actually exam #1

3 . A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be ordered? A ) Ferrous sulfate (Feosol) B ) Methylergonovine (Methergine) C ) D Bromocriptine (Parlodel) ) Docusate (Colace)

C

The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should be brought to the physicians attention first? White blood cell count of 18,000 Hemoglobin of 18.5 Hematocrit of 56 Bilirubin of 15

D A bilirubin of 15 is elevated and requires further immediate investigation.

Parents of a newborn are worried about dark areas over the sacrum of the newborn. What does the nurse explain this transitory skin discoloration is called? Epsteins pearls Milia Stork bites Mongolian Spots

D Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots.

What is the focus of current maternity practice? A. Hospital births for the majority of women B. The traditional family unit C. Separation of labor rooms from delivery rooms D. A quality family experience for each patient

D Current maternity practice focuses on a high-quality family experience for all families, traditional or otherwise.

1 1 When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure? A ) Early parentinfant contact following birth B ) Expert medical care for the labor and birth C ) Good nutrition and prenatal care during pregnancy D ) Grandparent involvement in infant care after birth

A

1 3 The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following would be a priority? A ) Placing the call light within her reach B ) Teaching her how the sitz bath works C ) Telling her to use the sitz bath for 30 minutes D ) Cleaning the perineum with the peri-bottle

A

1 A woman who is 12 hours postpartum had a pulse rate around 80 beats per. minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take? A ) Document the finding, as it is a normal finding at this time. B ) Contact the physician, as it indicates early DIC. C ) Contact the physician, as it is a first sign of postpartum eclampsia. D ) Obtain an order for a CBC, as it suggests postpartum anemia.

A

A postpartum woman who is breast-feeding tells the nurse that she is0 experiencing nipple pain. Which of the following would be least appropriate for the nurse to suggest? A ) Use of a mild analgesic about 1 hour before breast-feeding B ) Application of expressed breast milk to the nipples C ) Application of glycerin-based gel to the nipples D ) Reinstruction about proper latching-on technique

A

The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2 days after birth? Yellow Brown Greenish brown Black and tarry

A

The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. What is the most appropriate nursing response to this mother? Tell me how many hours per day your baby sleeps. It is normal for newborns to sleep most of the day. Newborns generally sleep 12 to 15 hours per day. You will find as the baby gets older, he sleeps less.

A Although it is true that newborns sleep a great deal of any 24-hour period, the nurse must find out what the mother means by too much before giving any information.

The nurse is interviewing the father of a 10-month-old infant. She is playing on the floor when she notices an electric outlet and reaches up to touch it. Her father says no firmly and removes her from near the outlet. The nurse should use this opportunity to teach the father that the infant: is old enough to understand the word no. is too young to understand the word no. should already know that electric outlets are dangerous. will learn safety issues better if she is spanked.

A By age 10 months, children are able to associate meaning with words. The father is using both verbal and physical cues to alert the child to dangerous situations. The child should be old enough to understand the word no. The 10-month-old is too young to understand the purpose of an electric outlet. The father is using both verbal and physical cues to teach safety measures. Physical discipline should be avoided.

In terms of fine motor development, what should the infant of 7 months be able to do? Transfer objects from one hand to the other and bang cubes on a table. Use thumb and index finger in crude pincer grasp and release an object at will. Hold a crayon between the fingers and make a mark on paper. Release cubes into a cup and build a tower of two blocks.

A By age 7 months, infants can transfer objects from one hand to the other, crossing the midline, and bang objects on a hard surface. The crude pincer grasp is apparent at about age 9 months, and releasing an object at will is seen around 8 months. The child can scribble spontaneously at age 15 months. At age 12 months, the child can release cubes into a cup and build a small tower.

Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner? Infant refuses a feeding Infant has an axillary temperature of 97 F Infant has three pasty, yellow-brown stools in 24 hours Infants diaper is not wet after 8 hours

D Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to prevent dehydration.

An Asian-American expectant father tells the nurse that he seems to be gaining weight, just like his wife. The nurse recognizes that this behavior is most likely a reflection of which? Couvade Embarrassment Ambivalence regarding the pregnancy Limited interest in the well-being of his wife

A Couvade is when expectant fathers sometimes experience physical symptoms similar to those of pregnant women, such as loss of appetite, nausea, headache, fatigue, and weight gain. The father did not express anything that would indicate embarrassment. There is no indication in the fathers statement that he is ambivalent to the pregnancy. There is no data in the question that indicates that the father is not interested in his wife.

The nurse is guiding parents in selecting a daycare facility for their infant. Which is especially important to consider when making the selection? Health practices of facility Structured learning environment Socioeconomic status of children Cultural similarities of children

A Health practices should be most important. With the need for diaper changes and assistance with feeding, young children are at increased risk when hand washing and other hygienic measures are not adhered to. A structured learning environment is not suitable for this age child. The socioeconomic status of children should have little effect on the choice of facility. Cultural similarities of children may be important to the families, but the health care practices of the facility are more important.

A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. The nurse should interpret this as: normal development. significant developmental lag. slightly delayed development due to prematurity. suggestive of a neurologic disorder such as cerebral palsy.

A Holding a rattle but not voluntarily grasping it is indicative of normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary. The infant is expected to be able to perform this task by age 3 months. If the childs age is corrected because of being 2 weeks preterm, the child is at the midpoint of the range for this developmental task and the behavior is age appropriate. No evidence of neurologic dysfunction is present.

A 4-month-old was born at 35 weeks of gestation. She seems to be developing normally, but her parents are concerned because she is a more difficult baby than their other child, who was term. The nurse should explain that: A infants temperaments are part of their unique characteristics. B infants become less difficult if they are not kept on scheduled feedings and structured routines. C the infants behavior is suggestive of failure to bond completely with her parents. D the infants difficult temperament is the result of painful experiences in the neonatal period. ANS: A

A Infant temperament has a strong biologic component. Together with interactions with the environment, primarily the family, the biologic component contributes to the infants unique temperament. Children perceived as difficult may respond better to scheduled feedings and structured caregiving routines than to demand feedings and frequent changes in routines. The infants temperament has been created by both biologic and environmental factors. The nurse should provide guidance in parenting techniques that are best suited to the infants temperament.

The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. What is the most appropriate intervention by the nurse? Do nothing because this is a normal occurrence. Report the discrepancy to the pediatrician immediately. Decrease the interval between the infants feedings. Try feeding the infant a different type of formula.

A It is typical for the newborn to lose 5% to 10% of his or her birth weight in the first 3 to 4 days of life. No change in the plan of care is needed.

Who advocated the establishment of the Childrens Bureau? A. Lillian Wald B. Florence Nightingale C. Florence Kelly D. Clara Barton

A Lillian Walk is credited with suggesting the establishment of a federal Childrens Bureau

Which information could be given to the parents of a 12-month-old child regarding appropriate play activities? Give large push-pull toys for kinetic stimulation. Place cradle gym across crib to facilitate fine motor skills. Provide child with finger-paints to enhance fine motor skills. Provide stick horse to develop gross motor coordination.

A The 12-month-old child is able to pull to standing and walk holding on or independently. Appropriate toys for a child this age include large pull toys for kinesthetic stimulation. A cradle gym should not be placed across the crib. Finger- paints are appropriate for older children. A 12- month-old child does not have the stability to use a stick horse.

When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior? The Moro reflex The grasp reflex An abnormality of the musculoskeletal system A neurological abnormality

A The Moro reflex is a normal neonatal reflex. It is elicited when the infants crib is jarred. The infant responds by drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position.

Which assessment of the newborn should be reported? Head circumference is 5 cm greater than the chest circumference Hands and feet are warm with a blue color Temperature is 36.6 C (97.8 F) Head has a longer than normal shape to it

A The circumference of the head should be less than 2 cm greater than that of the chest. All other listed assessments are within the norm.

• The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. The nurse should interpret this as a(n): normal finding. finding requiring a referral.abnormal finding. normal finding, but requires rechecking in 1 month.

A This is a normal finding. The anterior fontanel closes between ages 12 and 18 months. No further intervention is required.

What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.) Swaddling Rocking Offering a pacifier Distraction Cuddling

A , B, C, E Swaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective, noninvasive pain remedies. Distraction is not a dependable method of pain reduction with infants

1 4 A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which of the following? (Select all that apply.) A ) History of diabetes B ) Labor of 12 hours C ) Rupture of membranes for 16 hours D ) Hemoglobin level 10 mg/dL

A D E

The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that apply.) Reflexes Color Heart rate Respiration Weight

A, B, C, D The Apgar score is a standardized method of evaluating the newborns condition immediately after delivery. Five objective signs are measured: heart rate, respiration, muscle tone, reflexes, and color. The score is obtained 1 minute after birth and again after 5 minutes.

The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of the newborns physiology? (Select all that apply.) Very little subcutaneous fat Low metabolic rates Ineffective sweat glands Small fluid reserves Low red blood cell counts

A, C Newborns have very little subcutaneous fat, which offers little insulation against cold. Newborns have ineffective sweat glands and cannot cool themselves through evaporation.

Which is an appropriate play activity for a 7-month-old infant to encourage visual stimulation? Playing peek-a-boo Playing pat-a-cake Imitating animal sounds Showing how to clap hands

ANS: ABecause object permanence is a new achievement, peek-a-boo is an excellent activity to practice this new skill for visual stimulation. Pat-a-cake and showing how to clap hands will help with kinetic stimulation.

A nurse is conducting a teaching session for parents of infants. The nurse explains that which behavior indicates that an infant has developed object permanence? Recognizes familiar face, such as mother Recognizes familiar object, such as bottle Actively searches for a hidden object Secures objects by pulling on a string

ANS: C During the first 6 months of life, infants believe that objects exist only as long as they can see them. When infants search for an object that is out of sight, this signals the attainment of object permanence, whereby an infant knows an object exists even when it is not visible. Between ages 8 and 12 weeks, infants begin to respond differentially to the mother. They cry, smile, vocalize, and show distinct preference for the mother. This preference is one of the stages that influences the attachment process but is too early for object permanence. Recognizing familiar objects is an important transition for the infant, but it does not signal object permanence. The ability to understand cause and effect is part of secondary schemata development.

A nurse is assessing a 6-month-old infant. The nurse recognizes the posterior fontanel usually closes at which age? 6 to 8 weeks 10 to 12 weeks 4 to 6 months 8 to 10 months

A\The bones surrounding the posterior fontanel fuse and close by age 6 to 8 weeks; 10 to 12 weeks, 4 to 6 months, and 8 to 10 months are too late. The posterior fontanel is usually closed by age 8 weeks.

After reviewing information about postpartum blues, a group of students demonstrate understanding when they state which of the following about this condition? A Postpartum blues is a long-term emotional disturbance B Sleep usually helps to resolve the blues C The mother loses contact with reality D Extended psychotherapy is needed for treatment

B

1 2 A postpartum woman is having difficulty voiding for the first time after giving birth. Which of the following would be least effective in helping to stimulate voiding? A ) Pouring warm water over her perineal area B ) Having her hear the sound of water running nearby C ) Placing her hand in a basin of cool water D ) Standing her in the shower with the warm water on

C

1 5 A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem? A ) Lochia rubra with a fleshy odor B ) Respiratory rate of 16 breaths per minute C Temperature of 101 F D Pain rating of 2 on a scale from 0 to 10

C

1 7 When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which of the following? A ) Superficial structures above the muscle B ) Through the perineal muscles C ) Through the anal sphincter muscle

C

1 6 . The nurse is assessing a postpartum clients lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which of the following? A ) Scant B ) Light C ) Moderate

B

1 8 A nurse is observing a postpartum client interacting with her newborn and notes that the mother is engaging with the newborn in the enface position. Which of the following would the nurse be observing? A ) Mother placing the newborn next to bare breast. B ) Mother making eye-to-eye contact with the newborn C ) Mother gently stroking the newborns face D ) Mother holding the newborn upright at the shoulder

B

2 2 After teaching a postpartum woman about breastfeeding, the nurse determines that the teaching was successful when the woman states which of the following? . Possibility of increased breast sensitivity during sexual activity A I should notice a decrease in abdominal cramping during breast-feeding. B ) I should wash my hands before starting to breast-feed. C ) The baby can be awake or sleepy when I start to feed him. D ) The baby's mouth will open up once I put him to my breast

B

2 3 A postpartum woman who is bottle-feeding her newborn asks the nurse, About how much should my newborn drink at each feeding? The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding? A ) 1 to 2 ounces B ) 2 to 4 ounces C ) 4 to 6 ounces

B

4 . Which statement would alert the nurse to the potential for impaired bonding between mother and newborn? A ) You have your daddy's eyes B ) He looks like a frog to me C ) Where did you get all that hair? D ) He seems to sleep a lot

B

5 . After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A ) Presence of lochia serosa B ) Frequent scant voidings C ) Fundus firm, below umbilicus D ) Milk filling in both breasts

B

7 . The nurse administers RhoGAM to an Rh- negative client after delivery of an Rh- positive newborn based on the understanding that this drug will prevent her from: A ) Becoming Rh positive B ) Developing Rh sensitivity C ) Developing AB antigens in her blood

B

A nurse is working as part of a committee to establish policies to promote bonding and attachment. Which practice would be least effective in achieving this goal? A ) Allowing unlimited visiting hours on maternity units B ) Offering round-the-clock nursery care for all infants C ) Promoting rooming-in D ) Encouraging infant contact immediately after birth

B

2 . To decrease the pain associated with an episiotomy immediately after birth, which action by the nurse would be most appropriate? A ) Offer warm blankets. B ) Encourage the woman to void. C ) Apply an ice pack to the site. D ) Offer a warm sitz bath.

C

Which of the following would be considered to be a system barrier to the birth of prenatal care? Adolescent pregnant client Inability to schedule an appointment with the healthcare provider because of a busy hospital schedule Pregnant client has no health insurnace Having to sign in for the initial appointment and complete health history needs

B A delay in the ability to schedule an appointment with a health care provider is an example of a system barrier to the birth of prenatal care. An adolescent pregnant client would not be considered to be a system barrier but rather a psychosocial factor that would affect the pregnancy state. Having no health insurance is an example of a financial barrier to the birth of prenatal care. Completing a health history record is part of a comprehensive assessment.

At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli? 1 month 2 months 3 months 4 months

B At age 2 months, the infant has a social, responsive smile. A reflex smile is usually present at age 1 month. The 3-month-old can recognize familiar faces. At age 4 months, the infant can enjoy social interactions.

Which is a major concern among members of lower socioeconomic groups? Practicing preventive health care Meeting health needs as they occur Maintaining an optimistic view of life Maintaining group health insurance for their families

B Because of their economic uncertainty, lower socioeconomic groups place more emphasis on meeting the needs of the present rather than on future goals. Lower socioeconomic groups may value health care but generally cannot afford preventive health care. They may struggle for basic needs and often do not see a way to improve their situation. It is difficult to maintain optimism. Lower socioeconomic groups usually do not have group health insurance.

The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect the infant to now weigh approximately how many pounds? 10 15 20 25

B Birth weight doubles at about age 5 to 6 months. At 6 months, a child who weighed 7 pounds at birth would weigh approximately 15 pounds; 10 pounds is too little. The infant would have gone from the 50th percentile at birth to below the 5th percentile; 20 to 25 pounds is too much. The infant would have tripled the birth weight at 6 months.

The parents of a newborn girl express concern about the infants vaginal discharge, which appears to be bloody mucus. What does the nurse explain as the cause? Premature stimulation of the ovarian hormones by the pituitary system Cessation of female sex hormones transferred in utero from mother to infant The increased amount of circulating blood from the mother throughout pregnancy Trauma to the genitalia during the birth process

B Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth.

Which medical pioneer discovered the relationship between the incidence of puerperal fever and unwashed hands? A. Karl Cred B. Ignaz Semmelweis C. Louis Pasteur D. Joseph List

B Ignaz Semmelweis deduced that puerperal fever was septic, contagious, and transmitted by the unwashed hands of physicians and medical students.

The nurse is discussing development and play activities with the parent of a 2- month-old. Recommendations should include giving a first rattle at about which age? 2 months 4 months 7 months 9 months

B It is recommended that a brightly colored toy or rattle be given to the child at age 4 months. Grasping has begun as a deliberate act, and the infant grasps, holds, and begins shaking to hear a noise; 2 months is too young. The infant still has primarily reflex grips; 7 to 9 months is too old for the first rattle. The child should be given toys that provide for further exploration.

A patient chooses to have the certified nurse midwife (CNM) provide care during her pregnancy. What does the CNMs scope of practice include? A. Practice independent from medical supervision B. Comprehensive prenatal care C. Attendance at all deliveries D. Cesarean sections

B The CNM provides comprehensive prenatal and postnatal care, attends uncomplicated deliveries, and ensures that a backup physician is available in case of unforeseen problems.

The nurse is measuring the vital signs of a full-term newborn. Which finding is abnormal? An axillary temperature of 36.6 C (98 F) An apical pulse rate of 178 beats/min Respirations of 35 breaths/min Blood pressure of 80/50 mm Hg

B The normal range for a newborns pulse rate is 110 to 160 beats/min. A pulse rate outside of this range should be reported.

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding? Sucking Rooting Grasping Tonic neck

B The rooting reflex causes the infants head to turn in the direction of anything that touches the cheek in anticipation of food.

A parent asks the nurse when will my infant start to teethe? The nurse responds that the earliest age at which an infant begins teething with eruption of lower central incisors is _______ months? 4 6 8 12

B Teething usually begins at age 6 months with the eruption of the lower central incisors;

2 1 A nurse is developing a teaching plan for a postpartum woman who is breast- feeding about sexuality and contraception. Which of the following would the nurse most likely include? (Select all that apply.) A ) Resumption of sexual intercourse about two weeks after delivery B ) Possible experience of fluctuations in sexual interest C ) Use of a water-based lubricant to ease vaginal discomfort D ) Use of combined hormonal contraceptives for the first three weeks E ) Possibility of increased breast sensitivity during sexual activity

B C E

2 4 A nurse is observing a postpartum woman and her partner interact with the their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which of the following? (Select all that apply.) A ) Frequently ask for the newborn to be taken from the room B ) Identify common features between themselves and the newborn C ) Refer to the newborn as having a monkey- face D Make direct eye contact with the newborn ) E Refrain from checking out the newborns features )

B D

1 9 After teaching a group of students about risk factors associated with postpartum hemorrhage, the instructor determines that the teaching was successful when the students identify which of the following as a risk factor? (Select all that apply.) A ) Prolonged labor B ) Placenta previa C ) Null parity D ) Hydramnios

B D E

6 A primipara client who is bottle feeding her baby begins to experience breast . engorgement on her third postpartum day. Which instruction would be most appropriate to aid in relieving her discomfort? A ) Express some milk from your breasts every so often to relieve the distention. B ) Remove your bra to relieve the pressure on your sensitive nipples and breasts. C ) Apply ice packs to your breasts to reduce the amount of milk being produced. D ) Take several warm showers daily to stimulate the milk let-down reflex.

C

8 . Which of the following factors in a clients history would alert the nurse to an increased risk for postpartum hemorrhage? A ) Multiparity, age of mother, operative delivery B ) Size of placenta, small baby, operative delivery C ) Uterine atony, placenta previa, operative procedures D Prematurity, infection, length of labor )

C

After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify the development of a close emotional attraction to a newborn by parents during the first 30 to 60 minutes after birth as which of the following? A ) Reciprocity B ) Engrossment C ) Bonding D ) Attachment

C

While inspecting a newborn's head, the nurse identified a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting? Molding Caput succedaneum Cephalohematoma Enlarged fontanelle

C A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line.

A pregnant woman who has recently immigrated to the United States comments to the nurse, I am afraid of childbirth. It is so dangerous. I am afraid I will die. What is the best nursing response reflecting cultural sensitivity? A. Maternal mortality in the United States is extremely low. B. Anesthesia is available to relieve pain during labor and childbirth. C. Tell me why you are afraid of childbirth. D. Your condition will be monitored during labor and delivery.

C Asking the patient about her concerns helps promote understanding and individualizes patient care.

A parent asks the nurse at what age do most infants begin to fear strangers? The nurse should give which response? 2 months 4 months 6 months 12 months

C Between ages 6 and 8 months, fear of strangers and stranger anxiety become prominent and are related to the infants ability to discriminate between familiar and unfamiliar people. At 2 months, infants are just beginning to respond differentially to the mother. At age 4 months, the infant is beginning the process of separation- individuation when the infant begins to recognize self and mother as separate beings. Twelve months is too late and requires referral for evaluation if the child does not fear strangers at this age.

While the vital signs of a pregnant client in her third trimester are being assessed, the client complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate? Have the client stand up and retake her blood pressure. Have the client sit down and hold her arm in a dependent position. Have the client turn to her left side and recheck her blood pressure in 5 minutes. Have the client lie supine for 5 minutes and recheck her blood pressure on both arms.

C Blood pressure is affected by positions during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension. Pressures are significantly higher when the patient is standing. This would cause an increase in systolic and diastolic pressures. The arm should be supported at the same level of the heart. The supine position may cause occlusion of the vena cava and descending aorta, creating hypotension

During the course of the pregnancy, the client states that she feels a deep connection with her unborn child. This behavior illustrates the maternal task acquisition of: safe passage gaining acceptance fostering an interconnection developing empathy through physical actions.

C During pregnancy, it is important for the mother to relate to and connect with the unborn child as part of the initial attachment and bonding experience. Safe passage refers to securing safety as a primary concern through the pregnancy and birth process. Gaining acceptance relates to behaviors acknowledging the pregnancy as a part of ones maternal role. Pregnant woman may appear to be more nurturing during pregnancy, but this is not necessarily associated through physical actions.

A nurse is assessing a 12-month-old infant. Which statement best describes the infants physical development a nurse should expect to find? Anterior fontanel closes by age 6 to 10 months. Binocularity is well established by age 8 months. Birth weight doubles by age 5 months and triples by age 1 year.• Maternal iron stores persist during the first 12 months of life.

C Growth is very rapid during the first year of life. The birth weight has approximately doubled by age 5 to 6 months and triples by age 1 year. The anterior fontanel closes at age 12 to 18 months. Binocularity is not established until age 15 months. Maternal iron stores are usually depleted by age 6 months.

What action does the nurse implement to protect newborns from infection while in the nursery? Keep the newborn dressed warmly. Adjust room temperature between 23.8 C (75 F) and 26.6 C (80 F). Wash hands before touching each infant. Wear a disposable gown when giving infant care.

C Handwashing is the most reliable precaution available to prevent infection. The nurse washes his or her hands between handling different babies.

A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later? a. 2900 b. 3100 c. 3300 d. 3800

C In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight.

According to Piaget, the 6-month-old infant should be in which developmental stage? Use of reflexes Primary circular reactions Secondary circular reactions Coordination of secondary schemata

C Infants are usually in the secondary circular reaction stage from ages 4 to 8 months. This stage is characterized by a continuation of the primary circular reaction for the response that results. Shaking is performed to hear the noise of the rattle, not just for shaking. The use of reflexes is primarily during the first month of life. Primary circular reaction stage marks the replacement of reflexes with voluntary acts. The infant is in this stage from ages 1 to 4 months. The fourth sensorimotor stage is coordination of secondary schemata. This is a transitional stage in which increasing motor skills enable greater exploration of the environment.

By which age should the nurse expect an infant to be able to pull to a standing position? 6 months 8 months 11 to 12 months 14 to 15 months

C Most infants can pull themselves to a standing position at age 9 months. Infants who are not able to pull themselves to standing by age 11 to 12 months should be further evaluated for developmental dysplasia of the hip. At 6 months, infants have just obtained coordination of arms and legs. By age 8 months, infants can bear full weight on their legs. Any infant who cannot pull to a standing position by age 1 year should be referred for further evaluation.

A pregnant client relates a story of how her boyfriend is feeling her aches and pains associated with her pregnancy. She is concerned that her boyfriend is making fun of her concerns. How would you respond to this client statement? a. Tell her not to worry because it is natural for her boyfriend to make her feel better by identifying with her pregnancy. b. Refer the client to a psychologist for counseling to deal with this problem because it is clearly upsetting her. c. Explain that her boyfriend may be experiencing couvade syndrome and that this is a normal finding seen with male partners d. Ask the client specifically to define her concerns related to her relationship with her boyfriend and suggest methods to stop this type fo behavior by her significant other

C Provide factual information that will help reduce stress and modify acceptance. Telling her not to worry does not address the possibility that her boyfriend may be experiencing couvade syndrome. The client is expressing concern but does not have all the facts related to couvade syndrome and requires education, rather than referral. Couvade syndrome is not an abnormal condition and should be treated with acceptance and understanding.

What was the result of research done in the 1930s by the Childrens Bureau? A. Children with heart problems are now cared for by pediatric cardiologists. B. The Child Abuse and Prevention Act was passed. C. Hot lunch programs were established in many schools. D. Children's asylums were founded.

C School hot lunch programs were developed as a result of research by the Children's Bureau on the effects of economic depression on children.

At what age can most infants sit steadily unsupported? 4 months 6 months 8 months 10 months

C Sitting erect without support is a developmental milestone usually achieved by 8 months. At age 4 months, an infant can sit with support. At age 6 months, the infant will maintain a sitting position if propped. By 10 months, the infant can maneuver from a prone to a sitting position.

The nurse is going to use a bulb syringe to clear mucus from a newborns nose and mouth. What is the nurses first action? Place the tip in the nose and squeeze the bulb gently. Suction secretions from the nose before the mouth. Depress the bulb before inserting the syringe tip into the mouth. Insert the tip into the back of the mouth to reach mucus.

C The bulb is depressed, and then the tip is inserted into the mouth and then the nose. The depression is slowly released, creating the suction.

At what age does an infant start to recognize familiar faces and objects, such as a feeding bottle? 1 month 2 months 3 months 4 months

C The child can recognize familiar objects at approximately age 3 months. For the first 2 months of life, infants watch and observe their surroundings. The 4-month-old infant is able to anticipate feeding after seeing the bottle.

What is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old infant? Molding doesnt cause any problems. Dont worry about it. Did you deliver vaginally or by cesarean section? The babys head conformed to the shape of the birth canal. It will go away soon. A traumatic delivery can cause molding.

C The newborns head may be out of shape from molding. This refers to the shaping of the fetal head to conform to the size and shape of the birth canal.

What is the reason for vascular volume increasing by 40% to 60% during pregnancy? Prevents maternal and fetal dehydration Eliminates metabolic wastes of the mother Provides adequate perfusion of the placenta Compensates for decreased renal plasma flow

C The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. Preventing maternal and fetal dehydration is not the primary reason for the increase in volume. Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the increased vascular volume. Renal plasma flow increases during pregnancy.

What statement indicates the parent understands the guidelines for bathing a newborn? Ill use a mild soap to clean all of the body parts. I am going to add bath oil to the water to keep the babys skin soft. I should shampoo the head after washing the rest of the body. Ill wash from the feet upward and change the washcloth for the face.

C The shampoo is done last because the large surface area of the head predisposes the infant to heat loss.

Physiologic anemia often occurs during pregnancy because of: Inadequate intake of iron The fetus establishing iron stores Dilution of hemoglobin concentration Decreased production of erythrocytes

C When blood volume expansion is more pronounced and occurs earlier than the increase in red blood cells, the woman will have physiologic anemia, which is the result of dilution of hemoglobin concentration rather than inadequate hemoglobin. Inadequate intake of iron may lead to true anemia. If the woman does not take an adequate amount of iron, true anemia may occur when the fetus pulls stored iron from the maternal system. There is increased production of erythrocytes during pregnancy.

A pregnant clients mother is worried that her daughter is not big enough at 20 weeks of gestation. The nurse palpates and measures the fundal height at 20 cm, which is even with the woman's umbilicus. Which should the nurse report to the client and her mother? You're right. We'll inform the practitioner immediately Lightening has occurred, so the fundal height is lower than expected The body of the uterus is at the belly button level, just where it should be at this time When you come for next month's appointment, we'll check you again to make sure that the baby is growing.

C Youre right. Well inform the practitioner immediately. Lightening has occurred, so the fundal height is lower than expected. The body of the uterus is at the belly button level, just where it should be at this time.

The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not completely digested and can be seen in their infants stools. The nurses explanation of this is based on which statement? Child should not be given fibrous foods until digestive tract matures at age 4 years. Child should not be given any solid foods until this digestive problem is resolved. This is abnormal and requires further investigation. This is normal because of the immaturity of digestive processes at this age.

D

A pregnant client has come to the emergency department with complaints of nasal congestion and epistaxis. Which is the correct interpretation of these symptoms by the health care provider? Nasal stuffiness and nosebleeds are caused by a decrease in progesterone Theses conditions are abnormal. Refer the client to an ear, nose and throat specialist. Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and epistaxis are within normal limits Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds.

D

The nurse reveals to the patient that the over-the-counter test is verified and that she is pregnant. The patient confides to the nurse, We have wanted to be pregnant for some time. These last few days I have been questioning our decision. I am feeling really bad right now. What is the nurses best response? You will come around in time and you will grow to love this baby. Dont feel bad. It is the hormones of pregnancy talking right now. Why do you think you are feeling bad when you wanted to be pregnant? Your feelings are understandable. Ambivalence is not uncommon right now.

D Early in pregnancy, ambivalence is not uncommon because pregnancy is a life- changing event, even if planned and strongly desired. The client needs reassurance and validation of these natural feelings. Although it is true that the patient will grow to love the baby, this statement does not acknowledge her ambivalent feelings. Dont feel bad dismisses the patients natural feelings and is a nontherapeutic response. Why is nontherapeutic and places the patient on the defensive in her response.

What government program was implemented to increase the educational exposure of preschool children? A. WIC B. Title XIX of Medicaid C. The Children's Charter D. HeadStart

D HeadStart programs were established to increase educational exposure of preschool children

Which comment made by a new mother exhibits understanding of her toddlers response to a new sibling? I cant believe he is sucking his thumb again. He is being difficult and I dont have time to deal with him. When we brought the baby home, we made Michael stop sleeping in the crib. My husband is going to stay with the baby so I can take Michael to the park tomorrow.

D It is important for a mother to seek time alone with her toddler to reassure him that he is loved. It is normal for a child to regress when a new sibling is introduced into the home. The toddler may have feelings of jealousy and resentment toward the new baby taking attention away from him. Frequent reassurance of parental love and affection are important. Changes in sleeping arrangements should be made several weeks before the birth so the child does not feel displaced by the new baby.

Parents express concern about the milia on the face and nose of their infant. What is the nurses most helpful response when instructing the parents? Contact a pediatric dermatologist for topical medication. Squeeze out the white material after cleansing the face. Wash the infants face with a mild astringent several times a day. Leave the milia alone; it will disappear spontaneously. No treatment is needed.

D Milia require no treatment. This skin manifestation will disappear spontaneously.

The mother of a 4-day-old calls the pediatricians office because she is concerned about her infants skin. Which finding needs to be reported promptly to the childs pediatrician? The hands and feet feel cooler than the rest of the body. Skin is peeling on several parts of the infants body. There is a small pink patch on the left eyelid and one on the neck. Today, the infants skin has a yellowish tinge.

D Physiological jaundice becomes evident between the second and third days of life and lasts for about 1 week. Evidence of jaundice is reported and the newborn is evaluated.

Which client may require more help and understanding when integrating the newborn into the family? A primipara from an upper income family A primipara who comes from a large family A multipara (gravida 2) who has a supportive husband and mother A multipara (gravida 6) who has two children younger than 3 years

D Pregnancy tasks are more complex for the multipara (gravida 6), and she may need special assistance to integrate the infant into the family structure. A primipara from an upper income family has the financial resources to assist her with daily care of the home. This leaves her free to concentrate on the newborns needs. The primipara with a large support system has help available to her. The multipara (gravida 2) who has a supportive husband and mother has a support system to assist with integrating the infant into the family structure.

What symptom assessed in the newborn shortly after delivery should be reported? Cyanosis of the hands and feet Irregular heart rate Mucus draining from the nose Sternal or chest retractions

D Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.

The mother of a 2-week-old infant tells the nurse, I think the baby is constipated. Ive noticed she strains when she has a bowel movement. What is nurses most helpful response? Give the baby one serving of fruit per day. Increase the amount and frequency of her feedings. It sounds like the baby is uncomfortable because she is constipated. Newborns might strain with bowel movements because their muscles arent fully developed.

D Straining in the newborn period is normal. It results from underdeveloped abdominal musculature. No treatment is required.

On what knowledge would the nurse base a response to a mother who questions, Do you think my baby recognizes my voice? Voice recognition is delayed because the ears are not well developed at birth. Infants respond to voice by increasing movements and sucking. Infants initially respond to low-pitched voices. Neonates can distinguish a mothers voice from other sounds in the first days of life.

D The ability to discriminate between a mothers voice and other voices may occur as early as in the first 3 days of life.

What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn? Depressed and sunken Triangular shaped Smaller than the posterior fontanelle Open and diamond shaped

D The anterior fontanelle is diamond shaped and located at the junction of the two parietal and two frontal bones. It should not be raised or sunken, and it closes between 12 and 18 months of age.

A pregnant client comes into the medical clinic stating that her family and friends are telling her that she is always talking about the pregnancy and nothing else. She is concerned that something is wrong with her. What psychological behavior is she exhibiting? Antepartum obsession Ambivalence Uncertainty Introversion

D The client is exhibiting behaviors associated with introversion and/or narcissism. These are normal findings during pregnancy as long as they do not become obsessive to the exclusion of everything else. The client is talking about the pregnancy but there is no evidence that it is affecting her perception of reality and/or ability to perform ADLs.

While teaching an Asian client about prenatal care, the nurse notes that the client refuses to make eye contact. Which is the most likely cause? a A submissive attitude . b Lack of understanding . c Embarrassment about the subject . d Cultural beliefs about eye contact

D The nurse must understand that making eye contact means different things in different cultures. The nurse should have a basic understanding of normal responses of various cultures within her community. Asians believe that eye contact shows disrespect, not submission. Many Asian women may nod and smile during client teaching, but this does not show understanding. They are responding that they heard you; validation of information is important. Modesty is important in some cultures, but the main response with this questions is the cultural beliefs.

Which is a positive sign of pregnancy? Amenorrhea Breast changes Fetal movement felt by the woman Visualization of fetus by ultrasound

D The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of the fetus by ultrasound, and fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy. Breast changes are a presumptive sign of pregnancy. Fetal movement is a presumptive sign of pregnancy.

An urban area has been reported to have a high perinatal mortality rate. What information does this provide? A. Maternal and infant deaths per 100,000 live births per year B. Deaths of fetuses weighing more than 500 g per 10,000 births per year C. Deaths of infants up to 1 year of age per 1000 live births per year D. Fetal and neonatal deaths per 1000 live births per year

D The perinatal mortality rate includes fetal and neonatal deaths per 1000 live births per year.

The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. The nurses response should be based on knowledge that this is: unacceptable because of the risk of sudden infant death syndrome (SIDS). unacceptable because it does not encourage achievement of developmental milestones. acceptable to encourage fine motor development. acceptable to encourage head control and turning over.

D These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep on their backs and then be placed on their abdomens when awake to enhance development of milestones such as head control. The face-down position while awake and on the back for sleep are acceptable because they reduce risk of SIDS and allow achievement of developmental milestones. These position changes encourage gross motor, not fine motor, development.

While providing education to a primiparous client regarding the normal changes of pregnancy, what is important for the nurse to explain about Braxton Hicks contractions? These contractions may indicate preterm labor These are contractions that never cause any discomfort Braxton Hicks contractions only start during the third trimester These occur throughout pregnancy, but you may not feel them until the third trimester

D Throughout pregnancy, the uterus undergoes irregular contractions called Braxton Hicks contractions. During the first two trimesters, the contractions are infrequent and usually not felt by the woman until the third trimester. Braxton Hicks contractions do not indicate preterm labor. Braxton Hicks contractions can cause some discomfort, especially in the third trimester. Braxton Hicks contractions occur throughout the whole pregnancy.

The nurse in labor and birth is caring for a Muslim client during the active phase of labor. The nurse notes that the client quickly draws away when touched. Which intervention should the nurse implement? Ask the charge nurse to reassign you to another client. Assume that she doesnt like you and decrease your time with her. Continue to touch her as much as you need to while providing care. Limit touching to a minimum because physical contact may not be acceptable in her culture.

D Touching is an important component of communication in various cultures, but if the client appears to find it offensive, the nurse should respect her cultural beliefs and limit touching her. Asking the charge nurse to reassign you could be offensive to the client.

An expectant couple asks the nurse about intercourse during pregnancy and whether it is safe for the baby. What should the nurse tell the couple? Intercourse is safe until the third trimester. Safer sex practices should be used once the membranes rupture. Intercourse should be avoided if any spotting from the vagina occurs afterward. Intercourse and orgasm are often contraindicated if a history of or signs of preterm labor are present.

D Uterine contractions that accompany orgasm can stimulate labor and would be problematic if the woman is at risk for or has a history of preterm labor. Intercourse can continue as long as the pregnancy is progressing normally. Rupture of the membranes may require abstaining from intercourse. Safer sex practices are always recommended. Some spotting can normally occur as a result of the increased fragility and vascularity of the cervix and vagina during pregnancy.