Maternity Exam Relevant Questions

Which nursing intervention is appropriate in the management of the preterm infant with hypothermia? (SATA) 1. Warm the baby rapidly to reverse the hypothermia. 2. Monitor skin temperature every 2 hours to determine whether the infant's temperature is increasing. 3. Keep IV fluids at room temperature. 4. Initiate efforts to maintain the newborn in a neutral thermal environment. 5. Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment

Answer: 4, 5 Explanation: 4. The nurse should initiate efforts to block heat loss by evaporation, radiation, convection, and conduction. 5. The infant should be warmed slowly to prevent hypotension and apnea.

When caring for a newborn, the nurse must be alert for signs of cold stress, including: A) decreased activity level. B) increased respiratory rate. C) hyperglycemia. D) shivering.

B) increased respiratory rate.

A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for? A) ABO incompatibility B) twin-to-twin transfusion syndrome (TTTS) C) TORCH syndrome D) HELLP syndrome

B) twin-to-twin transfusion syndrome (TTTS)

Vitamin K is given to the newborn to: A) reduce bilirubin levels. B) increase the production of red blood cells. C) enhance ability of blood to clot. D) stimulate the formation of surfactant.

C) enhance ability of blood to clot.

A woman gave birth to a healthy infant boy 5 days ago. What type of lochia would the nurse expect to find when assessing this woman? a. Lochia rubra c. Lochia alba b. Lochia sangra d. Lochia serosa

d. Lochia serosa

An African-American woman noticed some bruises on her newborn girls buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called: a. lanugo b. vascular nevi c. nevus flammeus d. mongolian spots

d. mongolian spots

A woman at 7 weeks' gestation is diagnosed with hyperemesis gravidarum. Which nursing diagnosis would receive priority? 1. Fluid Volume: Deficient 2. Cardiac Output, Decreased 3. Injury, Risk for 4. Nutrition, Imbalanced: Less than Body Requirements

1. Fluid Volume: Deficient

What are maternal and neonatal risks associated with gestational diabetes mellitus? 1. Maternal preeclampsia and fetal macrosomia 2. Maternal placenta previa and fetal prematurity 3. Maternal hyperemesis and neonatal low birth weight 4. Maternal premature rupture of membranes and neonatal sepsis

1. Maternal preeclampsia and fetal macrosomia

A client who is at risk for seizures as a result of severe preeclampsia is receiving an IV infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? Select all that apply. 1 Proteinuria 2 Epigastric pain 3 Respirations of 10/min 4 Loss of patellar reflexes 5 Urine output of 40 mL/hr

3 Respirations of 10/min, 4 Loss of patellar reflexes

The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss? 1. Placing the newborn away from air currents 2. Pre-warming the examination table 3. Drying the newborn thoroughly 4. Removing wet linens from the isolette

3. Drying the newborn thoroughly The most common form of heat loss is evaporation. The newborn is particularly prone to heat loss by evaporation immediately after birth (when the baby is wet with amniotic fluid) and during baths; thus drying the newborn is critical.

A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should prompt the nurse to intervene? 1. Hyperactive sensorium 2. Increase in respiratory rate 3. Lack of the knee-jerk reflex 4. Development of a cardiac dysrhythmia

3. Lack of the knee-jerk reflex

Which one of the following statements about twin-to-twin transfusion syndrome is true? A. The venous blood of one twin is pumped into the arterial system of the other twin B. The arterial blood of one twin is pumped into the venous system of the other twin C. This syndrome is a common complication of multiple geatation D. Twin-to-twin transfusion syndrome occurs between the fetal umbilical cords

B. The arterial blood of one twin is pumped into the venous system of the other twin

In twin-to-twin transfusion syndrome, which one of the following statements is true? A. Both Twins are at risk of dying B. An anteriovenous shunting within the placenta is demonstrated C. The recipient twin may demonstrate polyhydramnios D. All of the above statements are true

D. All of the above statements are true

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss? a) Conduction b) Convection c) Evaporation d) Radiation

a) Conduction Explanation: A conduction heat loss results from direct contact with an object that is cooler.

Part of the health assessment of a newborn is observing the infant's breathing pattern. A full-term newborn's breathing pattern is predominantly: a. Abdominal with synchronous chest movements. b. Chest breathing with nasal flaring. c. Diaphragmatic with chest retraction. d. Deep with a regular rhythm.

a. Abdominal with synchronous chest movements.

Nurses can prevent evaporative heat loss in the newborn by: a. Drying the baby after birth and wrapping the baby in a dry blanket. b. Keeping the baby out of drafts and away from air conditioners. c. Placing the baby away from the outside wall and the windows. d. Warming the stethoscope and the nurse's hands before touching the baby.

a. Drying the baby after birth and wrapping the baby in a dry blanket.

While examining a newborn, the nurse notes uneven skin folds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has: a. Polydactyly. b. Clubfoot. c. Hip dysplasia. d. Webbing

c. Hip dysplasia.

As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits: a. Decreased respiratory rate. b. Bradycardia followed by an increased heart rate. c. Mottled skin with acrocyanosis. d. Increased physical activity.

c. Mottled skin with acrocyanosis.

When nurses help their expectant mothers assess the daily fetal movement counts, they should be aware that: a. Obese mothers familiar with their bodies can assess fetal movement as well as average-size women b. Alcohol or cigarette smoke can irritate the fetus into greater activity c. They should be alarmed when fetal movements stop entirely for 12 hours d. "Kick counts" should be taken every half hour and averaged every 6 hours, with every other 6-hour stretch off

c. They should be alarmed when fetal movements stop entirely for 12 hours

The nurse educator is presenting a class on the different kinds of miscarriages. Miscarriages, or spontaneous abortions, are classified clinically into which of the following different categories? (SATA) 1. Threatened abortion 2. Incomplete abortion 3. Complete abortion 4. Missed abortion 5. Acute abortion

1,2,3,4 Explanation: 1. Unexplained cramping, bleeding, or backache indicates the fetus might be in jeopardy. This is a threatened abortion. 2. In an incomplete abortion, parts of the products of conception are retained, most often the placenta. 3. In a complete abortion, all the products of conception are expelled. The uterus is contracted and the cervical os may be closed. 4. In a missed abortion, the fetus dies in utero but is not expelled.

A patient who underwent a vaginal delivery 3 hours earlier reports having severe perineal pain. Which would be the first step taken by the nurse in this situation? 1. Apply ice packs in the perineum. 2. Administer fluids to the patient 3. Administer blood to the patient. 4. Refer the patient for hematologic tests.

1. Apply ice packs in the perineum

The client with insulin-dependent type 2 diabetes and an HbA1c of 5.0% is planning to become pregnant soon. What anticipatory guidance should the nurse provide this client? 1. Insulin needs decrease in the first trimester and usually begin to rise late in the first trimester as glucose use and glycogen storage by the woman and fetus increase. 2. The risk of ketoacidosis decreases during the length of the pregnancy. 3. Vascular disease that accompanies diabetes slows progression. 4. The baby is likely to have a congenital abnormality because of the diabetes.

1. Insulin needs decrease in the first trimester and usually begin to rise late in the first trimester as glucose use and glycogen storage by the woman and fetus increase.

Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin) include which of the following? 1. Massaging eyelids gently following application 2. Irrigating eyes after instillation 3. Using a syringe to apply ointment 4. Instillation is in the upper conjunctival surface of each eye

1. Massaging eyelids gently following application

Which factor is known to increase the risk of gestational diabetes mellitus? 1. Previous birth of large infant 2. Maternal age younger than 25 3. Underweight before pregnancy 4. Previous diagnosis of type 2 diabetes mellitus

1. Previous birth of large infant

A 28-year-old woman has been an insulin-dependent diabetic for 10 years. At 36 weeks' gestation, she has an amniocentesis. A lecithin/sphingomyelin (L/S) ratio test is performed on the sample of her amniotic fluid. Because she is a diabetic, what would an obtained 2:1 ratio indicate for the fetus? 1. The fetus may or may not have immature lungs. 2. The amniotic fluid is contaminated. 3. The fetus has a neural tube defect. 4. There is blood in the amniotic fluid.

1. The fetus may or may not have immature lungs. Explanation: 1. Infants of diabetic mothers (IDMs) have a high incidence of false-positive results (i.e., the L/S ratio is thought to indicate lung maturity, but after birth the baby develops RDS).

A client with diabetes is receiving preconception counseling. The nurse will emphasize that during the first trimester, the woman should be prepared for which of the following? 1. The need for less insulin than she normally uses 2. Blood testing for anemia 3. Assessment for respiratory complications 4. Assessment for contagious conditions

1. The need for less insulin than she normally uses (Explanation: 1. Women with diabetes often require less insulin during the first trimester.)

While assessing a postpartum patient, the nurse finds that the patient has a fourth-degree laceration. What immediate interventions should the nurse perform while caring for the patient? 1. Apply an ice pack to limit edema during the first 12 to 24 hours. 2. Instruct the patient to use two or more perineal pads. 3. Teach the patient to avoid taking sitz baths. 4. Remind the patient to avoid doing perineal (Kegel) exercises.

1Apply an ice pack to limit edema during the first 12 to 24 hours.

While performing the fetal acoustic stimulation test (FAST) in a patient, the nurse observes that there is no fetal response even after 3 minutes of testing. Which test does the nurse suggest? 1. Amniocentesis 2. Biophysical profile (BPP) 3. Cordocentesis 4. Coombs' test

2. Biophysical profile (BPP) Lack of response after 3 minutes of FAST indicates that the fetus has low activity levels. In this situation, to accurately assess fetal activity, the nurse should recommend a BPP of the fetus. Amniocentesis helps detect genetic abnormalities in the fetus. Fetal activity cannot be determined using this technique. In cordocentesis, the umbilical blood is tested for Rh incompatibility and hemolytic anemia in the fetus. Coombs' test is used to determine the presence of antibody incompatibilities in the fetus and the mother.

The prenatal clinic nurse is caring for a client with hyperemesis gravidarum at 14 weeks' gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first? 1. Weigh the client. 2. Give 1 liter of lactated Ringer's solution IV. 3. Administer 30 mL Maalox (magnesium hydroxide) orally. 4. Encourage clear liquids orally.

2. Give 1 liter of lactated Ringer's solution IV. Explanation: 2. The vital signs indicate hypovolemia from dehydration, which leads to hypotension and increased pulse rate. Giving this client a liter of lactated Ringer's solution intravenously will reestablish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down.

The nurse is caring for a postpartum patient and finds that the patient has brown vaginal discharge. What is the cause of the discharge? 1. Lochia alba 2. Lochia serosa 3. Lochia rubra 4. Vaginal or cervical tear

2. Lochia serosa Lochia serosa is a pink or brown fluid containing old blood, serum, leukocytes, and tissue debris. The lochia serosa starts 3 to 4 days after childbirth. Lochia alba is a yellow to white fluid containing leukocytes, serum, epithelial cells, bacteria, and decidua. It starts 10 days after childbirth in most women. In the case of a vaginal tear, the patient would have bright red bleeding for more than 2 hours after delivery. Lochia rubra, a bright red fluid containing small clots, starts from the end of the childbirth and disappears within 2 hours.

A patient reports continuous bleeding 4 weeks after childbirth. Upon assessment, the nurse finds that the bleeding is bright red in color with an offensive odor. What does the nurse suspect as the cause of the bleeding? 1. Lochial; the odor is caused by infection. 2. Nonlochial; the odor is caused by infection. 3. Lochial; the odor is normal in all postpartum patients. 4. Nonlochial; the odor is normal in all postpartum patients.

2. Nonlochial; the odor is caused by infection.

The nurse is supervising care in the emergency department. Which situation most requires an intervention? 1. Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer's solution running at 125 mL/hour 2. Spotting of pinkish-brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour 3. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20 4. Dark red bleeding at 30 weeks' gestation with normal vital signs; client reports an absence of fetal movement

3. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20 Explanation: 3. Bleeding in the third trimester is usually a placenta previa or placental abruption. Observe the woman for indications of shock, such as pallor, clammy skin, perspiration, dyspnea, or restlessness. Monitor vital signs, particularly blood pressure and pulse, for evidence of developing shock.

The nurse knows that a lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid means which of the following? 1. Fetal lungs are still immature. 2. The fetus has a congenital anomaly. 3. Fetal lungs are mature. 4. The fetus is small for gestational age.

3. Fetal lungs are mature. Explanation: 3. The concentration of lecithin begins to exceed that of sphingomyelin, and at 35 weeks the L/S ratio is 2:1. When at least two times as much lecithin as sphingomyelin is found in the amniotic fluid, RDS is very unlikely.

The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? 1. The student nurse listens to bowel sounds then assesses the head for skull consistency and size and tension of fontanelles. 2. The student nurse checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate. 3. The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. 4. The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

3. The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. Neonatal assessment proceeds in a head-to-toe fashion.

A 40-year-old woman with a high body mass index is 10 weeks pregnant. Which diagnostic tool is appropriate for her at this time? 1. Amniocentesis 2. Biophysical profile 3. Transvaginal ultrasound 4. Maternal serum alpha-fetoprotein (MSAFP)

3. Transvaginal ultrasound Transvaginal ultrasound is useful for obese women whose thick abdominal layers cannot be penetrated adequately with the abdominal approach. A biophysical profile is a method of biophysical assessment of fetal well-being in the third trimester. An amniocentesis is performed after the fourteenth week of pregnancy. A MSAFP test is performed from week 15 to week 22 of the gestation (weeks 16 to 18 are ideal). An ultrasound is the method of biophysical assessment of the infant that is performed at this gestational age.

A 26-year-old client is 26 weeks pregnant. Her previous births include two large-for-gestational-age babies and one unexplained stillbirth. Which tests would the nurse anticipate as being most definitive in diagnosing gestational diabetes? 1. A 50g, 1-hour glucose screening test 2. A single fasting glucose level 3. A 100g, 1-hour glucose tolerance test 4. A 100g, 3-hour glucose tolerance test

4. A 100g, 3-hour glucose tolerance test (Explanation: 4. Gestational diabetes is diagnosed if two or more of the following values are met or exceeded after taking the 100 g, 3-hour OGTT: Fasting: 95 mg/dL; 1 hour: 180 mg/dL; 2 hours: 155 mg/dL; 3 hours: 140 mg/dL.)

During a prenatal checkup, the patient who is 7 months pregnant reports that she is able to feel about two kicks in an hour. The nurse refers the patient for an ultrasound. What is the primary reason for this referral? To check: 1. For fetal anomalies 2. Gestational age 3. Fetal position 4. For fetal well-being

4. For fetal well-being Fetal kick count is a simple method to determine the presence of complications related to fetal oxygenation and activity level. The fetal kick count during the third trimester of pregnancy is approximately 30 kicks an hour; a count lower than that is an indication of poor health of the fetus. Fetal anomalies may not affect the oxygenation levels of the fetus. The nurse already knows the gestational age of the fetus; therefore the nurse need not refer the woman for ultrasonography to find the gestational age. Fetal position does not affect the activity level of the fetus.

A pregnant patient after 20 weeks' gestation reports painless, bright red vaginal bleeding. Upon assessment, the nurse finds that the patient's vital signs are normal. Which condition does the nurse suspect in the patient? 1. Eclampsia 2. Preeclampsia 3. Pyelonephritis 4. Placenta previa

4. Placenta previa

The newborn's nurse should alert the health care provider when which newborn reflex assessment findings are seen? Select all that apply. A) Newborn turns head toward stimulus when eliciting rooting reflex but does not open mouth. B) Newborn's fingers fan out when palmar reflex checked. C) Newborn forces tongue outward when tongue touched. D) Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited. E) Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect.

A) Newborn turns head toward stimulus when eliciting rooting reflex but does not open mouth.

A primary herpes simplex infection in the first trimester can increase the risk of which of the following? A) Spontaneous abortion B) Preterm labor C) Intrauterine growth restriction D) Neonatal infection

A) Spontaneous abortion

The nurse is caring for a woman who is at 24 weeks of gestation with suspected severe preeclampsia. Which signs and symptoms would the nurse expect to observe? (Select all that apply.) A. Decreased urinary output and irritability B. Transient headache and +1 proteinuria C. Ankle clonus and epigastric pain D. Platelet count of less than 100,000/mm3 and visual problems E. Seizure activity and hypotension

A, C, D (Decreased urinary output and irritability are signs of severe eclampsia. Ankle clonus and epigastric pain are signs of severe eclampsia. Platelet count of less than 100,000/mm3 and visual problems are signs of severe preeclampsia. A transient headache and +1 proteinuria are signs of preeclampsia and should be monitored. Seizure activity and hyperreflexia are signs of eclampsia.)

1. What are modes of heat loss in the newborn? (Select all that apply.) a. Perspiration b. Convection c. Radiation d. Conduction e. Urination

ANS: B, C, D Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Perspiration and urination are not modes of heat loss in newborns

The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected.Select all that apply. 1. The medication should be instilled in the lower conjunctival sac of each eye .2. The eyelids should be massaged gently to distribute the ointment. 3. The medication must be given immediately after delivery. 4. The medication does not cause any discomfort to the infant. 5. The medication can interfere with the baby's ability to focus.

Answer: 1, 2, 5 Explanation: 1. Successful eye prophylaxis requires that the medication be instilled in the lower conjunctival sac of each eye. 2. After administration, the nurse massages the eyelid gently to distribute the ointment. 5. Eye prophylaxis medication can cause chemical conjunctivitis, which gives the newborn some discomfort and can interfere with the baby's ability to focus on the parents' faces.

A woman is 16 weeks pregnant. She has had cramping, backache, and mild bleeding for the past 3 days. Her physician determines that her cervix is dilated to 2 centimeters, with 10% effacement, but membranes are still intact. She is crying, and says to the nurse, "Is my baby going to be okay?" In addition to acknowledging the client's fear, what should the nurse also say? A) "Your baby will be fine. We'll start IV, and get this stopped in no time at all." B) "Your cervix is beginning to dilate. That is a serious sign. We will continue to monitor you and the baby for now." C) "You are going to miscarry. But you should be relieved because most miscarriages are the result of abnormalities in the fetus." D) "I really can't say. However, when your physician comes, I'll ask her to talk to you about it.

B) "Your cervix is beginning to dilate. That is a serious sign. We will continue to monitor you and the baby for now." *If bleeding persists and abortion is imminent or incomplete, the woman may be hospitalized, Ⅳ therapy or blood transfusions may be started to replace fluid, and dilation and curettage (D&C) or suction evacuation is performed to remove the remainder of the products of conception

A pregnant woman is diagnosed with abruptio placentae. When reviewing the woman's medical record, the nurse would expect which finding? A) soft, relaxed uterus on palpation B) sudden dark, vaginal bleeding C) fetal heart rate within normal range D) absence of pain

B) sudden dark, vaginal bleeding The uterus is firm to rigid to the touch with abruptio placentae; it is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. Bright red vaginal bleeding is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation.

A pregnant woman presents to the emergency department complaining of persistent nausea and vomiting. She is diagnosed with hyperemesis gravidarum. The nurse should include which information when teaching about diet for hyperemesis? (Select all that apply.) A. Eat three larger meals a day. B. Eat a high-protein snack at bedtime. C. Ice cream may stay down better than other foods. D. Avoid ginger tea or sweet drinks. E. Eat what sounds good to you even if your meals are not well-balanced.

B, C, E (The diet for hyperemesis includes: • Avoid an empty stomach. Eat frequently, at least every 2 to 3 hours. Separate liquids from solids and alternate every 2 to 3 hours.• Eat a high-protein snack at bedtime.• Eat dry, bland, low-fat, and high-protein foods. Cold foods may be better tolerated than those served at a warm temperature.• In general eat what sounds good to you rather than trying to balance your meals.• Follow the salty and sweet approach; even so-called junk foods are okay.• Eat protein after sweets.• Dairy products may stay down more easily than other foods.• If you vomit even when your stomach is empty, try sucking on a Popsicle.• Try ginger tea. Peel and finely dice a knuckle-sized piece of ginger and place it in a mug of boiling water. Steep for 5 to 8 minutes and add brown sugar to taste.• Try warm ginger ale (with sugar, not artificial sweetener) or water with a slice of lemon.• Drink liquids from a cup with a lid.)

A pregnant patient with chronic hypertension is at risk for placental abruption. Which symptoms of abruption does the nurse instruct the patient to be alert for? Select all that apply. A. Weight loss B. Abdominal pain C. Vaginal bleeding D. Shortness of breath E. Uterine tenderness

B, C, E (The nurse instructs the pregnant patient to be alert for abdominal pain, vaginal bleeding, and uterine tenderness as these indicates placental abruption. Weight loss indicates fluid and electrolyte loss and not placental abruption. Shortness of breath indicates inadequate oxygen, which is usually seen in a patient who is having cardiac arrest.)

The nurse is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning this infants care? A) Blood pressure 76/42 mm/Hg B) Faint heart murmur C) Respiratory rate 76 breaths/min D) Blood glucose 45 mg/dl

C) Respiratory rate 76 breaths/min

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (select all that apply) A. abundant lanugo B. vernix in the folds and creases C. positive moro reflex D. short, soft fingernails E. cracked peeling skin

C. positive moro reflex E. cracked peeling skin

Magnesium Sulfate is given to pregnant clients with preeclampsia to prevent which condition? A. Hemorrhage B. Hypertension C. Hypomagnesemia D. Seizures

D. Seizures

When blood pressure and other signs indicate that the preeclampsia is worsening, hospitalization is necessary to monitor the woman's condition closely. At that time, which of the following should be assessed? (SATA) a. Fetal heart rate b. Blood pressure c. Temperature d. Urine color e. Pulse and respirations

a,b,c,e a. Determine the fetal heart rate along with blood pressure, or monitor continuously with the electronic fetal monitor if the situation indicates. b. Determine blood pressure every 1 to 4 hours, or more frequently if indicated by medication or other changes in the woman's status. c. Determine temperature every 4 hours, or every 2 hours if elevated or if premature rupture of the membranes (PROM) has occurred. e. Determine pulse rate and respirations along with blood pressure.

A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability? (SATA) a. Newborns have less subcutaneous fat than do adults. b. Infants have a thick epidermis layer. c. Newborns have a large body surface to weight ratio. d. Infants have increased total body water. e. Newborns have more subcutaneous fat than do adults.

a,c,d Explanation: a. Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonate's decreased subcutaneous fat. c. Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonate's large body surface to weight ratio. d. Preterm infants have increased heat loss via evaporation due to increased total body water.

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. Tonic neck c. Stepping d. Plantar grasp

a. Babinski The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. 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.

A neonate is born at 33 weeks' gestation with a birth weight of 2400 grams. This neonate would be classified as: a. Low birth weight b. Very low birth weight c. Extremely low birth weight d. Very premature

a. Low birth weight Neonates with a birth weight of less than 2500 grams but greater than 1500 grams are classified as low birth weight.

A woman is being treated for preterm labor with magnesium sulfate. The nurse is concerned that the client is experiencing early drug toxicity. What assessment finding by the nurse indicates early magnesium sulfate toxicity? a. Patellar reflexes weak or absent b. Increased appetite c. Respiratory rate of 16 d. Fetal heart rate of 120

a. Patellar reflexes weak or absent

The perinatal nurse is assisting the student nurse with completion of documentation. The laboring woman has just given birth to a 2700 gram infant at 36 weeks' gestation. The most appropriate term for this is: a. Preterm birth b. Term birth c. Small for gestational age infant d. Large for gestational age infant

a. Preterm birth a. A preterm infant is an infant with gestational age of fewer than 36 completed weeks. b. Term births are infants born between 37 and 40 weeks. c. SAG infants at 36 weeks weigh less than 2000 grams. d. LAG infants at 36 weeks weigh over 3400 grams.

With regard to the respiratory development of the newborn, nurses should be aware that: a. the first gasping breath is an exaggerated respiratory reaction within 1 minute of birth. b. Newborns must expel the fluid from the respiratory system within a few minutes of birth. c. Newborns are instinctive mouth breathers. d. Seesaw respirations are no cause for concern in the first hour after birth.

a. the first gasping breath is an exaggerated respiratory reaction within 1 minute of birth. The first breath produces a cry. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose breathers; they may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.

Your patient is being induced because of her worsening preeclampsia. She is also receiving magnesium sulfate. It appears that her labor has not become active despite several hours of oxytocin administration. She asks the nurse, "Why is it taking so long?" The most appropriate response by the nurse would be: a."The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor." b."I don't know why it is taking so long." c."The length of labor varies for different women."d."Your baby is just being stubborn."

a."The magnesium is relaxing your uterus and competing with the oxytocin. It may increase the duration of your labor."

The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to: a.Assess fetal heart rate (FHR) and maternal vital signs b.Perform a venipuncture for hemoglobin and hematocrit levels c.Place clean disposable pads to collect any drainage d.Monitor uterine contractions

a.Assess fetal heart rate (FHR) and maternal vital signs

Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. Which is the most common cause of spontaneous abortion? a.Chromosomal abnormalities c.Endocrine imbalance b.Infections d.Immunologic factors

a.Chromosomal abnormalities

The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? a.Flexed posture b.Abundant lanugo c.Smooth, pink skin with visible veins d.Faint red marks on the soles of the feet

a.Flexed posture

Before the physician performs an external version, the nurse should expect an order for a: a.Tocolytic drug. c.Local anesthetic. b.Contraction stress test (CST). d.Foley catheter.

a.Tocolytic drug.

A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will most likely be classified as which of the following? a) Term, small for gestational age, and very-low-birth-weight infant b) Term, small for gestational age, and low-birth-weight infant c) Late preterm and appropriate for gestational age d) Late preterm, large for gestational age, and low-birth-weight infant

b) Term, small for gestational age, and low-birth-weight infant Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small for gestational age (SGA). Those who fall above the 90th percentile in weight are considered large for gestational age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLB). Those born weighing 500 to 1000 g are considered extremely very-low-birth-weight infants (EVLB).

The nurse is planning an in-service educational program to talk about disseminated intravascular coagulation (DIC). The nurse should identify which conditions as risk factors for developing DIC. (SATA) a. Diabetes mellitus b. Abruptio placentae c. Fetal demise d. Multiparity e. Preterm labor

b,c b. As a result of the damage to the uterine wall and the retroplacental clotting with covert abruption, large amounts of thromboplastin are released into the maternal blood supply, which in turn triggers the development of disseminated intravascular coagulation (DIC) and the resultant hypofibrinogenemia. c. Perinatal mortality associated with abruptio placentae is approximately 25%. If fetal hypoxia progresses unchecked, irreversible brain damage or fetal demise may result.

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? a. "I will record the # of movements or kicks" b. "I need to lie flat on my back to perform this procedure" c. "If I count fewer than 10 kicks in a 2 hour period I should count the kicks again over the next 2 hours" d. "I should place my hands on the largest part of my abdomen and concentrate of the fetal movements to count the kicks"

b. "I need to lie flat on my back to perform this procedure"

A nurse is caring for preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make? a. "The heat in the incubator rapidly dries the sweat of preterm newborns" b. "Preterm newborns lack adequate temperature control mechanisms" c. "Preterm newborns have a smaller body surface area that normal newborns d. "The added brown fat layer in a preterm newborn reduces his ability to generate heat"

b. "Preterm newborns lack adequate temperature control mechanisms"

A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant's body temperature every hour. Maintaining the newborn's body temperature is important for preventing: a. Respiratory depression. b. Cold stress .c. Tachycardia. d. Vasoconstriction.

b. Cold stress

For diagnostic and treatment purposes nurses should know the birth weight classifications of high risk infants. For example, extremely low birth weight (ELBW) is the designation for an infant whose weight is: a. Less than 1500 g. b. Less than 1000 g. c. Less than 2000 g. d. Dependent on the gestational age.

b. Less than 1000 g.

The nurse's initial action when caring for an infant with a slightly decreased temperature is to: a. notify the physician immediately. b. place a cap on the infant's head. c. tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d. change the formula because this is a sign of formula intolerance.

b. place a cap on the infant's head.

A pregnant woman at 29 weeks of gestation has been diagnosed with preterm labor. Her labor is being controlled with tocolytic medications. She asks when she would be able to go home. Which response by the nurse is most accurate? a."After the baby is born." b."When we can stabilize your preterm labor and arrange home health visits." c."Whenever the doctor says that it is okay." d."It depends on what kind of insurance coverage you have."

b."When we can stabilize your preterm labor and arrange home health visits."

Women with hyperemesis gravidarum: a.Are a majority, because 80% of all pregnant women suffer from it at some time. b.Have vomiting severe and persistent enough to cause weight loss, dehydration, and electrolyte imbalance. c.Need intravenous (IV) fluid and nutrition for most of their pregnancy. d.Often inspire similar, milder symptoms in their male partners and mothers.

b.Have vomiting severe and persistent enough to cause weight loss, dehydration, and electrolyte imbalance.

The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: a.Bleeding. b.Intense abdominal pain. c.Uterine activity. d.Cramping.

b.Intense abdominal pain.

An abortion in which the fetus dies but is retained within the uterus is called a(n): a.Inevitable abortion c.Incomplete abortion b.Missed abortion d.Threatened abortion

b.Missed abortion

What laboratory marker is indicative of disseminated intravascular coagulation (DIC)? a.Bleeding time of 10 minutes b.Presence of fibrin split products c.Thrombocytopenia d.Hyperfibrinogenemia

b.Presence of fibrin split products

A woman is experiencing preterm labor. The client asks why she is on betamethasone. Which is the nurse's best response? a. "This medication will halt the labor process until the baby is more mature." b. "This medication will relax the smooth muscles in the infant's lungs so the baby can breathe." c. "This medication is effective in stimulating lung development in the preterm infant." d. "This medication is an antibiotic that will treat your urinary tract infection, which caused preterm labor."

c. "This medication is effective in stimulating lung development in the preterm infant." Betamethasone or dexamethasone is often administered to the woman whose fetus has an immature lung profile to promote fetal lung maturation.

You're assessing the one minute APGAR score of a newborn baby. On assessment, you note the following about your newborn patient: heart rate 130, pink body and hands with cyanotic feet, weak cry, flexion of the arms and legs, active movement and crying when stimulated. What is your patient's APGAR score? a. APGAR 9 b. APGAR 10 c. APGAR 8 d. APGAR 5

c. APGAR 8

The nurse administers vitamin K to the newborn for which reason? a. Most mothers have a diet deficient in vitamin K, which results in the infant's being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.

c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.

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

c. Cephalohematoma

In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is: a. important in the production of red blood cells. b. necessary in the production of platelets. c. not initially synthesized because of a sterile bowel at birth. d. responsible for the breakdown of bilirubin and prevention of jaundice.

c. not initially synthesized because of a sterile bowel at birth.

Metabolic changes throughout pregnancy that affect glucose and insulin in the mother and the fetus are complicated but important to understand. Nurses should understand that: a.Insulin crosses the placenta to the fetus only in the first trimester, after which the fetus secretes its own. b.Women with insulin-dependent diabetes are prone to hyperglycemia during the first trimester because they are consuming more sugar. c.During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus. d.Maternal insulin requirements steadily decline during pregnancy.

c.During the second and third trimesters, pregnancy exerts a diabetogenic effect that ensures an abundant supply of glucose for the fetus.

Nurses should be aware that HELLP syndrome: a.Is a mild form of preeclampsia. b.Can be diagnosed by a nurse alert to its symptoms. c.Is characterized by hemolysis, elevated liver enzymes, and low platelets. d.Is associated with preterm labor but not perinatal mortality.

c.Is characterized by hemolysis, elevated liver enzymes, and low platelets.

Magnesium sulfate is given to women with preeclampsia and eclampsia to: a.Improve patellar reflexes and increase respiratory efficiency. b.Shorten the duration of labor. c.Prevent and treat convulsions. d.Prevent a boggy uterus and lessen lochial flow.

c.Prevent and treat convulsions.

A woman presents to the emergency department with complaints of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion? a.Incomplete b.Inevitable c.Threatened d.Septic

c.Threatened

Which finding should the nurse expect when assessing a client w/ placenta previa? a) Severe occipital headache b) History of thyroid cancer c) Previous premature delivery d) Painless vaginal bleeding

d) Painless vaginal bleeding Painless vaginal bleeding is often the only symptom of placenta previa.

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? a) Lanugo covering the neonate's body b) A sleepy, lethargic neonate c) Vernix caseosa covering the neonate's body d) Peeling and wrinkling of the neonate's epidermis

d) Peeling and wrinkling of the neonate's epidermis Postdate neonates lose the vernix caseosa, and the epidermis may become peeled and wrinkled. A neonate at 42 weeks' gestation is usually very alert and missing lanugo.

A gravid woman is carrying monochorionic twins. For which of the following complications should this pregnancy be monitored? a) Oligohydramnios b) Placenta previa c) Cephalopelvic disproportion d) Twin-to-twin transfusion

d) Twin-to-twin transfusion

A client has been admitted to the unit for tocolytic therapy. The nurse recognizes all except which of the following tocolytics may be used in this woman's care plan? a. Magnesium sulfate b. Terbutaline c. Indomethacin d. Corticosteroids

d. Corticosteroids

To assess fundal contraction 6 hours after cesarean birth, which action should the nurse perform? a. Assess lochial flow rather than palpating the fundus .b. Palpate forcefully through the abdominal dressing. c. Place hands on both sides of the abdomen and press downward. d. Gently palpate, applying the same technique used for vaginal deliveries.

d. Gently palpate, applying the same technique used for vaginal deliveries.

The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: a. Closure of fetal shunts in the circulatory system b. Full function of the immune defense system at birth c. Maintenance of a stable temperature d. Initiation and maintenance of respirations

d. Initiation and maintenance of respirations

A physician orders oral tocolytic therapy for a woman with preterm labor. Which agent would the nurse be least likely to administer? a. Terbutaline b. Indomethacin c. Nifedipine d. Magnesium sulfate

d. Magnesium sulfate Explanation: Magnesium sulfate is only given IV for preterm labor

Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels? a. Monitor urine for amount and characteristics. b. Encourage late feedings to promote intestinal elimination. c. All infants should be routinely monitored for iron intake. d. Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above.

d. Maintain the newborn's skin temperature at 36.5°C (97.8°F) or above.

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive: a. Tonic neck reflex b. Glabellar (Myerson) reflex. c.Babinski reflex. d. Moro reflex.

d. Moro reflex.

Postbirth uterine/vaginal discharge, called lochia:a. Is similar to a light menstrual period for the first 6 to 12 hours. b. Is usually greater after cesarean births. c. Will usually decrease with ambulation and breastfeeding. d. Should smell like normal menstrual flow unless an infection is present.

d. Should smell like normal menstrual flow unless an infection is present.

A newborn male is estimated to be 40 weeks of gestation following an assessment using the New Ballard Scale. A Ballard Scale finding consistent with this newborn's full-term status would be: a. Apical pulse rate of 120 beats/min, regular, and strong. b. Popliteal angle of 160 degrees. c. Weight of 3200 g placing him at the 50th percentile. d. Thinning of lanugo with some bald areas.

d. Thinning of lanugo with some bald areas.

During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is NOT one of these essential factors? a. Chemical b. Mechanical c. Thermal d. Psychologic

d. psychologic. Correct: This is not a factor in the initiation of breathing, rather it is sensory factors that contribute. These factors include handling by the provider, drying by the nurse, lights, smells, and sounds.

Nurses should be aware that chronic hypertension: a.Is defined as hypertension that begins during pregnancy and lasts for the duration of pregnancy. b.Is considered severe when the systolic blood pressure (BP) is greater than 140 mm Hg or the diastolic BP is greater than 90 mm Hg. c.Is general hypertension plus proteinuria. d.Can occur independently of or simultaneously with gestational hypertension.

d.Can occur independently of or simultaneously with gestational hypertension.

Glucose metabolism is profoundly affected during pregnancy because: a.Pancreatic function in the islets of Langerhans is affected by pregnancy. b.The pregnant woman uses glucose at a more rapid rate than the nonpregnant woman c.The pregnant woman increases her dietary intake significantly. d.Placental hormones are antagonistic to insulin, thus resulting in insulin resistance.

d.Placental hormones are antagonistic to insulin, thus resulting in insulin resistance.

In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the nurse to possible side effects? a.Urine output of 160 mL in 4 hours b.Deep tendon reflexes 2+ and no clonus c.Respiratory rate of 16 breaths/min d.Serum magnesium level of 10 mg/dL

d.Serum magnesium level of 10 mg/dL

The newborn was just born and is vigorously crying. The nurse understands that the air entering this newborn's lungs immediately after birth effects cardiopulmonary physiology by: a.decreasing pulmonary blood flow and increasing alveolar pCO2 levels. b.increasing pulmonary blood flow and pC02 levels. c.increasing alveolar p02 and pulmonary vascular resistance. d.increasing alveolar p02 and decreasing pulmonary vascular resistance.

d.increasing alveolar p02 and decreasing pulmonary vascular resistance.