OB Testbank: Test 2
The nurse is teaching a postpartum client information regarding weaning her infant from breastfeeding. Which client statement suggests a need for further teaching? 1. "Slow weaning should take place over a period of several months." 2. "By weaning my baby slowly, I'm giving him time to change his eating method at his own pace." 3. "If I wean my baby slowly, I am less likely to develop breast engorgement." 4. "Slowly weaning my baby is recommended to allow time for my psychologic adjustment."
1. "Slow weaning should take place over a period of several months."
The nurse suspects that a newborn needs a complete neurologic examination by a healthcare provider. What finding did the nurse use to make this clinical decision? Select all that apply. 1. Absence of the plantar grasp 2. Absence of the truncal reflex 3. Presence of the stepping reflex 4. Presence of a nonnutritive sucking reflex 5. Presence of bringing the hand to the mouth
1. Absence of the plantar grasp 2. Absence of the truncal reflex
The nurse is caring for a postpartum client who is 4 hours postoperative following a cesarean birth. Which nursing interventions are appropriate based on these data? Select all that apply. 1. Administering the prescribed analgesics, as needed 2. Encouraging ambulation to the bathroom to void 3. Encouraging leg exercises every 2 hours 4. Encouraging coughing and deep breathing every 2 to 4 hours 5. Encouraging the use of breathing, relaxation, and distraction
1. Administering the prescribed analgesics, as needed 3. Encouraging leg exercises every 2 hours 4. Encouraging coughing and deep breathing every 2-4 hours 5. Encouraging the use of breathing, relaxation, and distraction
The nurse is assessing the episiotomy of a client who is 2 days postpartum. In which order should the nurse complete this assessment? A. Edema B. Redness C. Ecchymosis D. Approximation E. Discharge/drainage 1. B, A, C, E, D 2. A, B, D, E, C 3. B, A, D, E, C 4. D, E, C, B, A
1. B, A, C, E, D REEDA
Which safety device is most appropriate for the nurse who conducts home care visits to postpartum mothers? 1. Cellular phone 2. Map of the area 3. Personal handgun 4. Can of Mace
1. Cellular phone
Which is the obese postpartum client at a greater risk for experiencing? Select all that apply. 1. Injury 2. Infection 3. Breast engorgement 4. Deep vein thrombosis 5. Respiratory complications
1. Injury 2. Infection 4. Deep vein thrombosis 5. Respiratory complications
The postpartum client, who delivered 4 hours ago, has a mediolateral episiotomy and large hemorrhoids. The client currently rates her pain at 7 on a scale of 1 to 10. She has a history of anaphylactic reaction to acetaminophen (Tylenol). Which nursing action is most appropriate? 1. Offering 800 mg ibuprofen (Advil) orally with food 2. Providing two oxycodone with acetaminophen tablets (Percocet) by mouth 3. Encouraging use of the prescribed topical anesthetic spray 4. Running very warm water into the tub and assisting her into the bath
1. Offering 800 mg ibuprofen (Advil) orally with food
Which will the nurse include in the family assessment for the postpartum client? Select all that apply. 1. Parental roles 2. Bonding behaviors 3. Sibling adjustment 4. Signs and symptoms of infection 5. Level of comfort with newborn care
1. Parental roles 2. Bonding behaviors 3. Sibling adjustment 5. Level of comfort with newborn care
The nurse is providing care to a lesbian postpartum client and her life partner. Which nursing actions are appropriate when providing care to this couple? Select all that apply. 1. Providing the couple with the same rights and care as those given to heterosexual couples 2. Educating the couple about heterosexual contraception during the postpartum period 3. Teaching the couple about when it is safe to resume sexual relations 4. Encouraging the couple to join a support group of other postpartum lesbian couples 5. Expecting the nonpregnant partner to assume the role of father
1. Providing the couple with the same rights and care as those given to heterosexual couples 3. Teaching the couple about when it is safe to resume sexual relations 4. Encouraging the couple to join a support group of other postpartum lesbian couples
The nurse is caring for a newborn with the following device: a Plastibell (used for circumcision) What should be included when instructing the parents about the newborn's care? Select all that apply. 1. The device should fall off in 8 days. 2. Apply petroleum jelly to the site after the device falls off. 3. Clean with warm water and mild soap after each diaper change. 4. Apply light pressure with a sterile gauze pad if bleeding occurs. 5. Abstain from applying cream or ointment while the device is present.
1. The device should fall off in 8 days. 2. Apply petroleum jelly to the site after the device falls off. 5. Abstain from applying cream or ointment while the device is present.
The nurse notes that a newborn has a dry scalp. What should the nurse include when teaching the parents about the care of this newborn? Select all that apply. 1. Use mild soap. 2. Use baby shampoo. 3. Wash the scalp daily. 4. Apply oil every other day. 5. Rinse the scalp with hot water.
1. Use mild soap. 2. Use baby shampoo. 3. Wash the scalp daily.
The nurse is conducting discharge teaching for a postpartum client who has an episiotomy. Which client actions indicate correct understanding of the information presented? Select all that apply. 1. Using topical anesthetics regularly 2. Remaining in the sitz bath for 20 minutes 3. Using the peri-bottle to cleanse the site after urination 4. Stating that she will loosen her buttocks prior to sitting down 5. Stating that she will continue to use an ice pack for pain after discharge
1. Using topical anesthetics regularly 2. Remaining in the sitz bath for 20 minutes 3. Using the peri-bottle to cleanse the site after urination
The nurse encounters a woman giving birth at the local shopping mall. What should the nurse do first? 1. Visualize the perineum. 2. Apply counterpressure to the perineum. 3. Ask a bystander for a dry piece of clothing. 4. Determine if the membranes have ruptured.
1. Visualize the perineum.
The client in labor arrives at the birthing unit with her partner. Which step of the admission process should be completed first? 1. Welcoming the couple 2. The sterile vaginal examination 3. Auscultation of the fetal heart rate 4.Checking for ruptured membranes
1. Welcoming the couple
The nurse is instructing a postpartum client on the use of perineal pads. Which statements should the nurse include in the teaching session? Select all that apply. 1. "Apply the pad from back to front." 2. "Change the pad after each perineal cleansing." 3. "Place the pad so that it applies pressure to the perineum." 4. "Change the pad each time you use the bathroom." 5. "Your pad should be loose to allow the perineum to 'breathe.' "
2. "Change the pad after each perineal cleansing." 4. "Change the pad each time you use the bathroom."
The nurse decides that a family with a newborn would benefit from a Social Services consultation. What statements were made by family members that caused the nurse to make this decision? Select all that apply. 1. "I think we're getting along better." 2. "I'm not going to let a baby make me fat." 3. "My mother could care less about this baby." 4. "At least help me if you don't want to get a job." 5. "That's fine. Go to work. Leave me here to do all of the work."
2. "I'm not going to let a baby make me fat." 3. "My mother could care less about this baby." 4. "At least help me if you don't want to get a job." 5. "That's fine. Go to work. Leave me here to do all of the work."
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." Which response by the nurse is most appropriate? 1. "We'll take good care of you and your baby. You'll be home before you know it." 2. "You'll be wearing sequential compression devices to prevent blood clots from forming in your legs." 3. "You will have a lot of pain, but there are medications that we give when it gets bad." 4. "You won't be able to nurse until the baby is 12 hours old because of your epidural."
2. "You'll be wearing sequential compression devices to prevent blood clots from forming in your legs."
What amount of weight loss, in pounds, should the nurse expect in an average postpartum client? 1. 5 to 8 2. 10 to 12 3. 12 to 15 4. 15 to 20
2. 10 to 12
During a home visit the nurse is concerned that a new mother is experiencing postpartum blues. What did the nurse assess to make this clinical determination? Select all that apply. 1. Fear 2. Anger 3. Euphoria 4. Anorexia 5. Weepiness
2. Anger 4. Anorexia 5. Weepiness
Which information is least likely recorded as a part of the initial newborn assessment? 1. Presence or absence of meconium-stained fluid 2. Blood draw for phenylketonuria (PKU) screening 3. Resuscitative measures required in the birthing area 4. Parents' desires regarding circumcision for a male infant
2. Blood draw for phenylketonuria (PKU) screening
The nurse is assisting a mother to bottle-feed her newborn, who has been crying. What should the nurse instruct the client to do before feeding the infant? 1. Offer a pacifier. 2. Burp the newborn. 3. Unwrap the newborn. 4. Stroke the newborn's spine and feet.
2. Burp the newborn.
What should be the nurse's priority when caring for an adolescent in labor? 1. Support persons 2. Developmental level 3. Cultural background 4. Plans for keeping the infant
2. Developmental level
The nurse is caring for a client who plans to relinquish her baby for adoption. Which nursing actions are appropriate based on this information? Select all that apply. 1. Encourage the client to see and hold her infant. 2. Encourage the client to express her emotions. 3. Respect any special requests for the birth. 4. Acknowledge the grieving process in the client. 5. Allow for access to the infant if the client requests it.
2. Encourage the client to express her emotions. 3. Respect any special requests for the birth. 4. Acknowledge the grieving process in the client. 5. Allow for access to the infant if the client requests it.
The nurse is observing a graduate nurse's assessment of a postpartum client. For which action by the graduate nurse should the nurse intervene? 1. Asking the client to void before applying clean gloves 2. Instructing visitors to leave the room prior to beginning the assessment 3. Requesting the client lie flat in bed with the head on a pillow prior to the fundal assessment 4. Discussing the effectiveness of comfort measures while performing the perineal assessment
2. Instructing visitors to leave the room prior to beginning the assessment
A postpartum client is not going to breastfeed her newborn. What should the nurse include when teaching this client about breast care? 1. The let-down reflex 2. Lactation suppression 3. The purpose of fundal massage 4. The cause of afterpains
2. Lactation suppression
The nurse is caring for a client who delivered by cesarean birth and during which she received a general anesthetic. Which will the nurse encourage to prevent or minimize abdominal distention? Select all that apply. 1. Increasing intake of cold beverages 2. Participating in leg exercises every 2 hours 3. Tightening the abdominal muscles 4. Ambulating as often as possible 5. Eating a high-protein general diet
2. Participating in leg exercises every 2 hours 3. Tightening the abdominal muscles 4. Ambulating as often as possible
The nurse is preparing to assess assigned clients on a postpartum unit. Which client should be seen first? 1. Multipara, second day postcesarean, moderate lochia serosa 2. Primipara, day of delivery, fundus firm 2 cm above umbilicus 3. Multipara, first postpartum day, 4 cm diastasis recti abdominis 4. Primipara, first postpartum day, hypoactive bowel sounds all quadrants
2. Primipara, day of delivery, fundus firm 2 cm above umbilicus
Every time the nurse enters the client's room, the client, who delivered 3 hours ago, asks the nurse something else about the birth experience. What action should the nurse take? 1. Answer questions quickly and try to divert attention to other subjects. 2. Review documentation of the birth experience and discuss it with the client. 3. Contact the healthcare provider because of changes in the client's memory. 4. Submit a referral to Social Services because of concerns about obsessive behavior.
2. Review documentation of the birth experience and discuss it with the client.
The nurse completes a postpartum assessment on a client who gave birth to her first child 12 hours ago. Assessment findings include: the client nauseated, but has not vomited in the last 2 hours; fundus was boggy but firmed with massage to 1 FB ↓ the uterus; client is experiencing moderately heavy lochia rubra and the perineum ecchymotic and edematous. The client's pain rating is 6 on scale of 1 to 10. Her partner is present and supportive. Breastfeeding has been successful 3 times. Which nursing diagnosis has the highest priority for this client? 1. Acute Pain related to perineal trauma 2. Risk for Deficient Fluid Volume related to uterine bleeding and nausea 3. Readiness for Enhanced Family Coping related to vaginal childbirth experience 4. Knowledge Deficit related to newborn care
2. Risk for Deficient Fluid Volume related to uterine bleeding and nausea
A new mother rarely interacts with the infant unless the infant begins to cry vigorously and she appears relieved when the nurse comes to check on the infant. What is the appropriate nursing intervention for this patient? 1. Contact Social Services with concerns of neglect. 2. Teach the client how to interact appropriately with the infant. 3. Take the infant to the nursery so the baby can receive more consistent care. 4. Provide the care the infant needs while continuing to evaluate the mother's actions.
2. Teach the client how to interact appropriately with the infant.
A client who delivered a day ago has chosen to breastfeed her infant. Which observation best indicates that the client understands breastfeeding? 1. The infant is crying when brought to the breast. 2. The client takes off her gown to achieve skin-to-skin contact. 3. The infant is held so that the nipple is accessed by turning the head. 4. The client puts the infant to breast when the baby is asleep to help wake the baby up.
2. The client takes off her gown to achieve skin-to-skin contact.
The nurse is making a visit to the home of a new mother. Which observation indicates that the mother and infant are in the phase of mutual regulation? 1. The infant grasps the mother's finger while nursing. 2. The mother vocalizes feelings of frustration with her infant. 3. The infant begins to seek out the mother over other individuals. 4. The mother spends more time making eye-to-eye contact with the infant.
2. The mother vocalizes feelings of frustration with her infant.
On the first postpartum day, the nurse teaches a client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. What should the nurse identify as the reason for the client's memory lapse? 1. Epidural anesthesia 2. The taking-in phase 3. The taking-hold phase 4. Postpartum hemorrhage
2. The taking-in phase
During a postpartum home visit the nurse reinforces the importance of holding the infant and having tummy time periodically through the day with the new mother. What did the nurse observe that indicated the mother needed additional teaching? Select all that apply. 1. Rapid respiratory rate 2. Weak gross motor skills 3. Crusted nasal secretions 4. Positional plagiocephaly 5. Sluggish upper body strength
2. Weak gross motor skills 4. Positional plagiocephaly 5. Sluggish upper body strength
A postpartum client becomes concerned when a gush of blood occurs during the fundal assessment. What should the nurse explain about this occurrence? 1. "Do not worry. I will make sure everything is fine." 2. "We see this from time to time. It's not a big deal." 3. "Blood has pooled in the vagina while you were in bed." 4. "The gush is an indication that your fundus is not contracting."
3. "Blood has pooled in the vagina while you were in bed."
During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate? 1. "Current research suggests there are no physical risks related to cosleeping, and this recommended as a healthy psychologic approach to family bonding. 2. "Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on the stomach." 3. "Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines." 4. "Cosleeping is not recommended; however, if you wish to do this, place your baby on a comforter, as opposed to directly on the mattress."
3. "Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines."
The maternal home care nurse, who is orienting a new nurse, discusses maternal psychologic adaptations and stressors. Which statement by the maternal home care nurse reflects the correct approach to addressing potential and actual postpartum depression in maternal clients? 1. "Because emotional disorders and imbalances are a very sensitive subject, we try not to offend clients by routinely bringing up the topic of postpartum depression." 2. "For women with a history of depression, we include education about postpartum depression." 3. "Teaching about postpartum depression is a routine part of education for all maternal clients." 4. "If we suspect a woman may have developed postpartum depression, then we provide specialized education about that topic."
3. "Teaching about postpartum depression is a routine part of education for all maternal clients."
On the second day postpartum, the client who is bottlefeeding experiences engorgement. Which should the nurse encourage to enhance the client's comfort? 1. Removing her bra 2. Applying heat to her breasts 3. Applying ice packs to her breasts 4. Limiting breastfeeding to twice daily
3. Applying ice packs to her breasts
The nurse is performing an assessment of early attachment. Which action indicates that the client is pleased with the baby's appearance and sex? 1. The mother enfolds the infant in her arms. 2. The mother feeds the infant every 2 to 3 hours as instructed. 3. The mother points out family traits she sees in the newborn. 4. The mother asks questions about how to properly bathe her infant.
3. The mother points out family traits she sees in the newborn.
The nurse is caring for an adolescent client who gave birth to her first child yesterday. Which nursing action indicates accurate understanding of adolescent parenting concepts? 1. The client's mother is included in all discussions and demonstrations. 2. The father of the baby is encouraged to change a diaper and give a bottle. 3. The nurse explains the characteristics and cues of the baby during the assessment. 4. A discussion on contraceptive methods is the first topic of teaching.
3. The nurse explains the characteristics and cues of the baby during the assessment.
The nurse is not familiar with the cultural background of new parents who have recently immigrated to the United States. What statement is best? 1. "You appear to be Muslim. Do you want your son to be circumcised?" 2. "Let me explain how newborn care takes place here in the United States." 3. "Your baby is a U.S. citizen. You must be very happy about that." 4. "Could you explain what your preferences are regarding child care?"
4. "Could you explain what your preferences are regarding child care?"
The nurse is teaching a postpartum client when light housekeeping can be resumed. Which response by the client indicates accurate understanding of the information provided? 1. "I can resume light housekeeping after the 6-week postpartum checkup." 2. "I can resume light housekeeping during my first week at home." 3. "I can resume light housekeeping during my second day at home." 4. "I can resume light housekeeping after my second week at home."
4. "I can resume light housekeeping after my second week at home."
A new mother is concerned about spoiling her newborn. Which statement should the home care nurse include in this teaching session with the new mother? 1. "Spoiling occurs when an infant is rocked to sleep every night." 2. "Newborns can be manipulative, so caution is advised." 3. "Crying is good for an infant, and letting them cry it out is advised." 4. "It is important to meet your infant's needs to develop a trusting relationship."
4. "It is important to meet your infant's needs to develop a trusting relationship."
During a home care visit, the new breastfeeding mother reports breast engorgement. Which statement by the home care nurse is most appropriate based on this information? 1. "Apply an ice compress to your breast before nursing." 2. "Encourage your baby to suckle for an average of 5 minutes per feeding." 3. "Apply warm compresses to your breast after you finish feeding your baby." 4. "When you are not nursing, wear a well-fitted nursing bra at all times, even when you sleep."
4. "When you are not nursing, wear a well-fitted nursing bra at all times, even when you sleep."
A new parent asks why the baby appears to be occasionally cross-eyed. When should the nurse instruct the parent that this finding will resolve? 1. 1 year 2. 2 weeks 3. 2 months 4. 4 months
4. 4 months
The nurse is preparing material to instruct a client who has given birth to her first child. What aspect of teaching is most important? 1. Determine if father-infant attachment is taking place. 2. Discuss adaptation to grandparenthood by her parents. 3. Describe the likely reaction of siblings to the new baby. 4. Assist the mother in identifying behavior cues of the baby.
4. Assist the mother in identifying behavior cues of the baby.
What should the nurse assess to determine healing of the uterus at the placental site? 1. Laboratory values 2. Uterine size 3. Blood pressure 4. Type, amount, and consistency of lochia
4. Type, amount, and consistency of lochia
The hospital is developing a new maternity unit. What aspects should be included in the planning of this new unit to best promote family wellness? 1. Normal newborn nursery centrally located to all client rooms 2. A kitchen with refrigerator stocked with juice and sandwiches 3. Small, cozy rooms with a client bed and rocking chair 4.A nursing model based on providing couplet care
4.A nursing model based on providing couplet care
The nurse is providing care to a postpartum client who is relinquishing custody of her newborn through an open adoption. Which nursing action is most important? 1. Assigning the client a room on the GYN surgical floor instead of the postpartum floor 2. Preparing to have teaching done in time for discharging the client at 24 hours postdelivery 3. Making an effort not to bring up the topic of the baby, and discuss the mother's health instead 4.Asking the client if she wants to feed her baby, and how much contact she wants to have
4.Asking the client if she wants to feed her baby, and how much contact she wants to have
The nurse documents that a postpartum client's volume of lochia is moderate. What did the nurse most likely assess to make this clinical determination? (photos not available)
Answer: 3 Explanation: 1. This would be estimated as a scant amount of lochia. 2. This would be estimated as a light amount of lochia. 3. This would be estimated as a moderate amount of lochia. 4. This would be estimated as a heavy amount of lochia.
In which order should the nurse conduct the examination of a postpartum client? 1. L-lochia 2. B-bowel 3. B-breast 4. U-uterus 5. B-bladder 6. E-emotional 7. H-Homans/hemorrhoids 8. E-episiotomy/laceration/edema
Answer: 3, 4, 5, 2, 1, 8, 7, 6
A postpartum client weighing 165 lb is prescribed to take 12 mg/kg/day of lysine to help with afterpains. If the client ingests 375 mg of lysine in food, how many additional milligrams of the supplement should the client take? (Calculate to the nearest whole number.)
Answer: 525 mg Explanation: First determine the client's weight in kilograms by dividing the weight in pounds by 2.2, or 165/2.2 = 75 kg. Then determine the amount of lysine that should be taken each day by multiplying the client's weight by 12, or 75 × 12 mg = 900 mg. If the client ingests 375 mg of lysine each day in food, then subtract this amount from the total amount of lysine, or 900 - 375 = 525 mg.
A client weighing 80 kg lost 5 kg of body weight immediately after delivery. In 2 days, another 3 kg has been lost. During a 6-week postpartum examination the client was pleased to learn of returning to her prepregnancy weight of 143 lb. How many kilograms of weight did the client lose during the 6 weeks postpartum? (Calculate to the nearest whole number.)
Answer: 7 kg Explanation: First determine the client's starting weight in pounds by multiplying her weight in kilograms by 2.2, or 80 × 2.2 = 176. Then subtract the prepregnancy weight from the pregnancy weight, or 176 - 143 = 33 pounds. Then divide the weight in pounds by 2.2, or 33/2.2 = 15 kg. Then subtract the total number of kilograms lost after delivery from the total weight of 15 kg. or 15 kg - 5 kg - 3 kg = 7 kg. The client lost 7 kg of weight in 6 weeks.
The nurse is teaching a group of new parents on ways to ensure body heat regulation of their newborns. Which diagram should the nurse use to explain the process of radiation?
Baby has heat coming off of them onto a surface.
The nurse is assessing the abdomen of a client who delivered an infant 1 hour ago. On the diagram, where should the nurse assess the client's uterine level?
Below the umbilicus. Explanation: Immediately after delivery of the placenta, the top of the fundus is in the midline and approximately halfway between the symphysis pubis and the umbilicus.
The nurse is preparing to inject a dose of vitamin K to a newborn after delivery. Identify on the diagram where the nurse should provide this injection. (location of an IM injection for a newborn
vastus lateralis Explanation: A one-time-only prophylactic dose of vitamin K 0.5 to 1.0 mg is given intramuscularly in the middle third of the vastus lateralis muscle, located in the lateral aspect of the thigh. The middle third of the vastus lateralis muscle is the preferred site for intramuscular injection in the newborn.
The nurse is instructing a group of new parents about normal newborn behavior. Which attendee's statement indicates that teaching was effective? 1. "My baby will be able to hear very well immediately after birth." 2. "My baby will have difficulty seeing me close up right after delivery." 3. "My baby should be discouraged from sucking on a pacifier if being bottle fed." 4. "My baby should be trained to breastfeed by being encouraged to suck on a pacifier before feedings."
1. "My baby will be able to hear very well immediately after birth."
A client scheduled for elective cesarean birth in 4 hours asks for a sip of coffee with creamer. How should the nurse respond? 1. "You can drink black coffee." 2. "You may have coffee with creamer." 3. "You are only allowed to drink water right now." 4."Since you are having surgery today, you're not allowed to have anything to eat or drink."
1. "You can drink black coffee."
The nurse has presented a teaching session on pain relief options to a prenatal class. Which client statement indicates that additional teaching is needed? 1. "An epidural can be continuous or one dose." 2. "General anesthesia is usually recommended for a cesarean section." 3. "Narcotics can be given through a client's epidural infusion catheter." 4. "A pudendal block usually works well to control pain during episiotomy repair."
2. "General anesthesia is usually recommended for a cesarean section."
The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. How should the nurse interpret this finding? 1. Prematurity 2. Facial paralysis 3. A normal position 4. A possible chromosomal abnormality
3. A normal position
The nurse is assessing newborns in the nursery. Which assessment finding places a newborn at risk for developing physiologic jaundice? 1. Molding 2. Mongolian spots 3. Cephalohematoma 4. Telangiectatic nevi
3. Cephalohematoma
The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? 1. Mean blood pressure 55 mmHg 2. Pulse rate 145, systolic murmur heard 3. Pauses in respiration lasting 30 seconds 4. Respiratory rate 60, crackles present bilaterally
3. Pauses in respiration lasting 30 seconds
The nurse notes the presence of a cephalohematoma on the head of a newborn. What did the nurse use to make this clinical determination? Select all that apply. 1. The head appears asymmetric. 2. The mass overrides the suture line. 3. The mass appears only on one side of the head. 4. The mass appeared on the second day after birth. 5. The mass appears larger when the newborn cries.
3. The mass appears only on one side of the head. 4. The mass appeared on the second day after birth.
An infant weighing 8 lb, 4 oz at birth weighs 7 lb, 15 oz 3 days later. What should the nurse explain to the parents about this change in the newborn's weight? 1. "This weight loss is unusual." 2. "This weight loss is less than expected." 3. "This weight loss is excessive." 4. "This weight loss is within normal limits."
4. "This weight loss is within normal limits."
The nurse is reviewing the medical records of several newborns. Which infant requires immediate intervention? 1. 24-hour-old term male with total bilirubin level of 2 2. 3-day-old term bottle-fed female with bilirubin of 11 3. 2-week-old postterm breastfed male with bilirubin of 10 4. 12-hour-old preterm female exhibiting icterus and lethargy
4. 12-hour-old preterm female exhibiting icterus and lethargy
A client in labor who is receiving a continuous infusion of a local anesthetic through an epidural catheter asks if ear ringing is supposed to occur. What is the most likely cause of the client's complaint? 1. Dehydration 2. Hypotension 3. Allergic reaction 4. Local anesthetic toxicity
4. Local anesthetic toxicity
The nurse notes that a 1-day-old infant's immunoglobulin M (IgM) antibodies are elevated. Which is the least likely cause for this elevation? 1. Placental leakage 2. Intrauterine exposure to syphilis 3. Intrauterine exposure to TORCH (toxoplasmosis, rubella, cytomegalovirus, herpesvirus hominis type 2 infection) syndrome 4. Maternal-fetal transfer of IgM while in utero
4. Maternal-fetal transfer of IgM while in utero
A newborn weighing 7.7 lb has an estimated bladder capacity of 20 mL. If 25 mL/kg of urine is expected to be produced each day, how many diaper changes will this baby need? (Calculate by rounding to the nearest whole number.)
Answer: 4 Explanation: First determine the baby's weight in kilograms by dividing 7.7 pounds by 2.2, or 7.7/2.2 = 3.5 kg. Then multiply the weight by 25 mL/kg = 25 × 3.5 = 87.5, which is the amount of urine produced by the newborn. Then divide the total amount of urine by the bladder capacity of 20 mL, or 87.5/20 = 4.375. With rounding, the baby will need an estimated 4 diaper changes each day.
The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching about a client admission has been effective?" 1. "A vaginal examination is performed if delivery appears to be imminent." 2. "Her prenatal record is reviewed for indications of domestic abuse." 3. "She will be positioned supine to facilitate a normal blood pressure." 4. "A urine specimen is obtained by catheter to check for protein and ketones."
1. "A vaginal examination is performed if delivery appears to be imminent."
The nurse is teaching a class for new parents. Which statement indicates that additional information is needed? 1. "Car seats are installed the same way in different models of cars. Our friends can show us how to install it." 2. "Genitals of babies look swollen and enlarged at birth as a result of the hormones in the mother's circulation." 3. "We can call the nurse help line any time of day or night if we have questions about our baby after we get home." 4. "Baby girls sometimes have a little bloody mucus in their diapers as a reaction to the high estrogen level in the mother."
1. "Car seats are installed the same way in different models of cars. Our friends can show us how to install it."
The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? 1. "Giving the baby his first bath can really give me a chance to get to know him." 2. "Newborns cannot focus their eyes, so it does not matter how I hold my new baby." 3. "My baby will be very sleepy immediately after birth, so he can go to the nursery." 4. "I should avoid looking directly into the baby's eyes to prevent frightening the baby."
1. "Giving the baby his first bath can really give me a chance to get to know him."
The nurse is instructing the parents of a newborn about the number of wet diapers to expect each day. Which statement by the parents indicates that further education is necessary? 1. "Our baby was born with kidneys that are too small." 2. "Feeding our baby frequently will help the kidneys function." 3. "Kidney function in an infant is very different from in an adult." 4. "A baby's kidneys do not concentrate urine well for several months."
1. "Our baby was born with kidneys that are too small."
The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Select all that apply. 1. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough." 2. "When we change the baby's diaper, we should change any wet clothing or blankets, too." 3. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." 4. "We should make sure that we keep our home air conditioned so the baby does not overheat." 5. "If the baby's body temperature gets too low, he will warm himself up without any shivering."
1. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough." 2. "When we change the baby's diaper, we should change any wet clothing or blankets, too." 3. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." 5. "If the baby's body temperature gets too low, he will warm himself up without any shivering."
The home care nurse notes jaundice on the skin over the sternum of a 3-day-old infant. What should the nurse explain to the parents about this finding? 1. "The liver of an infant is not fully mature and does not conjugate the bilirubin for excretion." 2. "The yellow color of your baby's skin indicates that you are breastfeeding too often." 3. "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should." 4."The infant received too many red blood cells after delivery because the cord was not clamped immediately."
1. "The liver of an infant is not fully mature and does not conjugate the bilirubin for excretion."
The blood pressure of a client receiving continuous epidural anesthesia for labor has changed from 132/78 mmHg to 78/42 mmHg. What action should the nurse perform first? 1. Administer oxygen. 2. Administer ephedrine 5 to 10 mg intravenously. 3. Verify the client is positioned to promote left uterine displacement. 4. Increase the flow rate of infusion of intravenous crystalloid solution.
1. Administer oxygen.
A young adolescent is in active labor but did not know that she was pregnant. What is the most important nursing action? 1. Assess blood pressure and check for proteinuria. 2. Obtain a Social Services referral to discuss adoption. 3. Determine who might be the father of the baby for paternity testing. 4. Ask the client what kind of birthing experience she would like to have.
1. Assess blood pressure and check for proteinuria.
The newborn at 24 hours of age has a red blood cell (RBC) count of 5.4 million per milliliter. Which entry should the nurse expect to find in the newborn's chart to explain this laboratory value? 1. Cord clamping delayed until pulsation ceased. 2. Infant is breastfed 15 to 20 minutes every 3 hours. 3. CBC drawn from the anterior surface of the left hand. 4. Placental abruption noted to be 80% at time of delivery.
1. Cord clamping delayed until pulsation ceased.
The nurse is planning to assess a newborn's neurologic status. Which behaviors should the nurse focus on during this assessment? Select all that apply. 1. Cry 2. Reflexes 3. Alertness 4. Motor activity 5. Resting posture
1. Cry 3. Alertness 4. Motor activity 5. Resting posture
The parents of a newborn are concerned that their baby continues to lose weight despite being held and cuddled. What should the nurse tell these parents? Select all that apply. 1. Excessive handling increases caloric use. 2. Permit the newborn to rest quietly when eyelids flutter. 3. Constant handling increases metabolic rate. 4. Gently flick the sole of the foot to stimulate. 5. Avoid stimulating when eye contact is absent.
1. Excessive handling increases caloric use. 2. Permit the newborn to rest quietly when eyelids flutter. 3. Constant handling increases metabolic rate. 5. Avoid stimulating when eye contact is absent.
The nurse is preparing a client in labor for an emergency cesarean section. Which medication should the nurse expect to be prescribed to prevent the effects of aspirated gastric contents? Select all that apply. 1. Famotidine (Pepcid) 2. Cimetidine (Tagamet) 3. Omeprazole (Prilosec) 4. Pantoprazole (Protonix) 5. Metoclopramide (Reglan)
1. Famotidine (Pepcid) 2. Cimetidine (Tagamet) 5. Metoclopramide (Reglan)
The nurse is preparing to admit a pregnant client who is Muslim to the birthing center. What should the nurse keep in mind during the labor process? Select all that apply. 1. Have long-sleeved gowns available. 2. Offer warm fluids to sip during the labor process. 3. Ask the spouse for permission before examining the client. 4. Ensure female healthcare providers examine the client. 5. Provide the spouse with water to cleanse the newborn upon birth.
1. Have long-sleeved gowns available. 3. Ask the spouse for permission before examining the client. 4. Ensure female healthcare providers examine the client. 5. Provide the spouse with water to cleanse the newborn upon birth.
A change in skin color requires further assessment of which physiologic functions? Select all that apply. 1. Hematocrit 2. Oxygenation 3. Glucose levels 4. Blood pressure 5. Bilirubin levels
1. Hematocrit 2. Oxygenation 3. Glucose levels 5. Bilirubin levels
The elderly grandmother of a newborn tells the client that rubbing alcohol should be applied to the cord stump to make it dry and fall off faster. What should the nurse instruct the client about cord care? Select all that apply. 1. Keep the umbilical cord stump clean. 2. Allow the umbilical cord stump to air dry. 3.Fold the diaper down under the cord stump. 4. Notify the healthcare provider if the cord stump appears dark in color. 5. Apply topical antibiotic ointment to the cord stump after each diaper change.
1. Keep the umbilical cord stump clean. 2. Allow the umbilical cord stump to air dry. 3.Fold the diaper down under the cord stump.
The newborn of a client who received nalbuphine hydrochloride (Nubain) for pain control was born less than an hour after the medication was given and is exhibiting signs of respiratory depression. Which medication should the nurse prepare to administer to the newborn? 1. Naloxone (Narcan) 2. Fentanyl (Sublimaze) 3. Pentobarbital (Nembutal) 4. Butorphanol tartrate (Stadol)
1. Naloxone (Narcan)
A client in labor received a dose of meperidine (Demerol) for pain control. Which assessment findings should the nurse suspect are adverse effects of this medication? Select all that apply. 1. Nausea 2. Pruritus 3. Sedation 4. Bradycardia 5. Hypotension
1. Nausea 2. Pruritus 3. Sedation
The nurse manager of the neonatal intensive care unit is preparing a handout for new parents. Which statement should the nurse include? 1. Neonates have a tendency to become dehydrated. 2. Sugar is always present in the urine of a newborn. 3. The kidneys are fully functional by 30 weeks' gestation. 4. Newborns can eliminate excess fluid as quickly as an adult.
1. Neonates have a tendency to become dehydrated.
A client in labor needs an emergency cesarean section. What should the nurse include when preparing this client for rapid induction of labor? Select all that apply. 1. Place a wedge under the right hip. 2. Insert an indwelling urinary catheter. 3. Insert an intravenous infusion catheter. 4. Provide a bolus of 1 L of intravenous fluid. 5. Preoxygenate with 3 to 5 minutes of 100% oxygen.
1. Place a wedge under the right hip. 2. Insert an indwelling urinary catheter. 3. Insert an intravenous infusion catheter. 5. Preoxygenate with 3 to 5 minutes of 100% oxygen.
Which nursing action can prevent or detect common side effects of epidural anesthesia? Select all that apply. 1. Preloading the client with a rapid infusion of IV fluids 2. Continuing the client on oral fluids only to prevent hypotension 3. Assisting the client to empty the bladder before the anesthesia is started 4. Use of intermittent fetal heart rate (FHR) monitoring so the client can use the birthing ball 5.Monitoring the fetal heart rate (FHR) for late deceleration and decrease in rate
1. Preloading the client with a rapid infusion of IV fluids 3. Assisting the client to empty the bladder before the anesthesia is started 5.Monitoring the fetal heart rate (FHR) for late deceleration and decrease in rate
A client experiencing contractions every 8 to 20 minutes that last 20 to 30 seconds requests pain medication. What should the nurse state as the effect of analgesics given at this time? 1. Prolonged labor 2. Maternal hypotension 3. Fetal respiratory depression 4. Decreased analgesic effectiveness at the end of labor
1. Prolonged labor
The nurse is caring for a 13-year-old client who is in labor. What actions should the nurse take to support this client's needs? Select all that apply. 1. Provide simple and concrete explanations. 2. Stay with the client during the labor process. 3. Provide soothing encouragement during the transition phase. 4. Provide positive reinforcement with a nonjudgmental manner. 5. Remain calm and provide clear directions during the second stage.
1. Provide simple and concrete explanations. 2. Stay with the client during the labor process. 3. Provide soothing encouragement during the transition phase. 5. Remain calm and provide clear directions during the second stage.
The nurse assesses a sleeping 1-hour-old, 39-weeks' gestation newborn. Which data should cause the nurse the most concern? 1. Respirations 68/min 2. Blood pressure 72/44 mmHg 3. Skin temperature 97.6°F 4. Heart rate 156 beats/min
1. Respirations 68/min
The nurse notes that a newborn has tremor-like movements. For which health problems should this newborn be further assessed? Select all that apply. 1. Seizures 2. Bilirubinemia 3. Hypocalcemia 4. Hypoglycemia 5. Substance withdrawal
1. Seizures 3. Hypocalcemia 4. Hypoglycemia 5. Substance withdrawal
A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice in a 37-hour-old newborn. What information should the nurse gather first? 1. Skin color 2. Fluid intake 3. Bilirubin level 4. Stool characteristics
1. Skin color
A newborn is demonstrating signs of needing comfort and security. What should the nurse instruct the parents about swaddling this infant? Select all that apply. 1. Swaddling should be loose. 2. Swaddling should be done with the arms at the sides. 3. Swaddling helps the newborn control body movements. 4. Swaddling should permit the newborn access to the mouth. 5. Swaddling should be tightly bound around the infant's torso.
1. Swaddling should be loose. 3. Swaddling helps the newborn control body movements. 4. Swaddling should permit the newborn access to the mouth.
The nurse receives shift change reports on infants born within the last 4 hours. Which newborn should the nurse see first? 1. Term male, grunting respirations 2. 37-week male, respiratory rate 45 3. 8 lb, 1 oz female, pulse 150 4. 39-week female, temperature 97°F
1. Term male, grunting respirations
While eliciting the Moro reflex in a newborn, the nurse notes that only the right arm moves. What should the nurse immediately assess based upon this finding? 1. The clavicle 2. Babinski reflex 3. The rooting reflex 4. Ortolani maneuver
1. The clavicle
Which actions must a nurse perform before weighing the newborn during the admission procedure? Select all that apply. 1. Zero the scale. 2. Clean the scale. 3. Cover the scale. 4. Take the infant's temperature. 5. Wrap the infant tightly in a blanket to prevent heat loss.
1. Zero the scale. 2. Clean the scale. 3. Cover the scale
Which statement by a breastfeeding class participant indicates that teaching was effective? Select all that apply. 1. "Breastfeeding is worthwhile, even if it costs more overall." 2. "Breastfed infants get more skin-to-skin contact and sleep better." 3. "Breastfed infants have fewer digestive and respiratory illnesses." 4. "Breastfeeding raises the level of a hormone that makes me feel good." 5. "Breastfeeding is complex and difficult, and I probably will not succeed."
2. "Breastfed infants get more skin-to-skin contact and sleep better." 3. "Breastfed infants have fewer digestive and respiratory illnesses." 4. "Breastfeeding raises the level of a hormone that makes me feel good."
A client in labor is concerned about needing a cesarean section and being asleep during the birth of her baby. Which nursing response is most appropriate? 1. "Your anesthesia provider will require that you go to sleep for surgery." 2. "If a cesarean section is needed, that does not necessarily mean you will need to go to sleep for surgery." 3. "We will do our best to make sure you deliver vaginally, so you do not need to have a cesarean section." 4."If you need a cesarean section, the anesthesia provider will awaken you as soon as possible after delivery so that you can see your baby quickly."
2. "If a cesarean section is needed, that does not necessarily mean you will need to go to sleep for surgery."
A pregnant client has not decided on a feeding method for her infant and asks for more information about breastfeeding and formula-feeding. Which client statement indicates that the teaching was successful? 1. "Breastfeeding is more expensive than formula-feeding." 2. "My baby has a lower risk of food allergies if I breastfeed." 3. "Formula-feeding gives the baby protection from infections." 4. "Breast milk cannot be stored; it has to be thrown away after pumping."
2. "My baby has a lower risk of food allergies if I breastfeed."
The mother of a 2-day-old infant newly diagnosed with sepsis asks why she could not detect the symptoms. What should the nurse reply to this mother? 1. "Your mothering skills will improve with time. You should take the newborn class." 2. "Newborns have immature immune function at birth, and illness is very hard to detect." 3. "Your baby did not get enough active acquired immunity from you during the pregnancy." 4. "The immunity your baby gets in utero does not start to function until 4 to 8 weeks of age."
2. "Newborns have immature immune function at birth, and illness is very hard to detect."
The new father asks what his baby will experience while sleeping and awake. How should the nurse respond? 1. "Babies have several sleep and alert states. Keep watching and you will notice them." 2. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." 3. "You may have noticed that your child was in an alert awake state for an hour after his birth." 4. "Birth is hard work for babies; it takes them a week or 2 to recover and become more awake."
2. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep."
A postpartum client calls the nursery to report that her 3-day-old newborn has passed a bright green stool. How should the nurse respond to the client? 1. "Your newborn has diarrhea." 2. "This is a normal occurrence." 3. "There may be a possible food allergy." 4. "Take your newborn to the pediatrician."
2. "This is a normal occurrence."
A client in labor who is requesting an epidural asks if the baby will be harmed. How should the nurse respond? 1. "Epidural anesthesia is very safe and there are no potential side effects that can affect your baby." 2. "We'll monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural." 3. "We'll assess your blood pressure every 15 minutes to make sure the epidural is not having any negative effects on your baby." 4. "Before your epidural is placed, we'll administer IV fluid to you in order to prevent the epidural from causing you problems."
2. "We'll monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural."
What is the purpose for the client in labor to utilize different breathing techniques? Select all that apply. 1. Reduces pain 2. A source of relaxation 3. A source of distraction 4. Speeds up the delivery process 5. An increased ability to cope with contractions
2. A source of relaxation 3. A source of distraction 5. An increased ability to cope with contractions
A client in labor did not attend prenatal classes and is experiencing severe pain. In which breathing technique should the nurse instruct the client to help with relaxation and control? Select all that apply. 1. Kussmaul breathing 2. Abdominal breathing 3. Slow-paced breathing 4. Pant-pant-blow breathing 5. Modified-paced breathing
2. Abdominal breathing 4. Pant-pant-blow breathing
The nursing instructor is demonstrating a newborn assessment using the Ballard gestational assessment tool. Which assessment should be performed after the first hour of birth? 1. Scarf sign 2. Arm recoil 3. Popliteal angle 4. Square window sign
2. Arm recoil
A client at 39 weeks' gestation is having a cesarean birth with general anesthesia. Which potential challenge is most relevant to the anesthesia care of this client? 1. Broad ligament hematoma 2. Difficulty with maternal intubation 3. Hypotension due to the intense blockade of sympathetic fibers 4. Fetal depression that is inversely proportional to maternal anesthetic depth and duration
2. Difficulty with maternal intubation
The nurse is caring for a client in the second stage of labor. What assessment findings indicate that birth is imminent? Select all that apply. 1. Drop in blood pressure 2. Increased bloody show 3. Bulging of the perineum 4. Subjective feeling of faintness 5. Uncontrollable urge to bear down
2. Increased bloody show 3. Bulging of the perineum 5. Uncontrollable urge to bear down
An expectant father has been at the bedside of his laboring partner for more than 12 hours. What would be an appropriate nursing intervention? 1. Insist that he leave the room for at least the next hour. 2. Offer to remain with his partner while he takes a break. 3. Suggest that the client's mother might be of more help. 4. Tell him he is not being as effective as he was and that he needs to let someone else take over.
2. Offer to remain with his partner while he takes a break.
Upon delivery of the newborn, which action most promotes parental attachment? 1. Placing the newborn under the radiant warmer 2. Placing the newborn on the maternal abdomen 3. Taking the newborn to the nursery for the initial assessment 4. Allowing the mother a chance to rest immediately after delivery
2. Placing the newborn on the maternal abdomen
The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? 1. Antibiotics decrease the incidence of hyperbilirubinemia. 2. Total bilirubin is the sum of the direct and indirect levels. 3. Conjugated bilirubin is eliminated in the conjugated state. 4. Unconjugated bilirubin is neurotoxic and cannot cross the placenta.
2. Total bilirubin is the sum of the direct and indirect levels.
Ketones are present in a urine specimen of a client in the beginning phases of labor. What should the nurse consider as the reason for this laboratory finding? Select all that apply. 1. Edema 2. Vomiting 3. Dehydration 4. Preeclampsia 5. Insulin resistance
2. Vomiting 3. Dehydration 5. Insulin resistance
The neonatal nurse specialist is describing neonatal care to nursing students. What statement should the specialist include when describing a proper method for preventing heat loss in the neonate? 1. "After delivery, the newborn is immediately placed in skin-to-skin contact with the mother." 2. "Immediately after delivery, the newborn is wrapped in a blanket and placed on the mother's chest." 3. "If the newborn is under a radiant-heated unit, the neonate is dried, placed on a dry blanket, and left uncovered under the radiant heat." 4."If a radiant-heated unit is used to keep the neonate warm, the neonate is dried, wrapped in a dry blanket, and placed under the radiant heat."
3. "If the newborn is under a radiant-heated unit, the neonate is dried, placed on a dry blanket, and left uncovered under the radiant heat."
A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? 1. "I cannot believe he can already digest fats, carbohydrates, and proteins." 2. "It is amazing that his whole digestive tract moves things along at birth." 3. "Incredibly, his stomach capacity is already a cupful when he was born." 4. "He will lose some weight but then miraculously regain it by about 10 days."
3. "Incredibly, his stomach capacity is already a cupful when he was born."
A postpartum client who received spinal anesthesia for the delivery has not voided for 5 hours and is concerned about nerve damage. How should the nurse respond about this concern? 1. "Spinal anesthesia can sometimes cause nerve damage." 2. "You are probably dehydrated. Please increase your water intake." 3. "It may be several hours before you're able to control your urination." 4. "You should be able to control your bladder by now. I'll ask the anesthesia provider to visit with you."
3. "It may be several hours before you're able to control your urination."
One minute after delivery the following is assessed in a neonate: heart rate 120 beats per minute, vigorous cry, actively moving, resists attempts to straighten an arm, facial grimace with sole flicking, body pink, extremities blue. What Apgar score should the nurse assign to this infant? 1. 6 2. 7 3. 8 4. 9
3. 8
A client states that her water broke 2 hours ago. What findings should the nurse identify as indications of normal labor? Select all that apply. 1. Protein of +1 in urine 2. Maternal pulse of 160 3. Blood pressure of 120/80 4. Odorless, clear fluid on underwear 5. Fetal heart rate (FHR) of 130 with average variability
3. Blood pressure of 120/80 4. Odorless, clear fluid on underwear 5. Fetal heart rate (FHR) of 130 with average variability
The mother of a newborn with iron deficiency anemia asks if breastfeeding or using a formula high in iron is better for the baby. How should the nurse respond? 1. Breastfeeding, because breast milk has higher levels of iron compared to formula 2. Formula-feeding, because formula has higher levels of iron compared to breast milk 3. Breastfeeding, because although breast milk has lower levels of iron compared to formula, it is more easily absorbed by the infant 4. Formula-feeding, because although formula has lower levels of iron compared to breast milk, it is more easily absorbed by the infant
3. Breastfeeding, because although breast milk has lower levels of iron compared to formula, it is more easily absorbed by the infant
The client in labor has 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? 1. Obtain a clean-catch urine specimen. 2. Apply an internal fetal scalp electrode. 3. Keep the client on bed rest at this time. 4. Encourage the husband to remain in the room.
3. Keep the client on bed rest at this time.
Five minutes after delivery, the neonate's body is pink with blue extremities. The heart rate is 150. The infant demonstrates a vigorous cry and good respiratory effort, and is actively moving. His elbows and hips are flexed, with his knees positioned up toward his abdomen. When the nurse flicks the soles of his feet, the neonate withdraws his leg. Which nursing interventions are appropriate? 1. Rescue breathing and stimulation 2. Stimulation and resuscitative efforts 3. Nasopharyngeal suctioning and blow-by oxygen 4. Oxygen via face mask and endotracheal suctioning
3. Nasopharyngeal suctioning and blow-by oxygen
A client in labor is having a pudendal block. For which adverse effects should the nurse assess this client? Select all that apply. 1. Infection 2. Spinal headache 3. Perforated rectum 4. Sciatic nerve trauma 5. Broad ligament hematoma
3. Perforated rectum 4. Sciatic nerve trauma 5. Broad ligament hematoma
The nurse attempts to take the vital sign of the newborn, but the newborn is crying. What intervention would be appropriate? 1. Taking the vital signs 2. Waiting until the newborn stops crying 3. Placing a gloved finger in the newborn's mouth 4.Swaddling the newborn with several warm blankets in an attempt to calm the newborn
3. Placing a gloved finger in the newborn's mouth
A new mother is concerned because the anterior fontanelle swells when the newborn cries. What normal findings should the nurse include when teaching the new mother about this concern? Select all that apply. 1. The fontanelles might bulge. 2. The fontanelles might be depressed. 3. The fontanelles can swell with crying. 4. The fontanelles can pulsate with the heartbeat. 5. The fontanelles can swell when stool is passed.
3. The fontanelles can swell with crying. 4. The fontanelles can pulsate with the heartbeat. 5. The fontanelles can swell when stool is passed.
The nurse explains normal newborn behavior to new parents who are concerned about the baby's desire to be held. Which statement indicates that teaching has been effective? 1. "Some babies are easier to deal with than others." 2. "Our baby spends more time in the active alert phase." 3. "We are lucky to have a baby with a calm disposition." 4. "Cuddliness is a social behavior that some babies have."
4. "Cuddliness is a social behavior that some babies have."
Nursing students describe actions while practicing physical assessment of a newborn using a model. Which nursing student's statement indicates the need for further teaching? 1. "I auscultated the infant's heart tones for 1 minute." 2. "I palpated peripheral pulses in all the newborn's extremities." 3. "I obtained a higher blood pressure on the legs than on the arms." 4. "I obtained the infant's heart rate by observing the cardiac monitor."
4. "I obtained the infant's heart rate by observing the cardiac monitor."
A 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? 1. "Your baby must be dehydrated." 2. "Bring your infant to the clinic immediately." 3. "This is due to overriding of the cranial bones during labor." 4. "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth."
4. "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth."
A new adolescent mother is concerned about being able to properly care for the newborn at home because her mother thinks she is too young. What should the nurse say to this client? 1. "You are very young, and parenting will be a challenge for you." 2. "Your mother was probably right. Be very careful with your baby." 3. "Mothers have instincts that kick in when they get their babies home." 4. "We can give the baby's bath together. I'll help you learn how to do it."
4. "We can give the baby's bath together. I'll help you learn how to do it."
The charge nurse is reviewing the plans of care for four clients in labor. Which care plan requires additional information before implementing? 1. Administration of a spinal anesthetic to a client who is scheduled for a vaginal delivery 2. Administration of a spinal anesthetic to a client with a history of irritable bowel syndrome (IBS) 3. Administration of epidural anesthesia to a client who is in the first stage of labor and has a shellfish allergy 4. Administration of epidural anesthesia to a client with a history of vomiting secondary to hyperemesis gravidarum
4. Administration of epidural anesthesia to a client with a history of vomiting secondary to hyperemesis gravidarum
Before the nurse begins to dry the newborn off after birth, which assessment finding should be documented to ensure an accurate gestational rating on the Ballard gestational assessment tool? 1. Size of the areolae 2. Creases on the sole 3. Body surface temperature 4. Amount and area of vernix coverage
4. Amount and area of vernix coverage
The nurse is making an initial assessment of a newborn. Which data would be considered normal? 1. Chest circumference 30 cm, head circumference 29 cm 2. Chest circumference 38 cm, head circumference 31.5 cm 3. Chest circumference 32.5 cm, head circumference 38 cm 4. Chest circumference 31.5 cm, head circumference 33.5 cm
4. Chest circumference 31.5 cm, head circumference 33.5 cm
A client in labor who rates pain as 9 on a scale from 1 to 10 requests pain medication after refusing epidural anesthesia. What action should the nurse take prior to administering butorphanol tartrate (Stadol) as prescribed? 1. Offer epidural anesthesia again. 2. Administer oxygen via face mask at 6 to 10 L per minute. 3. Obtain maternal vital signs and assess the fetal heart rate (FHR). 4. Instruct on the actions and contraindications associated with the medication.
4. Instruct on the actions and contraindications associated with the medication.
The nurse is assessing a newborn's musculoskeletal status. How should the nurse assess for clubfoot? 1. Stimulate the sole of the foot 2. Adduct the foot and listen for a click 3. Extend the foot and observe for pain 4. Move the foot to midline and determine resistance
4. Move the foot to midline and determine resistance
The nurse is planning the care of a 1-day-old infant. Which intervention would protect the newborn from heat loss by convection? 1. Drying the newborn thoroughly 2. Prewarming the examination table 3. Removing wet linens from the isolette 4. Placing the newborn away from air currents
4. Placing the newborn away from air currents
A client in labor is being prepared for epidural anesthesia. What should the nurse expect to perform in order to prevent the most common complication associated with this anesthesia? 1. Observe fetal heart rate variability. 2. Place the client in the semi-Fowler position. 3. Teach the client appropriate breathing techniques. 4. Rapidly infuse 500 to 1000 mL of intravenous fluids.
4. Rapidly infuse 500 to 1000 mL of intravenous fluids.
Prior to receiving lumbar epidural anesthesia, in which position should the nurse place the client in labor? 1. Lying prone with a pillow under the chest 2. On the right side in the center of the bed with the back curved 3. On the left side with the bottom leg straight and the top leg slightly flexed 4. Sitting on the edge of the bed with the back slightly curved and feet on a stool
4. Sitting on the edge of the bed with the back slightly curved and feet on a stool
A client in labor wants to have a medication-free birth. What should the nurse include when discussing alternatives to pain medication with this client? 1. Emphasize that no medication will be given. 2. Review that the use of medications allows for rest and less fatigue. 3. Explain that pain relief will allow a more enjoyable birth experience. 4. Summarize how maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia.
4. Summarize how maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia.
During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. How should the nurse document this finding? 1. Nevus flammeus 2. Nevus vasculosus 3. A Mongolian spot 4. Telangiectatic nevi
4. Telangiectatic nevi
The nurse wants to demonstrate to a new family their infant's individuality. Which assessment tool should the nurse use? 1. Ortolani maneuver 2. Ballard Maturity Scale 3. Dubowitz Gestational Age Scale 4.Brazelton Neonatal Behavioral Assessment Scale
4.Brazelton Neonatal Behavioral Assessment Scale
The nurse is assessing a 2-day-old male infant that has been circumcised. Which finding requires immediate intervention? 1. The umbilical cord clamp has been removed. 2. The mother is ready to breastfeed on demand. 3. The infant maintains temperature when wrapped in a blanket. 4.The infant has had a dry diaper since the circumcision procedure.
4.The infant has had a dry diaper since the circumcision procedure.
The nurse is assisting a new mother to breastfeed. In which order should the nurse review the steps with the mother? 1. Bring the newborn to the breast. 2. The newborn opens mouth wide. 3. Tickle the newborn's lips with the nipple. 4. Have the newborn face the mother tummy-to-tummy. 5. Position the newborn so the newborn's nose is at level of the nipple.
5. Position the newborn so the newborn's nose is at level of the nipple. 4. Have the newborn face the mother tummy-to-tummy. 1. Bring the newborn to the breast. 3. Tickle the newborn's lips with the nipple. 2. The newborn opens mouth wide.
The newborn of a client who received butorphanol tartrate (Stadol) 20 minutes before delivery is demonstrating respiratory depression. The infant, weighing 9.9 lb, is prescribed naloxone (Narcan) 0.1 mg/kg. How many mg of the medication should the nurse administer to the newborn? (Calculate to the hundredth decimal point.)
Answer: 0.45 mL Explanation: First calculate the newborn's weight in kilograms by dividing the weight in pounds by 2.2, or 9.9/2.2 = 4.5 kg. Then multiply the prescribed dose of 0.1 mg × 4.5 kg = 0.45 mg. The nurse should provide the newborn with 0.45 mg of naloxone.
The nurse is assisting with a precipitous birth. In which order should the nurse perform the following actions after the birth of the fetal head? 1. Instruct the client to push. 2. Suction the baby's mouth, throat, and nose. 3. Exert upward traction to the fetal head to facilitate birth of the posterior shoulder. 4. Exert downward traction on the fetal head to facilitate movement of the anterior shoulder.
Answer: 2, 4, 3, 1 2. Suction the baby's mouth, throat, and nose. 4. Exert downward traction on the fetal head to facilitate movement of the anterior shoulder. 3. Exert upward traction to the fetal head to facilitate birth of the posterior shoulder. 1. Instruct the client to push.
A newborn weighing 8.8 lb is prescribed bottle-feedings every 3 hours to achieve the caloric intake of 120 calories/kg each day. How many calories should be in each ounce of feeding? (Calculate to the nearest whole number.)
Answer: 60 calories Explanation: First determine the infant's weight in kilograms by dividing the weight in pounds by 2.2, or 8.8/2.2 = 4 kg. Then determine the total number of calories per day by multiplying 120 calories × 4 = 480. Then divide the total calories by 8 (feedings every 3 hours are determined by dividing 24 hours by 3 = 8), or 480/8 = 60 calories. Each feeding should provide the newborn with 60 calories.
