Saunders maternity

The nurse is planning for the nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test?

Heelstick blood glucose

The nurse is providing a teaching session to an adolescent female regarding sexual maturation. The nurse recognizes that successful teaching has occurred if the adolescent female makes which statement?

"Breast changes most commonly occur before growth of pubic and axillary hair."

The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?

"Circumcision has been delayed to save tissue for surgical repair."

A postpartum nurse is reinforcing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further teaching?

"I need to bathe my newborn after a feeding."

The nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which statement indicates that the mother needs further teaching?

"I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed?

"I will breastfeed, especially for the first 6 weeks postpartum."

A newborn is diagnosed with a hiatal hernia. The mother of the newborn asks the nurse to explain the diagnosis. The nurse recognizes that the mother understands this condition when she makes which statement?

"My baby has a portion of the stomach protruding through the esophageal hiatus of the diaphragm."

A client has been examined in the clinic and has been diagnosed with pelvic inflammatory disease. The client asks the nurse to describe this condition. Which description of pelvic inflammatory disease by the nurse is accurate?

"Pelvic inflammatory disease is an infectious process that involves the uterine, tubes and uterus."

The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure?

"The uterus weighs about 2 ounces."

A nursing instructor asks a nursing student to describe Montgomery's tubercles of the breast. Which response by the student indicates successful learning regarding Montgomery's tubercles?

"These are sebaceous glands that are located in the areola."

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student needs further teaching if which responses are made? Select all that apply.

**Prevents large particles such as bacteria from passing to the fetus **Provides an exchange of nutrients and waste products between the mother and the fetus

The nurse in a women's health clinic is reinforcing instructions to a client that is being treated for pelvic inflammatory disease (PID). Which information is essential for the nurse to reinforce before discharge? Select all that apply.

**Refrain from sexual activity for 3 weeks. **Get plenty of rest and increase fluid intake. **Inform your sexual partner of the need for treatment, even if no signs/symptoms are present.

The nurse is teaching an adolescent female about menstruation. Which statements if made by the adolescent female demonstrate a need for further teaching? Select all that apply.

1. "The average duration of menstruation is 3 days." 5. "The day of ovulation is counted as the first day of the menstrual cycle." Correct Answer: 1, 5

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which are functions of amniotic fluid? Select all that apply.

1. Allows for fetal movement 2. Is a measure of kidney function 3. Surrounds, cushions, and protects the fetus 4. Maintains the body temperature of the fetus

The nurse is admitting a newborn infant to the nursery and notes that the primary health care provider has documented that the newborn has an omphalocele. Which interventions are appropriate for the nurse to use with this newborn? Select all that apply.

1.Protect defect from trauma. 4.Administer prophylactic antibiotics as prescribed. 5.Keep viscera moist with saline soaked dressings.

The nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick, white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which action is the best?

Document the findings

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse would tell the mother that which is a sign of infection?

A moist cord with discharge

The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding would the nurse expect to note in a healthy breast-feeding mother and newborn?

A mother breast-feeding with the newborn in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow

Which safety measures would be implemented at delivery and when working in the newborn nursery? Select all that apply.

Adhere to standard precautions during delivery and in the nursery Instruct the parents to not release their newborn infant to anyone wearing improper identification. Fingerprint the mother and footprint the infant on the identification card before removing the infant from the delivery room.

The nurse is preparing a newborn infant that is undergoing diagnostic studies to determine if tracheoesophageal fistula is present. The nurse determines which of the following are clinical manifestations of tracheoesophageal fistula? Select all that apply.

Apnea Cyanosis Excessive salivation Abdominal distention

The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care?

Ask about the newborn's blood type and direct Coombs'.

A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). When assisting with care for the newborn, which would be the priority concern?

Aspiration

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother would be taught which intervention?

Begin with the eyes and face.

The nurse discusses infant feeding options with a client following a vaginal delivery of a 6-pound full-term infant. The mother has been diagnosed with human immunodeficiency virus (HIV). Which is the appropriate method of feeding for this client?

Bottle-feeding with a tolerated formula

A newborn infant has coarctation of the aorta (COA). The nurse would expect to note which findings in the infant?

Bounding radial pulses and absent or weak femoral and pedal pulses

The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse would perform which action?

Clap the hand or slap on the mattress.

The nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers?

Clean around the cord with plain water as needed until the cord falls off

The nursing student is assigned to care for an adolescent female client in the health care clinic who has the potential diagnosis of gonorrhea. Which signs/symptoms if found in this client support this diagnosis? Select all that apply.

Edematous labia Acute severe pelvic pain Presence of greenish-yellow purulent endocervical discharge

The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action would the nurse plan to best facilitate bonding between the newborn and parents?

Encourage the parents to touch their newborn.

The nurse is collecting data from a client with epididymitis. The nurse would expect to note which signs and symptoms of this problem?

Fever, nausea and vomiting, and painful scrotal edema

The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which statement would the nurse make to the client?

Hands should be washed thoroughly before holding the infant."

A client presents to a women's health clinic and would like to begin taking an oral contraceptive pill (OCP). The nurse reviews the client's past medical history and suspects that oral contraceptives may not be the best option for her. Which information in the client's past medical history would trigger the nurse to question oral contraceptives for this client? Select all that apply.

Hepatitis Cholecystitis Chronic obstructive pulmonary disorder (COPD

The nurse is reviewing the discharge instructions for an 18-month-old toddler who underwent an orchiopexy procedure to treat bilateral cryptorchidism. Which of the following statements from the parent would indicate a need for further teaching?

I need to give my child baths starting tonight to help keep the surgical site clean"

The postpartum nurse is caring for a mother whose blood type is O-negative and her newborn who is type A-positive. The nurse is drawing ordered labs on the mother and determines which laboratory test would provide the nurse with information about the mother's sensitization to fetal red blood cells?

Indirect Coomb's test

The nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which guideline?

Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.

The nurse is caring for a 45-year-old client. The client has 3 healthy children, all born via spontaneous vaginal birth. The client has been diagnosed with mild uterine prolapse and asks the nurse what she can do to prevent further prolapse. The nurse would include which instructions in the teaching plan? Select all that apply.

Lose weight Eat a diet high in fiber Perform Kegel exercises Take stool softeners daily as needed

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which would be included in the plan of care?

Maintaining standard precautions at all times while caring for the neonate

The nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?

Monitor neonate response to feedings and the weight gain pattern.

Which nursing interventions would be implemented for a newborn receiving phototherapy for hyperbilirubinemia? Select all that apply.

Monitor the temperature frequently. Protect the eyes with an opaque mask. Monitor and document the number and consistency of stools.

The nurse is assisting in developing a plan of care for a newborn with spina bifida (myelomeningocele type). The nurse includes measures in the plan to monitor for increased intracranial pressure (ICP). Which action will detect the presence of an increase in ICP?

Monitoring the anterior fontanel for bulging

The nurse caring for a neonate that is 3 hours old would assess for which signs of cold stress? Select all that apply.

Mottling of skin Increased respirations with apnea

The nurse is caring for a newborn with respiratory distress syndrome (RDS). Which data obtained by the nurse indicate potential complications associated with this disorder?

No audible breath sounds in left lung; heart sounds louder in right side of chest

The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?

Notify the registered nurse.

The nurse is caring for a newborn whose mother had an elevated temperature during a prolonged labor. Which intervention would be important to include in the newborn's plan of care?

Observe vital signs and central nervous system status frequently during the first 2 days.

The nurse is caring for a client with a possible ectopic pregnancy. The nurse would perform the following actions in which priority order? Arrange the actions in the order they should be performed. All options must be used.

Obtain urine specimen- 2 Prepare the client for ultrasound-3 Assess emotional state-4 Assess the client for signs of increased pain or vaginal bleeding-1

The nurse assisting in the care of a newborn has a standing prescription to administer the hepatitis B vaccine to the infant. The nurse would plan to perform which action when carrying out this prescription?

Obtain written parental consent.

The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which data, if noted in the infant, indicate that the criterion for early discharge has not been met?

The infant has evidence of significant jaundice.

The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who had an orchiopexy procedure done to treat cryptorchidism. The nurse would determine the parents understood the discharge instructions if they state which play activity is best for the child after this procedure?

Playing with clay

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse would give which response to the client?

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

The nurse is collecting data on a 2-day-old newborn who was born with suspected Hirschsprung's disease. Which clinical manifestations support this diagnosis? Select all that apply.

Refusal to feed Visible peristalsis The mother reports the infant has not had a bowel movement yet

The nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH of 7.25, Pao2 of 80 mm Hg, Paco2 of 50 mm Hg, and HCO3- of 24 mEq. Which interpretation would the nurse make of these results?

Respiratory acidosis

The nurse is collecting initial data on a newborn in the delivery room. Which observations would the nurse expect to note in a healthy newborn? Select all that apply.

Respiratory rate of 40 breaths/minute Three umbilical cord vessels, two arteries, and one vein

The nurse is collecting data from a client who is suspected of having mittelschmerz. Which finding, on data collection, is most closely associated with this disorder?

Sharp pain located on the right side of the pelvis

The nurse is collecting data on a newborn infant with a diagnosis of a hiatal hernia. Which findings would the nurse expect to note in the infant? Select all that apply.

Short episodes of apnea Coughing and wheezing

In caring for a preterm newborn, what knowledge related to skin care would the nurse consider when providing nursing care? Select all that apply.

Skin of the preterm baby is thinner than that of the full-term infant. A preterm baby has less subcutaneous fat than the full-term infant. The posture of the preterm infant will expose more skin to potential heat loss. The preterm infant has a high body surface area in relation to body weight.

breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which food would the nurse instruct the mother to avoid?

Soft cheeses

The nurse would monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn?

Tachypnea and retractions

The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse?

normal finding

A postpartum nurse has reinforced instructions to a new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the following day asks the mother to perform the procedure. Which observation made by the nurse indicates that the mother is performing the procedure correctly?

The mother begins to wash the newborn by starting with the eyes and face.

The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate?

The neonate cries incessantly.

The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings would the nurse expect to note during data collection for this newborn? Select all that apply.

The newborn is irritable The newborn cries incessantly. The newborn is difficult to console. The newborn hyperextends and postures.

The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. Which nursing instruction to the mother is appropriate?

To bring the infant to the clinic

The nurse in the newborn nursery is preparing to feed a non-breastfeeding newborn a first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these signs, the nurse might suspect that the newborn has which condition?

Tracheoesophageal fistula

In providing initial care to the newborn following delivery, what is the nurse's priority action?

Turn the infant's head to the side.

The nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action?

Warming the crib pad before placing the newborn in the crib

The nurse at an outpatient cardiology clinic is reviewing the medical history of a 48-year-old client during a routine exam. The client is complaining of the inability to maintain an erection and asks the nurse what could be causing it. Which information would the nurse include as possible contributing factors to his erectile dysfunction? Select all that apply.

Weight of 245lbs Total cholesterol 223 mg/dL Serum creatinine 1.86 mg/dL

The nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome?

Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying."

The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response?

Within acceptable ranges

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action would be to monitor which clinical parameter?

blood glucose level

An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with what problem?

drug withdrawal

The nursing student is preparing to administer a medication to a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication and placement for the prophylaxis of ophthalmia neonatorum caused by gonococcal or chlamydia infection. The student correctly identifies which medication and location?

erythromycin in eyes

The maternity nursing instructor asks a nursing student to identify the hormones that are produced by the ovaries. Which hormones identified by the student indicate an understanding of the hormones produced by this endocrine gland? Select all that apply.

estrogen and progesterone

A nursing student is asked to identify the layers of tissue found within the uterus. Which student responses are correct with regard to the tissue layers of the uterus? Select all that apply.

myometrium, perimetrium, endometrium