Chapter 25 (Prenatal) & 31 (Newborn Care)

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure 2. Reinforce the dressing 3. Document the findings 4. Contact HCP

3

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of the newborn? Select all that apply. 1. Lethargy 2. Sleepiness 3. Irritability 4. Constant crying 5. Difficult to comfort 6. Cuddles when being held

3, 4, 5

A nonstress test is performed on a pregnant client and the results indicate nonreactive findings. The HCP prescribes a contraction stress test and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a c-section

1

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord she noticed the cord was moist and that discharge was present. What is the most appropriate nursing action for this mother? 1. Bring the infant to the clinic 2. This is a normal occurrence and no further action is needed 3. Increase the number of times the cord is cleaned per day 4. Monitor cord for another 24 - 48 hours and call the clinic if the discharge continues

1

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the rooms 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probably signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. 1. Ballotment 2. Chadwick's sign 3. Uterine enlargement 4. Positive pregnancy test 5. Fetal heart rate detected by nonelectronic device 6. Outline of fetus via radiography or ultrasonography

1, 2, 3, 4

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. 1. Cyanosis 2. Tachypnea 3. Hypotension 4. Retractions 5. Audible grunts 6. Barrel chest

1, 2, 4, 5

A rubella titer result of a 1 day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breastfeeding (BF) needs to be stopped for 3 months 2. Pregnancy needs to be avoided for 1 - 3 months 3. The vaccine is administered by the subcutaneous route 4. Exposure to immunosuppressed individuals needs to be avoided 5. A hypersensitivity reaction can occur if the client has an allergy to eggs 6. The area of the injection needs to be covered with a sterile gauze for 1 week

2, 3, 4, 5

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "I will place my baby's crib close to the door" 2. "Some health care personnel won't have name badges" 3. "I will ask the nurse to attend to my infant if my husband is not here and I am napping" 4. "It's okay to allow the nurse assistant to carry my newborn to the nursery"

3

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Nagele's rule, which expected date of delivery should the nurse document in the client's chart? 1. July 12, 2019 2. July 26, 2019 3. August 12, 2019 4, August 26, 2019

2

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately" 2. "The vaginal discharge may be bothersome, but is a normal occurrence." 3. "Report to the ED at the maternity center immediately" 4. "Use tampons if the discharge is bothersome, but be sure to change them every 2 hours"

2

The nurse creates a plan of care for a woman with HIV infection and her newborn. The nurse should include what intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the infant 3. Initiating referral to evaluate for blindness, learning problems, or behavioral problems 4. Instructing the BF mother regarding treatment of the nipples with nystatin ointment

2

The nurse in a NICU receives a phone call to prepare for the administration of a 43 week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1. Turn on the apnea and cardiorespiratory monitors 2. Connect the resuscitation bag to the oxygen outlet 3. Set up the IV line with 5% dextrose in water 4. Set the radiant warmer control temperature at 36.5C or 97.6F

2

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts". Which statement by the client indicates need for further instruction? 1. "I will record the # of movements or kicks" 2. "I need to lie flat on my back to perform this procedure" 3. "If I count fewer than 10 kicks in a 2 hour period I should count the kicks again over the next 2 hours" 4. "I should place my hands on the largest part of my abdomen and concentrate of the fetal movements to count the kicks"

2

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5 year old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

2

The nurse is planning care for a newborn of a mother with diabetes. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen

2

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight 6 lb, 14 oz (3120 g) 4. Head circumference appropriate for gestational age

2

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast fed. The nurse should provide which instruction to the mother? 1. Feed the newborn less frequently 2. Continue to BF every 2 - 4 hours 3. Switch infant to bottle feeding for 2 weeks 4. Stop BF and switch to bottle feeding permanently.

2

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of the finding, which nursing action is appropriate? 1. Contact HCP 2. Instruct client to maintain bed rest for the remainder of the pregnancy 3. Inform the client that these contractions are common and may occur throughout the pregnancy 4. Call the maternity unit and inform them that the client will be admitted in a preterm labor condition

3

The nurse is performing an assessment of a pregnant client who is 28 weeks of gestation. The nurse measures the fundal height in cm, and notes it is approximately 30 cm. How should the nurse interpret this finding? 1. The client is measuring large for gestational age 2. The client is measuring small for gestational age 3. The client is measuring normal for gestational age 4. More evidence is needed to determine size for gestational age

3

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. Strict bed rest required after procedure 2. Hospitalization necessary for 24 hours after procedure 3. Informed consent needs to be signed before procedure 4. A fever is expected after procedure because of the trauma to the abdomen

3

The nurse administers erythromycin ointment (0.5%) to a newborn's eyes and the mother asks why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized 2. Prevents cataracts in the newborn born in a woman who is susceptible to rubella 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor 4. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with untreated gonnococcal infection

4

The nurse is creating a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow newborn to establish own sleep-rest pattern 2. Maintain the newborn in brightly lit area of nursery 3. Encourage frequent handling of newborn by parents and staff 4. Monitor the newborn's response to feedings and weight gain pattern

4

The nurse prepares to administer phytonadione (vitamin K) injection to a newborn and the mother asks why the infant needs the injection. What best response should the nurse provide? 1. "Your newborn needs the medicine to develop immunity" 2. "The medicine will protect your newborn from being jaundiced" 3. Newborns have sterile bowels and the medicine promotes the growth of bacteria in the bowel" 4. "Newborns are deficient in Vitamin K, and this injection prevents your newborn from bleeding"

4

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1. Avoid stimulation 2. Decreased fluid intake 3. Expose all of the newborn's skin 4. Monitor skin temperature closely 5. Reposition newborn every 2 hours 6. Cover the newborn's eyes with eye shields or patches

4, 5, 6