the twins to prevent exhaustion and fatigue. ■ 2. Plan for each parent to spend equal amounts of time with each twin. ■ 3. Avoid assistance from other family members until attachment occurs. ■ 4. Relate to each twin individually to enhance the attachment process.

■ 4. Relate to each twin individually to enhance the attachment process.

Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which of the following statements by the infant's mother indicates understanding of the disease and its management? Select all that apply. ■ 1. "My baby can't have milk-based formulas." ■ 2. "My baby will grow out of this by the age of 2." ■ 3. "This is a hereditary disease, so any future children will have it, too." ■ 4. " My baby will eventually become retarded because of this disease." ■ 5. "We have to follow a strict phenylalanine diet." ■ 6. "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow."

1, 5, 6

An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifi er in the infant's mouth during these feedings. The nurse replies that the pacifi er helps in what ways? Select all that apply. ■ 1. Teaches the infant to suck and swallow. ■ 2. Provides oral stimulation. ■ 3. Keeps oral mucus membranes moist while the tube is in place. ■ 4. Reminds the infant how to suck. ■ 5. Stimulates secretions that help gastric emptying.

2, 4, 5

The nurse is completing discharge instructions with a new mother and is concerned about her safety. Which statement by the client indicates the client needs further instructions? ■ 1. "I will need to be checked out by the doctor in a week." ■ 2. "I need to wear a sports bra for a few days so I don't get milk." ■ 3. "I can get pregnant now if I don't use birth control." ■ 4. "I may feel sad for a few days but should be OK within a few days."

■ 1. "I will need to be checked out by the doctor in a week."

A neonate born at 29 weeks' gestation received nasal continuous positive airway pressure. The neonate is receiving oxygen at 1 L/minute via nasal cannula at a fraction of inspired oxygen (FIO2) of 0.23. The pulse oximetry reading is 70% saturation. In which order of priority from fi rst to last should the nurse take these actions? 1. Increase the FIO2. 2. Make sure the pulse oximeter is correlating to the heart rate. 3. Assess the neonate for color. 4. Assess the neonate for respiratory effort.

4, 3, 2, 1

In response to the nurse's question about how she is feeling, a postpartum client states that she is fi ne. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation? ■ 1. Taking in. ■ 2. Taking on. ■ 3. Taking hold. ■ 4. Letting go.

■ 1. Taking in.

A male neonate born at 38 weeks' gestation by cesarean delivery after prolonged rupture of the membranes and a maternal oral temperature of 102° F (38.8° C) is being observed for signs and symptoms of infection. Which of the following would alert the nurse to notify the physician? ■ 1. Leukocytosis. ■ 2. Apical heart rate of 132 bpm. ■ 3. Behavioral changes. ■ 4. Warm, moist skin.

■ 3. Behavioral changes.

After the physician explains the prognosis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condition, the nurse determines that the mother needs further instructions when she says which of the following? ■ 1. "As my child grows, she may have increased fatigue and diffi culty breathing." ■ 2. "My child may need to have antibiotics if she develops an infection." ■ 3. "This condition occurs more commonly in females than in males." ■ 4. "About half of the children born with this defect heal spontaneously."

■ 4. "About half of the children born with this defect heal spontaneously."

When developing the plan of care for a primiparous client during the fi rst 12 hours after vaginal delivery, which of the following concerns of the client should be the nurse's primary focus of care? ■ 1. The neonate. ■ 2. The family. ■ 3. The client's own comfort. ■ 4. The client's signifi cant other.

■ 3. The client's own comfort.

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she is aware of a "let-down sensation" in her breasts and asks what causes it. The nurse explains that the let-down sensation is stimulated by which of the following? ■ 1. Adrenalin. ■ 2. Estrogen. ■ 3. Prolactin. ■ 4. Oxytocin.

■ 4. Oxytocin.

On the fi rst postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for: ■ 1. Puerperal infection. ■ 2. Vaginal lacerations. ■ 3. History of drug abuse. ■ 4. Perineal hematoma.

■ 4. Perineal hematoma.

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should: ■ 1. Write down the results, read back the results to the caller from the laboratory, and receive confi rmation from the caller that the nurse understands the results. ■ 2. Repeat the results to the caller from the laboratory, write the results on scrap paper fi rst, and then transfer the results to the chart. ■ 3. Indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery. ■ 4. Request that the laboratory send the results by e-mail to transfer to the client's electronic record.

1. Write down the results, read back the results to the caller from the laboratory, and receive confi rmation from the caller that the nurse understands the results.

A viable female neonate was delivered 10 minutes ago and is in stable condition under a radiant warmer. To prevent infant heat loss by convection, the nurse should: ■ 1. Move the infant away from cool window surfaces. ■ 2. Make certain the infant has no contact with cool surfaces. ■ 3. Dry the infant's skin with a towel. ■ 4. Position the infant away from drafts and cooling ducts. Use rationale in 9th Edition, page 132. (A)

■ 4. Position the infant away from drafts and cooling ducts.