Exam 4

Which newborn assessment finding requires the nurse to take an action? a. Glucose level of 40 mg/dL b. Axillary temperature of 37° C (98.6° F) c. Mild yellow tinge to skin at 32 hours of age d. Mild inflammation of conjunctiva after eye prophylaxis

ANS: A A glucose level of 40 mg/dL requires an action. Follow agency policy and health care provider orders regarding feeding infants with low glucose levels. A common practice is to feed the newborn if the glucose screening shows a level of 40 to 45 mg/dL or less to prevent further depletion of glucose. Infants with severe hypoglycemia may need intravenous feedings to provide glucose rapidly. A normal temperature for a newborn is 36.5° to 37.5° C (97.7° to 99.5° F). Mild jaundice at 32 hours of age is physiologic jaundice and does not need an action by the nurse, just further monitoring. Some infants develop a mild inflammation a few hours after prophylactic eye treatment.

A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital 5 days after her son was circumcised. She is very concerned. On which rationale should the nurse base a reply? a. The yellow crust should not be removed. b. This yellow crust is an early sign of infection. c. Discontinue the use of petroleum jelly to the tip of the penis. d. After circumcision, the diaper should be changed frequently and fastened snugly.

ANS: A Crust is a normal part of healing. The normal yellowish exudate that forms over the site should be differentiated from the purulent drainage of infection. The only contraindication for petroleum jelly is the use of a PlastiBell. The diaper should be fastened loosely to prevent rubbing or pressure on the incision site.

The nurse is assessing a newborn's circumcision 30 minutes after the procedure. The nurse notes excessive bleeding coming from the circumcised area. Which priority intervention should the nurse implement? a. Apply pressure to the site. b. Continue to observe for another 30 minutes. c. Apply the diaper tightly over the circumcised area. d. Apply petroleum jelly to the site with a small piece of gauze.

ANS: A If excessive bleeding occurs after a circumcision, pressure is applied to the site. The nurse notifies the physician, who may apply Gelfoam or epinephrine or suture the small blood vessels. A small amount of blood loss may be significant in an infant, who has a small total blood volume. Continuing to observe could mean additional blood loss. Applying the diaper tightly will not stop the bleeding. Petroleum jelly is applied to keep the diaper from sticking to the circumcised area. It will not stop the bleeding.

3. Decreased surfactant production in the preterm lung is a problem because a.surfactant keeps the alveoli open during expiration. b.surfactant causes increased permeability of the alveoli. c.surfactant dilates the bronchioles, decreasing airway resistance. d.surfactant provides transportation for oxygen to enter the blood supply.

ANS: A Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not affect the bronchioles. By keeping the alveoli open, surfactant permits enhanced oxygen exchange. Infants treated with surfactant have higher survival rates.

15. The nurse is performing an initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system? a. Respiratory b. Cardiovascular c. Gastrointestinal d. Musculoskeletal

ANS: A Tachypnea, a respiratory rate of more than 60 breaths/min, is the most common sign of respiratory distress. Retractions occur when the soft tissue around the bones of the chest is drawn in with the effort of pulling air into the lungs. Xiphoid (substernal) retractions occur when the area under the sternum retracts each time the infant inhales. When the muscles between the ribs are drawn in so that each rib is outlined, intercostal retractions are present. A reflex widening of the nostrils occurs when the infant is receiving insufficient oxygen. Nasal flaring helps decrease airway resistance and increase the amount of air entering the lungs. PTS: 1 DIF: Cognitive Level: Understanding REF: 384 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

In which position should the parents be instructed to place their newborn for sleep? a. On the back b. On the left side c. On the right side d. On the abdomen

ANS: A The American Academy of Pediatrics (AAP) in 2011 recommended that mothers and fathers be taught to place infants on the back for sleep, because this position is associated with the lowest rate of SIDS. The side-lying position is not advised because of the possibility that the infant might roll to the prone position. The newborn should not be placed on the abdomen.

2. Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Stepping c. Tonic neck d. Plantar grasp

ANS: A The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The stepping reflex occurs when infants are held upright, with their heel touching a solid surface, and the infant appears to be walking. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infant's toes curl over the nurse's finger. PTS: 1 DIF: Cognitive Level: Application REF: 392, 393 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

17. The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding? a. Depress the tip of the nose. b. Stroke the outer aspect of the foot. c. Place a finger in the palm of the hand. d. Rotate the hips in an upward and outward direction.

ANS: A The nurse assesses for jaundice at least every 8 to 12 hours and is particularly watchful when infants are at increased risk for hyperbilirubinemia. Jaundice is identified by pressing the infant's skin over a firm surface, such as the end of the nose or the sternum. The skin blanches as the blood is pressed out of the tissues, making it easier to see the yellow color that remains. Jaundice is more obvious when the nurse assesses in natural light. Jaundice begins at the head and moves down the body, and the areas of the body involved should be documented. Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL. The Babinski reflex is assessed by stroking the outer aspect of the foot. The grasp reflex is determined by placing a finger in the newborn's palm. The Barlow and Ortolani tests are methods of assessing for hip instability in the newborn period. Both legs should abduct equally in normal infants. Abducting the affected hip may be difficult. A hip click may be felt or heard but is usually normal and is different from the clunk of hip dysplasia when the femoral head moves in the hip socket. PTS: 1 DIF: Cognitive Level: Application REF: 396 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

11. The clients says, "My baby is so thin and wrinkled. It looks like he has too much skin." Which is the most therapeutic response by the nurse to the new client's statement? a. "You sound disappointed about how your infant looks." b. "All mothers are concerned about how their babies look." c. "Don't worry. In no time he'll fill out his skin and look just fine." d. "You know, all the cigarettes you smoked interfered with the nourishment he needed."

ANS: A The nurse should clarify the client's statement and allow her to verbalize her feelings. "All mothers are concerned about how their babies look" generalizes her concerns and does not answer the mother's question. "Don't worry. In no time he'll fill out his skin and look just fine" does not directly answer the mother's question and could leave her feeling like she asked an unacceptable question. "You know, all the cigarettes you smoked interfered with the nourishment he needed" is condescending and hurtful and would not allow for further conversation between the nurse and mother. PTS: 1 DIF: Cognitive Level: Application REF: 408-409 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity

4. A preterm infant is on a ventilator, with intravenous lines and other medical equipment. When the parents come to visit for the first time, what is the most important action by the nurse? a.Encourage the parents to touch their infant. b.Reassure the parents that the infant is progressing well. c.Discuss the care they will give their infant when the infant goes home. d.Suggest that the parents visit for only a short time to reduce their anxiety.

ANS: A Touching the infant will increase the development of attachment. As the infant's condition improves the parents should be encouraged to provide Kangaroo care. It is important to keep the parents informed regarding the infant's progress; however, the nurse needs to be honest with the explanations. Discussing home care is an important part of parent teaching, although is not the most important priority during the first visit. Parents should be encouraged to visit for as long as they are comfortable.

BLANK is a rare event during delivery where the maternal patent experiences a profound inflammatory response to amniotic fluid entering the circulatory system. a. AFE b. DIC c. Sepsis d. Hypovolemia

ANS: A Amniotic Fluid Embolism (AFE), also referred to as Anaphylactoid Syndrome of Pregnancy, is an extremely rare and unpredictable event with high morbidity and mortality for the patient and fetus/newborn. AFE is thought to occur when amniotic fluid enters the maternal circulation triggering a sequence of life-threatening pro-inflammatory immune maternal reactions at or close to the time of birth.

An obstetric patient has presented to the clinic with a heart rate of 140, blood pressure of 90/56, and labored respiratory rate of 20. The patient is pale and reports frequent vomiting and has not been able to keep anything down for over 24 hours. The nurse recognizes that the patient is presenting signs of a. Hypovolemia b. Poor nutrition c. Pneumonia d. Urinary tract infection

ANS: A Hypovolemia results from fluid loss, such as vomiting. The cardiac system attempts to compensate by increasing the heart rate in an attempt to maintain oxygenation to the vital organs. Physiologic attempts to compensate for decreased blood volume and oxygenation of essential organs is by increasing the rate and effort of the heart and lungs by preferential shunting of arterial blood from less essential organs, such as the skin, extremities, and uterus, to more essential organs such as the heart, brain, and lungs.

he nurse is aware that which diagnosis places the maternal patient at higher risk forsepsis? a. Urinary Tract Infection b. Hypovolemia c. Disseminated Intravascular Coagulation d. Shock

ANS: A Infection, such as a urinary tract infection, places the patient at higher risk for sepsis. Sepsis can cause hypovolemia, DIC, and shock.

The clinic nurse is getting the maternal patient ready to see the provider for her urgent care visit related to increased fatigue and vomiting. The nurse notices that the patient has a fruity odor to her breath. Which action should the nurse take next? a. Obtain a blood glucose measurement b. Notify the provider that the patient is ready c. Call 911 and report an emergency requiring transport d. Nothing, as this is a normal finding in pregnancy

ANS: A The patient with DKA may present with hallmark signs and symptoms such as elevated glucose levels, polyuria, polydipsia, nausea/vomiting, fruity ketonic breath, tachycardia, hypotension, dehydration/dry mucous membranes, weakness, altered mental status, and coma (Morrison & Everett, 2016). Initial laboratory evaluation is paramount in the diagnosis.

22. Which are early signs of hypoglycemia in the newborn for which the nurse should assess?(Select all that apply.) a. Jitteriness b. Poor feeding c. Respiratory difficulty d. An increase in temperature e. A capillary refill of 2 seconds

ANS: A, B, C Early signs of hypoglycemia include jitteriness and other central nervous system signs and signs of respiratory difficulty, a decrease in temperature, and poor feeding. A capillary refill of 2 seconds is a normal finding in the newborn. PTS: 1 DIF: Cognitive Level: Analysis REF: 395, 396 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

20. The nurse is conducting a body system assessment of the newborn. Which are abnormal findings that the nurse should report? (Select all that apply.) a. Low-set ears b. Yellow sclera c. A doll's eye sign d. Edema of the eyelids e. Absence of the grasp reflex

ANS: A, B, E Low-set ears may indicate chromosomal abnormalities. The sclera should be white or bluish white. A yellow color indicates jaundice. Absence of reflexes may indicate a serious neurologic problem. The doll's eye sign is a normal finding in the newborn; when the head is turned quickly to one side, the eyes move toward the other side. Edema of the eyelids and subconjunctival hemorrhages (reddened areas of the sclera) result from pressure on the head during birth, which causes capillary rupture in the sclera. PTS: 1 DIF: Cognitive Level: Application REF: 392 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

23. The nurse is performing a gestational age assessment on a newborn. Which characteristics indicate a preterm newborn? (Select all that apply.) a. Translucent skin b. Extended limp arms and legs c. The ear springs back when folded d. Square window angle of 45 degrees or less e. Large clitoris and labia minora in the female newborn

ANS: A, B, E The very preterm infant's skin is translucent because it is thin and has little subcutaneous fat beneath the surface. Preterm neonates have immature flexor muscles and little energy or muscle tone. Therefore they have extended and limp arms and legs that offer little resistance to movement by the examiner. In the preterm female infant, the labia majora are small and separated, and the clitoris and labia minora are large by comparison. In the term neonate, the ear springs back to its original position immediately. The more mature the neonate, the smaller the angle of the square window assessment until the palm folds flat against the forearm at term, the result of maternal hormones at the end of pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: 406 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity MATCHING

The nurse reviewing is reviewing the lab results for a pregnant patient who presented with signs and symptoms of sepsis. The nurse notes that the lactate level is 3 mmol/L. What can the nurse conclude from this finding? a. Nothing, this is a normal laboratory finding. b. Inconclusive based on the lactate level alone. c. The patient is septic and needs immediate treatment. d. The patient is septic but does not require treatment.

ANS: B A serum lactate level is recommended in the first hour of bundle implementation (Rhodes, et.al. 2017). Lactate levels increase in response to anaerobic metabolism from poor tissue perfusion in a septic patient. Normal lactate levels are < 2 mmol/L. Levels > 4 mmol/L are associated with increased mortality rates in nonpregnant patients and non-laboring pregnant patients; however, levels may exceed 4 mmol/L in a laboring patient in the absence of sepsis, making diagnosis difficult.

Critical care of the obstetric patient in the Intensive Care Unit is complicated by a. OB nurses not having critical care experience b. ICU nurses not having Fetal Heart Rate Monitoring experience c. Lack of monitoring equipment d. Lack of emotional support

ANS: B As OB complexities increase, managing and balancing maternal and fetal care needs can be challenging. Often in ICU, OB nurses are utilized at the bedside to assess pregnancy related issues and interpret fetal heart rate (FHR) monitoring as ICU nurses do not typically have this skillset or knowledge.

Magnesium sulfate for fetal neuroprotection is an option for patients at high risk for delivery between weeks gestation, if a contraindication does not exist. a. 10 and 12 2/7 b. 23 and 36 6/7 c. 20 and 25 4/7 d. 25 and 41 0/7

ANS: B Magnesium sulfate for fetal neuroprotection is an option for patients at high risk for delivery between 23 and 32 6/7 weeks gestation, if a contraindication does not exist.

BLANK is the abnormal accumulation of blood outside of the vascular space in the lungs? a. Sepsis b. Pulmonary Edema c. Disseminated Intravascular Coagulation d. Diabetic Keto Acidosis

ANS: B Pulmonary edema is the abnormal accumulation of fluid outside of the vascular space in the lungs and is a common cause of respiratory compromise in the OB population. The fluid can accumulate in the interstitial space, alveoli, and cells. Excess fluid within the interstitial space and alveolar spaces results in decreased gas exchange between the alveoli and blood vessels. Decreased oxygen diffusion results in hypoxemia and potentially tissue hypoxia.

16. The postpartum nurse is providing care to a woman 2 hours after birth and to her newborn. On review of the newborn's chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mother's chart? a. Race—non-white b. A longer than usual labor c. Administration of an epidural d. Delivery by cesarean section

ANS: B A caput succedaneum is an area of localized edema that appears over the vertex of the newborn's head as a result of pressure against the mother's cervix during labor. The pressure interferes with blood flow from the area, causing localized edema at birth. The edematous area crosses suture lines, is soft, and varies in size. The longer the labor, the more pronounced the caput. Mongolian spots are associated with infants born to non-white parents. An epidural may be a contributing factor to a prolonged labor, but it is the pressure of the head against the cervix that gives rise to the caput. If labor is prolonged without descent of the head, a cesarean section may follow but is not the cause of the caput. PTS: 1 DIF: Cognitive Level: Analysis REF: 387 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

3. Infants who develop cephalohematoma are at increased risk for: a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.

ANS: B Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalohematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas. PTS: 1 DIF: Cognitive Level: Understanding REF: 387 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

19. An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable and muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of a. RDS. b. PIVH. c. BPD. d. ROP.

ANS: B IVH or PIVH (intraventricular hemorrhage or periventricular hemorrhage) can be seen during the first week of life. Signs and symptoms are based on the extent of hemorrhage. Typically, one would see lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, acidosis, and seizures. If the newborn had RDS or BPD, there would be more respiratory symptoms exhibited. If the infant had ROP, there would be signs and symptoms related to the eyes. Other physical characteristics are reported as being normal.

Which should the nurse implement to prevent the kidnapping of a newborn from the hospital? a. Restricting the amount of time infants are out of the nursery b. Questioning anyone who is seen walking in the hallways carrying an infant c. Allowing no visitors in the maternity area except those who have identification bracelets d. Instructing the parents to not give the baby to anyone except the nurse assigned that day

ANS: B Infants should be transported in the hallways only in their cribs. Restricting the amount of time infants are out of the nursery will be difficult to monitor and will limit the mother's support system from visiting. Infants need to spend time with the parents to facilitate the bonding process. It is impossible for one nurse to be on call for one mother and baby for the entire shift, so the parents need to be able to identify the nurses who are working on the unit.

15. Following the vaginal birth of a macrosomic infant, the nurse should evaluate the infant for a.hyperglycemia. b.clavicle fractures. c.hyperthermia. d. an increase in red blood cells.

ANS: B Macrosomic infants may have a complicated birth and are susceptible to birth injuries, such as fractured clavicles, cephalohematomas, and brachial palsy. A macrosomic infant would have the potential to become hypoglycemic and would be at risk for hypothermia. An increase in red blood cells would not be the priority assessment for a macrosomic infant.

9. Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Maintain room temperature at 70° F. b. Place a blanket over the scale before weighing the infant. c. Take the rectal temperature every hour to detect early changes. d. Undress the infant completely for assessments so that they can be finished quickly.

ANS: B Padding the scale prevents heat loss from the infant to a cold surface by conduction. The room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. Hourly assessments are not necessary for a normal newborn with a stable temperature. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature by convection. PTS: 1 DIF: Cognitive Level: Application REF: 390 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

10. The nurse is performing a gestational age assessment on a newborn. Which characteristic shows the greatest gestational maturity? a. The infant's arms and legs are extended. b. There is some peeling and cracking of the skin. c. There are few rugae on the scrotum and the testes are high in the scrotum. d. The arm can be positioned with the elbow beyond the midline of the chest.

ANS: B Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. Extended arms and legs is a sign of preterm infants. Few rugae on the scrotum show a younger age in the newborn. The arm being able to be positioned with the elbow beyond the midline of the chest is a result of the scarf sign and indicates a newborn of a younger age. PTS: 1 DIF: Cognitive Level: Application REF: 409 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

1. Which is the most useful factor in preventing premature birth? a.High socioeconomic status b.Adequate prenatal care c.Aid to Families with Dependent Children d.Women, Infants, and Children (WIC) nutritional program

ANS: B Prenatal care is vital for identifying possible problems. People with higher socioeconomic status are more likely to seek adequate prenatal care, which is the most helpful for prevention of premature births. Lower socioeconomic groups do not seek out health care, which puts them at risk for preterm labor. Aid to Families with Dependent Children and WIC assist in the nutritional status of the pregnant woman; however, the most helpful intervention for the prevention of premature births is adequate prenatal care.

8. In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level? a.Necrotizing enterocolitis (NEC) b.Retinopathy of prematurity (ROP) c.Intraventricular hemorrhage (IVH) d.Bronchopulmonary dysplasia (BPD)

ANS: B ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. IVH is caused by rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow. BPD is caused by the use of positive-pressure ventilation against the immature lung tissue.

In reviewing safety concerns for the newborn nursery, an ad hoc committee has been organized to discuss methods to prevent infant abduction. Which option can be used to facilitate improved outcomes related to this potential problem? a. Allow only immediate adult family members to visitor the newborn nursery during unrestricted visiting hours. b. Require identification with picture ID confirmation of all family members and/or staff who want to have contact with the newborn. c. Make sure that all emergency exits are accessible to staff and clients on the unit. d. Limit the number of visitors to two per client who can be on the unit during visiting hours to maintain security.

ANS: B Requiring appropriate identification is the best method of preventing possible infant abduction. Evidenced-based practice has indicated that potentially "family and/or staff or someone representing themselves as such" is more likely to attempt an infant abduction. The unit should be a closed or locked unit and require admittance to maintain security. Limiting the visitors to two per client may cause increased stress to the new family because they want to share this experience. Preventing siblings from visiting by only allowing immediate adult family members may prevent beginning sibling attachment and cause separation and stress anxiety to the mother and children.

When an infant's temperature drops from 98.7 to 97.4 F (37 to 36.3 C), the nurse should: a. instruct parents on cold stress. b. determine time and amount of last feeding. c. increase the temperature in the mother's room. d. evaluate infant for the presence of a blood sugar level higher than 50 mg/dL.

ANS: B Temperature instability in the neonate may be caused by a decrease in blood glucose levels. Infants who do not maintain adequate intake will not have adequate energy to maintain temperature; instructing parents on cold stress and increasing the temperature in the room are interventions to maintain a stable temperature but will not correct the underlying problem. A blood sugar level higher than 50 mg/dL is a normal finding.

The nurse is preparing a male infant for circumcision. On review of the chart, the nurse notes that the consent has been signed, vitamin K has been administered, the temperature has been between 36.8° to 37° C (98.2° to 98.6° F), and the heart rate range is 126 to 144 beats per minute (bpm). Which finding, if omitted from the chart, would cause the nurse to have to cancel the circumcision? a. Consent b. Vitamin K c. Heart rate d. Temperature

ANS: B The administration of the vitamin K prevents excessive bleeding. The infant could be at risk for hemorrhage without the vitamin K. Other assessment measures can be used to fulfill the remaining assessments, such as a verbal consent can be obtained, the skin can be palpated to determine temperature, and overall color can give the health care provider information about the infant's heart rate. The only replacement for vitamin K is time to allow for the development of vitamin K in the gastrointestinal (GI) system.

5. Which explains why a newborn with a congenital defect of the penis should not be circumcised? a. There is increased risk of infection. b. The foreskin might be needed for future repairs. c. A circumcision will make the defect more visible. d. There is no medical rationale for a circumcision.

ANS: B The foreskin may be used to correct a defect. There is no significant increase in infection. A circumcision would not make the defect more noticeable. A circumcision is a decision made by the parents, but in this case the foreskin might be used to correct a defect. PTS: 1 DIF: Cognitive Level: Understanding REF: 399 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

The postpartum nurse is reviewing oral-nasal bulb suctioning with a first-time mom. Which statement will the nurse need to correct? a. "Depress the bulb prior to inserting the tip." b. "Suction the nose first and then the mouth." c. "Keep a bulb syringe in the bassinet at all times." d. "Gradually release the pressure on the bulb while withdrawing it."

ANS: B The mouth should be suctioned first because the infant may gasp when the nose is suctioned, causing aspiration of mucus or fluid in the mouth. Then the nose is suctioned gently and only if necessary. Suctioning is traumatic to the delicate tissues and may cause edema of the nasal passages. The remaining statements are correct.

18. An infant at term was born at 0105, or 1:05 AM. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score? a. 0115-0130 b. 0200-0600 c. 1400-1800 d. 2000-2300

ANS: B The new Ballard score is often used to assess gestational age based on neuromuscular and physical characteristics. It is designed to assess gestational age from 20 to 44 weeks and provides accurate information within 2 weeks. It is most accurate when performed within 12 hours of birth. PTS: 1 DIF: Cognitive Level: Application REF: 406 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

Administration of medications after birth is the topic of discussion during a prenatal education class. Which statement indicates to the nurse that the pregnant patient understands the primary indication for the administration of vitamin K? a. "The nurse will draw blood to determine if vitamin K is needed." b. "Vitamin K prevents the possibility of bleeding problems in my baby." c. "My baby will receive a shot when the nurse administers the vitamin K." d. "Vitamin K will be administered shortly after birth, generally within the first hour."

ANS: B This indication is the reason for vitamin K administration. Vitamin K is given to neonates because they cannot synthesize it in the intestines without bacterial flora. This places them at risk for hemorrhagic disease of the newborn (vitamin K deficiency disease). One dose of vitamin K intramuscularly after birth prevents bleeding problems until the infant is able to produce vitamin K in sufficient amounts. Although the injection is usually given within the first hour after birth, it can be delayed until the infant has finished breastfeeding shortly after birth.

16. An infant delivered prematurely at 28 weeks' gestation weighs 1200 g. Based on this information the infant is classified as a.SGA. b.VLBW. c.ELBW. d.low birth weight at term.

ANS: B VLBW (very-low-birth-weight) infants weigh 1500 g or less at birth. SGA infants fall below the tenth percentile in growth charts. ELBW (extremely low-birth-weight) infants weigh 100 g or less at birth. Low birth weight pertains to an infant weighing 2500 g or less at birth. This option is incorrect because it specifies at term and the infant in question is designated as preterm at 28 weeks' gestation.

Betamethasone for fetal lung maturity is recommended between weeks gestation. a. 10 and 12 2/7 b. 23 and 36 6/7 c. 20 and 25 4/7 d. 25 and 41 0/7

ANS: B Betamethasone for fetal lung maturity is recommended between 23 and 36 6/7 weeks gestation.

Which of the following is NOT a cause of disseminated intravascular coagulation (DIC)? a. Trauma to tissues b. Trauma to vascular endothelium c. Trauma to the uterine wall d. Trauma to red blood cells or platelets

ANS: C Disseminated intravascular coagulation (DIC), also called consumptive coagulopathy, is a life-threatening condition involving systemic activation of coagulation, formation of fibrin clots, decreased tissue oxygenation, and consumption of coagulation factors. DIC is a secondary complication of an underlying condition. In each of the disease processes that cause DIC, tissue factor initiates massive release of clotting factors, resulting in systemic, rather than local, activation and circulation of thrombin, plasmin, and fibrin clot formation. This process is activated by one or more processes: 1. Trauma to tissues 2. Trauma to vascular endothelium 3. Trauma to red blood cells or platelets

The nurse is preparing to administer antibiotics to the maternal patient with suspected sepsis. The nurse is aware that the antibiotic dose should be given when? a. As soon as possible, no matter what b. Only after blood cultures have been drawn c. Within an hour of recognition of sepsis risk d. After verifying the timing with the ordering provider

ANS: C Whenever possible, obtain all necessary cultures prior to antibiotic initiation. However, empiric antibiotic therapy should not be delayed beyond the first hour of bundle implementation as mortality rates increase appreciably with every hour delay.

6. A maculopapular rash with a red base and a small white papule in the center is: a. milia. b. Mongolian spots. c. erythema toxicum. d. café-au-lait spots.

ANS: C A maculopapular rash with a red base and a small white papule in the center is a description of erythema toxicum, a normal rash in the newborn. Milia are minute epidermal cysts on the face of the newborn. Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sacrum. Café-au-lait spots are pale tan (the color of coffee with milk) macules. Occasional spots occur normally in newborns. PTS: 1 DIF: Cognitive Level: Analysis REF: 400 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

19. The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the following figures depicts this birthmark? a. b. c. d.

ANS: C A nevus flammeus (port wine stain) is a permanent, flat, pink to dark reddish-purple mark that varies in size and location. Erythema toxicum is a red blotchy area that may have white or yellow papules or vesicles in the center; it is not a birthmark. Mongolian spots are bluish-black marks that resemble bruises. They usually occur in the sacral area but may appear on the buttocks, arms, shoulders, and other areas. A nevus simplex is also called salmon patch, stork bite, or telangiectatic nevus. It is a flat pink or reddish discoloration from dilated capillaries that occurs over the eyelids, just above the bridge of the nose, or at the nape of the neck. PTS: 1 DIF: Cognitive Level: Analysis REF: 400, 401 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE

An hour after birth, the nurse assesses a newborn's temperature and notes that it is 36.2° C (97.2° F). The next activity planned for the newborn is the bath, and the new mother and father are invited to participate in the procedure. What is the nurse's next action? a. Take the infant's temperature rectally. b. Ask the father to test the water to determine if it is too hot. c. Delay the bath until the newborn's temperature is above 36.7° C (98° F). d. Explain to the new parents that no soap should be used to cleanse the eyes.

ANS: C A temperature of 36.7° C (98° F) or higher is often used to determine when to bathe the infant. The infant can lose heat in the bath through the process of evaporation. Rectal temperatures are avoided because they can traumatize the rectal mucosa. The water temperature should be approximately 38° to 40° C (100.4° to 104° F). The nurse and not the father needs to determine if the bath water is the correct temperature to avoid scalding the newborn. Explain the process of giving a bath during the procedure. Informing the parents before the procedure may result in loss of information.

4. Which action should the nurse take if a discrepancy is found between the measurements of a newborn and the normative criteria? a. Remeasure the infant. b. Consider this a normal deviation. c. Perform an expanded assessment. d. Inform the parents so that they can follow the infant's growth.

ANS: C An expanded assessment is necessary to look for data to verify the measurements of the infant. Remeasuring the infant is helpful but an expanded assessment would be a better action. A discrepancy is not a normal deviation. An expanded assessment is needed first so as not to alarm the parents unnecessarily. PTS: 1 DIF: Cognitive Level: Application REF: 390 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

12. Which assessment finding of a newborn requires prompt action by the nurse? a. Respiratory rate of 50 breaths/min b. Cyanosis of the extremities c. Pause in breathing lasting 20 seconds d. Pause in breathing for 15 seconds followed by rapid respirations

ANS: C Apnea is a pause in breathing lasting 20 seconds or more, or accompanied by cyanosis, pallor, bradycardia, and/or decreased muscle tone. Apnea is abnormal and requires prompt intervention. A respiratory rate of 50 breaths/min is still within the normal range. Tachypnea is considered to be 60 breaths/min or more. Cyanosis of the extremities or acrocyanosis is normal during the first day after birth and if the infant becomes cold. Periodic breathing is pauses in breathing lasting 5 to 10 seconds without other changes followed by rapid respirations for 10 to 15 seconds. This occurs in some full-term infants during the first few days but is more common in preterm infants. PTS: 1 DIF: Cognitive Level: Application REF: 384 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

14. Inspection of a newborn's head following birth reveals a hard ridged area and significant molding. The anterior and posterior fontanels show no sign of depression. Delivery history indicates that the mother was pushing for over 3 hours and had epidural anesthesia, and vacuum extraction was used. Based on this information the nurse would first: a. continue to monitor newborn and anticipate that molding will subside. b. inspect and document location of fontanels to complete the head assessment. c. contact the neonatologist. d. note findings as being within normal limits as a result of the strenuous birth process.

ANS: C Assessment data reveal a significant finding, and the nurse should suspect craniosynostosis (premature closing of sutures) and therefore should contact the neonatologist immediately. Even though the birth process was difficult and vacuum extraction was used, this does not account for the physical findings. Continuing to monitor is not a prudent action and, because this is more than molding, it will not go away. Although it is important to note the presence of fontanels, the immediate action would be to make the appropriate referral for medical intervention. PTS: 1 DIF: Cognitive Level: Analysis REF: 404 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

The nurse is explaining the procedure of newborn screening to parents before discharge. Which statement by the parents indicates a need for further teaching? a. "We understand the tests are performed at 24 to 48 hours." b. "We're glad all the tests can be done on one blood sample." c. "We wish the tests would screen for congenital hypothyroidism." d. "We know that if the tests are done before 24 hours, the tests will need to be repeated at 1 to 2 weeks."

ANS: C Common disorders often included in newborn screening are phenylketonuria (PKU), hypothyroidism, galactosemia, hemoglobinopathies such as sickle cell disease and thalassemia, and congenital adrenal hyperplasia. The parents need further teaching if they say that congenital hypothyroidism is not screened. The newborn screening tests are performed at 24 to 48 hours after birth. Newborn screening requires a blood sample taken from the infant's heel, and only one blood sample is needed for all tests. Tests performed within the first 24 hours of life are less sensitive than those performed after 24 hours. Infants tested before 12 to 24 hours of age should have repeat tests at 1 to 2 weeks of age so that disorders are not missed because of early testing.

A 38 weeks' gestation fetus is delivered via cesarean section and transported to the newborn nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an initial assessment in the newborn nursery. Which is the priority nursing diagnosis? a. Risk for injury related to potential equipment malfunction of radiant warmer b. Altered tissue perfusion related to use of medications during delivery process c. Ineffective airway clearance due to mode of delivery and use of anesthetics d. Risk for ineffective thermoregulation related to gestational age

ANS: C Delivery via cesarean section may affect the newborn's ability to remove excess fluid secretions because the infant did not move down the birth canal and thus may be at risk for airway concerns. There is no evidence to support that the equipment is malfunctioning. Although the use of medications may affect the newborn in terms of respiratory, cardiac, and neurologic depression, Apgar scores do not indicate any immediate deficit. The infant is at term based on reported gestational age and therefore is not a risk for ineffective thermoregulation because of this fact.

14. Which statement regarding large-for-gestational age (LGA) infants is most accurate? a.They weigh more than 3500 g. b.They are above the 80th percentile on gestational growth charts. c.They are prone to hypoglycemia, polycythemia, and birth injuries. d.Postmaturity syndrome is the most common complication.

ANS: C Hypoglycemia, polycythemia, and birth injuries are all common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on gestational growth charts. Postmaturity syndrome is not an expected complication with LGA infants.

12. What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction? a.All body parts appear proportionate. b.The extremities are disproportionate to the trunk. c.The head seems large compared with the rest of the body. d.One side of the body appears slightly smaller than the other.

ANS: C In asymmetric intrauterine growth restriction, the head is normal in size; but, appears large because the infant's body is long and thin due to lack of subcutaneous fat. The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head. The body parts are out of proportion, with the body looking smaller than anticipated. The body, arms, and legs have lost subcutaneous fat so they will look small compared with the head.

5. Which preterm infant should receive gavage feedings instead of bottle feedings? a.Sucks on a pacifier during gavage feedings b.Sometimes gags when a feeding tube is inserted c.Has a sustained respiratory rate of 70 breaths per minute d.Has an axillary temperature of 36.9C (98.4F), an apical pulse of 149 beats/minute, and respirations of 54 breaths per minute

ANS: C Infants less than 34 weeks of gestation or those who weigh less than 1500 g generally have difficulty with bottle-feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths per minute. Providing a pacifier during gavage feedings gives positive oral stimulation and helps the infant associate the comfortable feeling of fullness with sucking. The presence of the gag reflex is important before initiating bottle-feeding. Axillary temperature of 36.9C (98.4F), an apical pulse of 149 beats/minute, and respirations of 54 breaths per minute are within expected limits and an indication that the infant is not having respiratory problems at that time.

18. Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette? a.Hypothermia because of phototherapy treatment b.Impaired skin integrity related to diarrhea as a result of phototherapy c.Fluid volume deficit related to phototherapy treatment d.Knowledge deficit (parents) related to initiation of medical therapy

ANS: C Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia are at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit. The infant is losing fluid via insensible losses, increased output (in the form of diarrhea), and limited intake. Lack of knowledge is a pertinent nursing diagnosis for these parents; but, physiologic needs take precedence at this time.

13. The nurse is receiving a shift report in the newborn nursery. Which client should the nurse assess first? a. 38-weeks' gestation female newborn with a blood sugar level of 60 mg/dL b. Term male newborn with a noted axillary temperature of 37.2° C (99° F) c. 40-weeks' gestation female newborn with reported poor feed at last attempt d. 39-weeks' gestation male newborn who has been crying prior to initial bath

ANS: C Newborns who are poor feeds may be showing initial signs of hypoglycemia, so this newborn should be assessed first at the start of the shift. Although the newborn is term, and it is more likely to see hypoglycemia with preterm infants, sometimes hypoglycemia is asymptomatic. Blood sugar results are within normal range and the newborn is considered to be term. Temperature is within normal range and the newborn is term. This newborn is considered to be term, and crying alone does not increase risk stratification. PTS: 1 DIF: Cognitive Level: Analysis REF: 396 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment

17. The nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respirations. The infant's color and heart rate remain unchanged. The nurse suspects that the infant a.is exhibiting signs of RDS. b.requires tactile stimulation around the clock to ensure that apneic periods do not progress further. c.is experiencing periodic breathing episodes and will require continuous monitoring while in the nursery unit. d.requires the use of CPAP to promote airway expansion.

ANS: C Periodic breathing can occur in term or preterm infants; it consists of periods of breathing cessation (5 to 10 seconds) followed by a period of increased respirations (10 to 15 breaths per minute). It is not associated with any color or heart rate changes. Infants who exhibit this pattern should continue to be observed. There is no clinical evidence that the infant is exhibiting signs of respiratory distress syndrome (RDS). There is no indication that a pattern of tactile stimulation should be initiated. Continuous positive airway pressure (CPAP) and tactile stimulation would be indicated if the infant were to have apneic spells.

10. Which statement regarding newborns classified as small for gestational age (SGA) is accurate? a.They weigh less than 2500 g. b.They are born before 38 weeks of gestation. c.They are below the tenth percentile on gestational growth charts. d.Placental malfunction is the only recognized cause of this condition.

ANS: C SGA infants are defined as below the tenth percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are classified as preterm. There are many factors that contribute to the development of an SGA infant, not just placental malfunction.

7. A newborn who is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight? a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th

ANS: C The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. An infant between the 10th and 90th percentiles is average for gestational age. An infant in less than the 10th percentile is small for gestational age. PTS: 1 DIF: Cognitive Level: Analysis REF: 411 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

A nursing student has been caring for a client and her newborn all morning. After taking the newborn to the nursery for tests, the student is returning the newborn to the mother. Which procedure is correct for identifying the newborn? a. Ask the mother to state her name and the name of her infant. b. Call out the mother's full name before leaving the infant with her. c. Have the mother read her printed band number and verify that it matches the infant's number. d. Return the infant with no special procedure because the student knows the mother and infant.

ANS: C The mother and infant should have identifying arm bands with matching numbers. The other actions do not adequately verify the identities of mother and infant.

8. A new client asks, "Why are you doing a gestational age assessment on my baby?" The nurse's best response is: a. "It was ordered by your physician." b. "This must be done to meet insurance requirements." c. "It helps us identify infants who are at risk for any problems." d. "The gestational age determines how long the infant will be hospitalized."

ANS: C The nurse should provide the mother with accurate information about various procedures performed on the newborn. Assessing gestational age is a nursing assessment and does not have to be ordered. It is not needed for insurance needs. Gestational age does not dictate hospital stays. Problems that occur because of gestational age may prolong the stay. PTS: 1 DIF: Cognitive Level: Application REF: 411 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

What should the nurse teach to parents about using a bulb syringe? a. Use it only once a day. b. Suction the back of the throat vigorously. c. Insert the syringe into the sides of the mouth. d. Always suction the mouth before suctioning the nose.

ANS: C The syringe should be inserted into the sides of the mouth rather than the back of the throat to avoid a vagal response and bradycardia. Suction can occur as needed. Vigorous suction of the back of the throat may stimulate the vagal nerve and produce bradycardia. The mouth should be suctioned first to prevent aspiration.

7. A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is a.soft and supple skin. b.a hematocrit level of 55%. c.lack of subcutaneous fat. d.an abundance of vernix caseosa.

ANS: C This post-term infant has actually lost weight in utero, which is seen as loss of subcutaneous fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the expected range of all newborns. There is no vernix caseosa in a post-term infant.

21. To differentiate between caput succedaneum and cephalohematoma in a newborn, the nurse would consider the following clinical information. (Select all that apply.) a. These are both normal presentations because of the birth process and will resolve within 24 to 48 hours. b. Cephalohematoma manifests as a localized area of swelling as compared with caput succedaneum, which appears as a general swelling of the head. c. A cephalohematoma can develop several hours or days after the birth event, whereas caput succedaneum is noted shortly before or immediately after the birth event. d. Edema that crosses suture lines is observed with caput succedaneum. e. With a cephalohematoma, bleeding occurs between the bone and skull.

ANS: C, D, E Cephalohematoma can be detected up to 24 to 48 hours after the birth process. This clinical condition is caused by bleeding between the periosteum and skull and is a serious medical condition. Caput succedaneum occurs in the presence of pressure from the vaginal canal on the fetal head during the birth process. Swelling is localized and crosses the suture line, whereas with cephalohematoma the swelling is more generalized and crosses the suture line. Caput resolves within 12 to 48 hours after the birth event. PTS: 1 DIF: Cognitive Level: Application REF: 387 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

1. The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? a. Negative Barlow test b. Equal knee heights c. Negative Ortolani sign d. Thigh and gluteal creases are asymmetric

ANS: D Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. If the hip is dislocated, the knee on the affected side will be lower. A positive Ortolani sign yields a clunking sensation and indicates a dislocated femoral head moving into the acetabulum. During a positive Barlow test, the examiner can feel the femoral head move out of the acetabulum. PTS: 1 DIF: Cognitive Level: Understanding REF: 389 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

Which principle is important in providing and teaching cord care? a. Cord care is done only to control bleeding. b. Alcohol is the only agent used for cord care. c. It takes a minimum of 24 days for the cord to separate. d. Keeping the cord dry will decrease bacterial growth.

ANS: D Bacterial growth increases in a moist environment, so keeping the umbilical cord dry impedes bacterial growth. Cord care is done to prevent infection and aid in the drying of the cord. No agents are necessary to facilitate drying of the cord. The cord will fall off within 10 to 14 days.

9. In caring for the post-term infant, thermoregulation can be a concern, especially in an infant who also has a(n) a.hematocrit level of 58%. b.RBC count of 5 million/mcL. c.WBC count of 15,000 cells/mm3. d.blood glucose level of 25 mg/dL.

ANS: D Because glucose is necessary to produce heat, the infant who is also hypoglycemic will not be able to produce enough body heat. A hematocrit level of 58% is within the expected range for newborns. WBC count may be as high as 30,000 cells/mm3. RBC count ranges from 3.9 to 5.5 million/mcL.

Which is the purpose of state-required newborn screening? a. Keep the state records updated. b. Document the number of births. c. Allow for accurate statistical information. d. Recognize and treat newborn disorders early.

ANS: D Early treatment of disorders will prevent morbidity associated with some common newborn disorders. Keeping state records and documenting the number of births are not the purposes of newborn screening. The number of births is not indicated by the newborn screening test.

13. Which data should alert the nurse caring for an SGA infant that additional calories may be needed? a.The latest hematocrit was 53%. b.The infant's weight gain is 40 g/day. c.The infant is taking 120 mL/kg every 24 hours. d.Three successive temperature measurements were 36.1C, 35.5C, and 36.1C (97, 96, and 97F).

ANS: D Low body temperature indicates that additional calories are needed to maintain body temperature. The hematocrit is within the expected range for a newborn. A weight gain of about 20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day.

6. Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem? a.Group all care activities together to provide long periods of rest. b.Keep charts on top of the incubator so the nurses can write on them there. c.While giving a report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation. d.Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.

ANS: D Parents should be taught the signs of overstimulation so they will learn to adapt their care to the needs of their infant. Grouping care activities may under stimulate the infant during those long periods and overtire the infant during the procedures. Keeping charts on the incubator and giving the report in front of the incubator may cause overstimulation. Any clip boards or binders in use should be kept at the desk, never on top of the incubator.

2. In comparison with the term infant, the preterm infant has a.more subcutaneous fat. b.well-developed flexor muscles. c.few blood vessels visible through the skin. d.greater surface area in proportion to weight.

ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat, well-developed flexor muscles, and few blood vessels visible through the skin are features that are more characteristic of a term infant.

11. Which nursing action is especially important for an SGA newborn? a.Promote bonding. b.Observe for and prevent dehydration. c.Observe for respiratory distress syndrome. d.Prevent hypoglycemia with early and frequent feedings.

ANS: D The SGA infant has poor glycogen stores and is subject to hypoglycemia. Promoting bonding is a concern for all infants and is not specific to SGA infants. Dehydration is a concern for all infants and is not specific to SGA infants. Respiratory distress syndrome is most commonly seen in preterm infants.

Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is appropriate for the newborn? a. Deltoid muscle b. Gluteal muscles c. Rectus femoris muscle d. Vastus lateralis muscle

ANS: D The vastus lateralis muscle is located away from the sciatic nerve and femoral blood vessels. Gluteal muscles are not used until a child has been walking for at least 1 year to develop these muscles. The rectus femoris is used only if absolutely necessary because this muscle is located closer to the sciatic nerve and blood vessels, which poses a greater danger. The deltoid is not a recommended site for newborn injections.

An infant's temperature is recorded at 36 C (96.8 F) during the morning assessment in the newborn nursery. Which priority action should the nurse implement? a. Note the findings in the electronic health record (EHR). b. Unwrap the infant and inspect for abnormalities. c. Provide the infant with glucose water. d. Make sure that the infant is wrapped securely with a blanket and recheck temperature in 15 minutes.

ANS: D This temperature potentially indicates hypothermia, so the infant should be wrapped securely in a blanket and reassessed after that intervention. Findings should be documented in the EHR, but this is not the priority intervention. Unwrapping the infant would lead to further compromise and additional risk for the core temperature to drop. Feeding the infant with glucose water may eventually be used as an intervention if the infant shows additional signs of hypoglycemia, which may accompany hypothermia.

The nurse answers the call light for a patient on the L&D floor. The patient, in active labor, states "something is wrong, I feel really anxious" and then loses consciousness. The nurse assesses and finds the patient has no pulse. Which action should the nurse take next? a. Insert 2 large-bore IVs b. Clear the room of clutter c. Assess fetal heart tones d. Initiate basic life support

ANS: D Initiating basic life support, including CPR, is the first step when a patient is found to be without a pulse. The other answers are important but are not the first step in maintaining oxygenation to the tissues, including the fetus, during a cardiac arrest.

24. A new mother is preparing for discharge. She plans on bottle feeding her baby. Which statement indicates to the nurse that the mom needs more information about bottle feeding? a. "I should encourage my baby to consume the entire amount of formula prepared for each feeding." b. "I can make up a 24-hour supply of formula and refrigerate the bottles so I am ready to feed my baby." c. "I will hold my baby in a cradle hold and alternate sides from left to right when I feed my baby." d. "I will generally feed my baby every 3 to 4 hours or more often as signs of hunger are displayed."

a. "I should encourage my baby to consume the entire amount of formula prepared for each feeding." Rationale: Infants will stop suckling when they are full. Encouraging them to overeat may lead to problems with regurgitation and possible aspiration. The mother can prepare a single bottle or a 24-hour supply if adequate refrigeration is available. Show the parents how to position the infant in a semi-upright position, such as the cradle hold. This allows them to hold the infant close in a face-to-face position. The bottle is held with the nipple kept full of formula to prevent excessive swallowing of air. Placing the infant in the opposite arm for each feeding provides varied visual stimulation during feedings. Feed the infant every 3 to 4 hours but avoid rigid scheduling and take cues from the infant.

2. Which woman is most likely to continue breastfeeding beyond 6 months? a. A woman who avoids using bottles. b. A woman who uses formula for every other feeding. c. A woman who offers water or formula after breastfeeding. d. A woman whose infant is satisfied for 4 hours after the feeding.

a. A woman who avoids using bottles. Rationale: Women who avoid using bottles and formula are more likely to continue breastfeeding. Use of formula decreases breastfeeding time and decreases the production of prolactin and, ultimately, the milk supply. Overfeeding after breastfeeding causes a sense of fullness in the infant, so the infant will not be hungry in 2 to 3 hours. Formula takes longer to digest. The new breastfeeding mother needs to nurse often to stimulate milk production.

8. Which is the first step in assisting the breastfeeding mother to nurse her infant? a. Assess the woman's knowledge of breastfeeding. b. Provide instruction on the composition of breast milk. c. Discuss the hormonal changes that trigger the milk-ejection reflex. d. Help her obtain a comfortable position and place the infant to the breast.

a. Assess the woman's knowledge of breastfeeding. Rationale: The nurse should first evaluate the woman's knowledge and skill in breastfeeding to determine her learning needs. Assessment should occur prior to instruction. Discussing the hormonal changes and helping her obtain a comfortable position may be part of the instructional plan; however, assessment should occur first to determine what instruction is needed.

1. The breastfeeding patient should be taught a safe method to remove her breast from the baby's mouth. Which suggestion by the nurse is most appropriate? a. Break the suction by inserting your finger into the corner of the infant's mouth. b. A popping sound occurs when the breast is correctly removed from the infant's mouth. c. Slowly remove the breast from the baby's mouth when the infant has fallen asleep and the jaws are relaxed. d. Elicit the Moro reflex in the baby to wake the baby up, and remove the breast when the baby cries.

a. Break the suction by inserting your finger into the corner of the infant's mouth. Rationale: Inserting a finger into the corner of the baby's mouth between the gums to break the suction avoids trauma to the breast. A popping sound indicates improper removal of the breast from the baby's mouth and may cause cracks or fissures in the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple, making it sore. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended.

1. Late in pregnancy, the patient's breasts should be evaluated by the nurse to identify any potential concerns related to breastfeeding. Which of the following nipple conditions make it necessary to intervene prior to birth. (Select all that apply.) a. Flat nipples b. Cracked nipples c. Everted nipples d. Inverted nipples e. Nipples that contract when compressed

a. Flat nipples d. Inverted nipples e. Nipples that contract when compressed Rationale: Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling them between the fingers. Inverted nipples are retracted into the breast tissue. These nipples appear normal; however, they will draw inward when the areola is compressed by the infant's mouth. Dome-shaped devices known as breast shells can be worn during the last weeks of pregnancy and between feedings after birth. The shells are placed inside the bra, with the opening over the nipple. The shells exert slight pressure against the areola to help the nipples protrude. The helpfulness of breast shells has been debated. A breast pump can be used to draw the nipples out before feedings after birth. Everted nipples protrude and are normal. No intervention will be required. Cracked, blistered, and bleeding nipples occur after breastfeeding has been initiated and are the result of improper latching on. The infant should be repositioned during feeding. The application of colostrum and breast milk after feedings will aid in healing.

22. A mother conveys concern over the fact that she is not certain if her newborn is receiving enough nutrients from breastfeeding. This is the baby's first clinic visit after birth. What information can you provide that will help alleviate her fears regarding nutrient status for her newborn? a. Monitor the infant's output; as long as at least six or more diapers are changed in a 24-hour period, the baby is receiving sufficient intake. b. Tell the mother that if a baby is satisfied with feeding, she or he will be content and not fussy. c. Tell the mother that breast milk contains everything required for the infant and not to worry about nutrition. d. Provide nutrition information in the form of pamphlets for the mother to take home with her so that she uses them as a point of reference.

a. Monitor the infant's output; as long as at least six or more diapers are changed in a 24-hour period, the baby is receiving sufficient intake. Rationale: The presence of wet diapers confirms that the infant is receiving enough milk. Recording weight and seeing an increase in weight is also an objective finding that can be used to note nutritional status. Newborns may be fussy and still be receiving adequate nutrition. Although breast milk is potentially the perfect food for the newborn, not everyone's breast milk has the same nutrient quality, therefore recording of weight gain and output measurements (wet diapers and stool production) confirm nutritional status. Providing the mother with educational pamphlets may be advisable; however, does not address the immediate problem.

9. Which of the following is an important consideration in positioning a newborn for breastfeeding? a. Placing the infant at nipple level facing the breast b. Keeping the infant's head slightly lower than the body c. Using the forefinger and middle finger to support the breast d. Limiting the amount of areola the infant takes into the mouth

a. Placing the infant at nipple level facing the breast Rationale: Positioning the infant at nipple level will prevent downward pulling of the nipple and subsequent nipple trauma. Keeping the infant's head slightly lower will pull the nipple down and cause trauma. The forefinger and middle finger can be used to support the breast; however, this is not an important consideration in positioning the newborn. The infant should take in as much areola as possible to prevent trauma to the nipples.

10. The patient should be taught that when her infant falls asleep after feeding for only a few minutes, she should do which of the following? a. Unwrap and gently arouse the infant. b. Wait an hour and attempt to feed again. c. Try offering a bottle at the next feeding. d. Put the infant in the crib and try again later.

a. Unwrap and gently arouse the infant. Rationale: The infant who falls asleep during feeding may not have fed adequately and should be gently aroused to continue the feeding. Breastfeeding should continue. By offering a bottle, breast milk production will decrease. The infant should be aroused and feeding continued.

18. A new mother asks why she has to open a new bottle of formula for each feeding. What is the nurse's best response? a. "Formula may turn sour after it is opened." b. "Bacteria can grow rapidly in warm milk." c. "Formula loses some nutritional value once it is opened." d. "This makes it easier to keep track of how much the baby is taking."

b. "Bacteria can grow rapidly in warm milk." Rationale: Formula should not be saved from one feeding to the next because of the danger of rapid growth of bacteria in warm milk. Formula will have bacterial growth before turning sour. This will cause problems in a newborn with an immature immune system. The loss of some nutritional value after the formula is opened is not the reason for using fresh bottles with each feeding. The danger of bacterial growth is the primary concern.

5. How many kilocalories per kilogram (kcal/kg) of body weight does a full-term formula-fed infant need each day? a. 50 to 75 b. 100 to 110 c. 120 to 140 d. 150 to 200

b. 100 to 110 Rationale: The term newborn being fed with formula requires 100 to 110 kcal/kg to meet nutritional needs each day. 50 to 75 kcal/kg is too little and 120 to 140 kcal/kg and 150 to 200 kcal/kg are too much. Requirements for breastfed infants are different.

21. A mother is attempting to breastfeed her infant in the hospital setting. The infant is sleepy and displays some audible swallowing, the maternal nipples are flat, and the breasts are soft. The nurse has attempted to teach the mother positioning on one side, and now the mother wants to place the infant to the breast on the other side. Based on LATCH scores, what score would the nurse assign to this feeding session? a. 10 and document findings in the chart. b. 6 and further teach and assist the mother in feeding activities. c. 5 and tell the mother to discontinue feeding attempts at this time because the infant is too sleepy. d. 8 and no further assistance is needed for feeding.

b. 6 and further teach and assist the mother in feeding activities. Rationale: The LATCH assessment tool is used to identify whether mothers need additional instruction in the area of breastfeeding. The LATCH categories are latch, audible communication/swallowing, type of nipple, comfort of breasts, and holding position of infant. The assessment data reveal a score of 6 (0 + 2 + 1 + 2 + 1). The mother will need additional assistance during breastfeeding at this time.

17. What is the most serious consequence of propping an infant's bottle? a. Colic b. Aspiration c. Dental caries d. Ear infections

b. Aspiration Rationale: Propping the bottle increases the likelihood of choking and aspiration if regurgitation occurs. Colic can occur in any infant. Dental caries becomes a problem when milk stays on the gums for a long period of time. This may cause a buildup of bacteria that will alter the growing teeth buds. However, this is not the most serious consequence. Ear infections can occur when the warm formula runs into the ear and bacterial growth occurs.

19. A new mother asks whether she should feed her newborn colostrum because it is not "real milk." The nurse's best answer includes which information? a. Colostrum is unnecessary for newborns. b. Colostrum is high in antibodies, protein, vitamins, and minerals. c. Colostrum is lower in calories than milk and should be supplemented by formula. d. Giving colostrum is important in helping the mother learn how to breast-feed before she goes home.

b. Colostrum is high in antibodies, protein, vitamins, and minerals. Rationale: Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Colostrum provides immunity and enzymes necessary to clean the gastrointestinal system, among other things. Supplementation is not necessary. It will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge, but the importance of the colostrum to the infant is top priority.

2. For which infant should the nurse anticipate the use of soy formula? (Select all that apply.) a. Preterm infant b. Infant with galactosemia c. Infant with phenylketonuria d. Infant with lactase deficiency e. Infant with a malabsorption disorder

b. Infant with galactosemia d. Infant with lactase deficiency e. Infant with a malabsorption disorder Rationale: Soy formula may be given to infants with galactosemia or lactase deficiency or those whose families are vegetarians. Soy milk is derived from the protein of soybeans and supplemented with amino acids. The formulas are also used for infants with malabsorption disorders. The preterm infant may require a more concentrated formula, with more calories in less liquid. Modifications of other nutrients are also made. Human milk fortifiers can be added to breast milk to adapt it for preterm infants. Low-phenylalanine formulas are needed for infants with phenylketonuria, a deficiency in the enzyme to digest phenylalanine found in standard formulas.

6. Which hormone is essential for milk production? a. Estrogen b. Prolactin c. Progesterone d. Lactogen

b. Prolactin Rationale: Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Progesterone decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced.

3. A new mother asks the nurse, "How will I know early signs of hunger in my baby?" The nurse's best response is which of the following? (Select all that apply.) a. Crying b. Rooting c. Lip smacking d. Decrease in activity e. Sucking on the hands

b. Rooting c. Lip smacking e. Sucking on the hands Rationale: Early signs of hunger in a baby are rooting, lip smacking, and sucking on the hands. Crying is a late sign, and the baby's activity will increase, not decrease.

20. A mother is breastfeeding her newborn son and is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The ideal nursing response would be to a. tell the patient to wear a bra at all times to provide more support to breast tissue. b. have the patient put the infant to her breast more frequently. c. place ice packs on breast tissue after infant feeding. d. explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing.

b. have the patient put the infant to her breast more frequently. Rationale: The patient may be experiencing the signs of engorgement. Intervention methods such as placing the infant to feed more frequently may help prevent physical complaints of tenderness to milk accumulation. Wearing a bra at all times will not help resolve engorgement issues but can provide comfort. Ice packs provide symptomatic relief but do not resolve engorgement issues. Warm water compresses are more likely to provide comfort. Engorgement is not a normal finding but is a common presentation in nursing mothers. These symptoms will not dissipate with continuation of breastfeeding.

23. A breastfeeding mother asks the postpartum nurse if any supplementation is necessary once her breast milk comes in. What is the nurse's most appropriate response? a. "Are you concerned about your ability to adequately nurse your baby?" b. "Do you eat a well-balanced diet, high in protein and carbohydrates?" c. "Breast milk is low in vitamin D and supplementation with 400 IU is d. "Your breast milk has all the vitamins and will adequately meet your baby's needs."

c. "Breast milk is low in vitamin D and supplementation with 400 IU is Rationale: Generally, nutrients provided in breast milk are present in amounts and proportions needed by the infant. However, recent studies have shown that the vitamin D content of breast milk is low, and daily supplementation with 400 IU of vitamin D is recommended within the first few days of life. Breastfeeding infants who are not exposed to the sun and those with dark skin are particularly at risk for insufficient vitamin D. Formula-fed infants who drink less than 1 quart of vitamin D-fortified milk per day should also be supplemented. Although the fatty acid content of breast milk is influenced by the mother's diet, malnourished mothers' milk has about the same proportions of total fat, protein, carbohydrates, and most minerals as milk from those who are well nourished. Levels of water-soluble vitamins in breast milk are determined by the mother's intake. It is important for breastfeeding women to eat a well-balanced diet to maintain their own health and energy levels.

3. In which condition is breastfeeding contraindicated? a. Triplet birth b. Flat or inverted nipples c. Human immunodeficiency virus infection d. Inactive, previously treated tuberculosis

c. Human immunodeficiency virus infection Rationale: Human immunodeficiency virus is a serious illness that can be transmitted to the infant via body fluids. Because the amount of milk being produced depends on the amount of suckling of the breasts, providing enough milk should not be a problem. Nipple abnormality can begin to be treated during pregnancy but may begin after birth. Many methods help flat or inverted nipples to become more erect. Only active tuberculosis patients would be cautioned not to breastfeed.

7. Which recommendation should the nurse make to a patient to assist in initiating the milk-ejection reflex? a. Wear a well-fitting firm bra. b. Drink plenty of fluids. c. Place the infant to the breast. d. Apply cool packs to the breast.

c. Place the infant to the breast. Rationale: Oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. A firm bra is important to support the breast; however, will not initiate the let-down reflex. Drinking plenty of fluids is necessary for adequate milk production; but, will not initiate the let-down reflex. Cool packs to the breast will decrease the let-down reflex. For many mothers simply thinking of her infant will result in the let-down reflex.

4. Which type of formula should not be diluted before being administered to an infant? a. Powdered b. Concentrated c. Ready to use d. Modified cow's milk

c. Ready to use Rationale: Ready to use formula can be poured directly from the can into the baby's bottle and is ideal (although expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cow's milk is more difficult for the infant to digest and is not recommended, even if it is diluted.

15. A breastfeeding patient who was discharged yesterday calls to ask about a tender hard area on her right breast. What should the nurse's first response be? a. "This is a normal response in breastfeeding mothers." b. "Notify your doctor so he can start you on antibiotics." c. "Stop breastfeeding because you probably have an infection." d. "Try massaging the area and apply heat; it is probably a plugged duct."

d. "Try massaging the area and apply heat; it is probably a plugged duct." Rationale: A plugged lactiferous duct results in localized edema, tenderness, and a palpable hard area. Massage of the area followed by heat will cause the duct to open. This is a normal deviation but requires intervention to prevent further complications. Tender hard areas are not the signs of an infection, so antibiotics are not indicated. Fatigue, aching muscles, fever, chills, malaise, and headache are signs of mastitis. She may have a localized area of redness and inflammation.

11. To prevent breast engorgement, what should the new breastfeeding mother be instructed to do? a. Feed her infant no more than every 4 hours. b. Limit her intake of fluids for the first few days. c. Apply cold packs to the breast prior to feeding. d. Breast-feed frequently and for adequate lengths of time.

d. Breast-feed frequently and for adequate lengths of time. Rationale: Engorgement occurs when the breasts are not adequately emptied at each feeding or if feedings are not frequent enough. Breast milk moves through the stomach within 1.5 to 2 hours, therefore waiting 4 hours to feed is too long. Frequent feedings are important to empty the breast and establish lactation. Fluid intake should not be limited with a breastfeeding mother; that would decrease the amount of breast milk produced. Warm packs should be applied to the breast before feedings.

16. Which is an important consideration regarding the storage of breast milk? a. Can be thawed and refrozen b. Can be frozen for up to 6 months c. Should be stored only in glass bottles d. Can be kept refrigerated for 4 days

d. Can be kept refrigerated for 4 days Rationale: If used within 4 days after being refrigerated, breast milk will maintain its full nutritional value. It should not be refrozen. Ideally frozen milk should be used within 6 months. Frozen milk should be kept at the back of the freezer. Milk can be stored in glass or rigid polypropylene plastic containers with a tight cap. Frozen milk should be thawed in the refrigerator and need used within 48 hours.

14. Which technique should the nurse recommend to the postpartum patient in order to prevent nipple trauma? a. Assess the nipples before each feeding. b. Limit the feeding time to less than 5 minutes. c. Wash the nipples daily with mild soap and water. d. Position the infant so the nipple is far back in the mouth.

d. Position the infant so the nipple is far back in the mouth. Rationale: If the infant's mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, causing trauma to the area. Assessing the nipples for trauma is important; however, it will not prevent sore nipples. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. Soap can be drying to the nipples and should be avoided during breastfeeding.

13. How should the nurse explain milk supply and demand when responding to the question, "Will I produce enough milk for my baby as she grows and needs more milk at each feeding?" a. Early addition of baby food will meet the infant's needs. b. The breast milk will gradually become richer to supply additional calories. c. As the infant requires more milk, feedings can be supplemented with cow's milk. d. The mother's milk supply will increase as the infant demands more at each feeding.

d. The mother's milk supply will increase as the infant demands more at each feeding. Rationale: The amount of milk produced depends on the amount of stimulation of the breast. Increased demand with more frequent and longer breastfeeding sessions results in more milk available for the infant. Solids should not be added until about 4 to 6 months, when the infant's immune system is more mature. This will decrease the chance of allergy formations. Mature breast milk will stay the same. The amounts will increase as the infant feeds for longer times. Supplementation will decrease the amount of stimulation of the breast and decrease the milk production.

12. As the nurse assists a new mother with breastfeeding, the mother asks, "If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?" The nurse's best response is that it contains a. more calcium. b. more calories. c. essential amino acids. d. important immunoglobulins.

d. important immunoglobulins. Rationale: Breast milk contains immunoglobulins that protect the newborn against infection. Calcium levels are higher in formula than breast milk. This higher level can cause an excessively high renal solute load if the formula is not diluted properly. The calorie counts of formula and breast milk are about the same. All the essential amino acids are in formula and breast milk. The concentrations may differ.