maternity test 7

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Before drying off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool? A) Amount and area of vernix coverage B) Creases on the sole C) Size of the areola D) Body surface temperature

The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? A) The newborn maintains a normal temperature B) An increase of serum bilirubin levels C) Weight loss D) Skin blanching yellow

The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following? Select all that apply. A) Lights can stay on all the time. B) The eyes do not need to be covered. C) The lights will need to be removed for feedings. D) Newborns do not get overheated. E) Weight loss is not a complication of this system.

A, B, D, E

In utero, what is the organ responsible for gas exchange? A) Umbilical vein B) Placenta C) Inferior vena cava D) Right atrium

The community nurse is working with poor women who are formula-feeding their infants. Which statement indicates that the nurse's education session was effective? A) "I should use only soy-based formula for the first year." B) "I should follow the instructions for mixing the powdered formula exactly." C) "It is okay to add more water to the formula to make it last longer." D) "The mixed formula can be left on the counter for a day."

Which of the following functions primarily to provide low-income women and children who are at risk for medical or nutritional problems with nutritious foods to supplement their diets, nutrition education and counseling, and screening and referrals to other health, welfare, and social programs? A) A B M B) W I C C) I L C A D) L L L I

Benefits of skin-to-skin care as a developmental intervention include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Routine discharge B) Stabilization of vital signs C) Increased periods of awake-alert state D) Decline in episodes of apnea and bradycardia E) Increased growth parameters

B, D, E

The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this client? Select all that apply. A) Make sure she gets a kosher diet. B) Expect that most visitors will be women. C) Uncover only the necessary skin when assessing. D) The father will take an active role in infant care. E) She will prefer a male physician.

B,C

Which of the following symptoms would be an indication of postpartum blues? Select all that apply. A) Overeating B) Anger C) Mood swings D) Constant sleepiness E) Crying

B,C,E

Which of the following are considered risk factors for development of severe hyperbilirubinemia? Select all that apply. A) Northern European descent B) Previous sibling received phototherapy C) Gestational age 27 to 30 weeks D) Exclusive breastfeeding E) Infection

B,D,E

1) The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first? A) 37-week male, respiratory rate 45 B) 8 pound 1 ounce female, pulse 150 C) Term male, nasal flaring D) 4-hour-old female who has not voided

The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority? A) Tissue Integrity, Impaired B) Infection, Risk for C) Gas Exchange, Impaired D) Family Processes, Dysfunctional

The nurse teaches the parents of an infant who was recently circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur? A) Wrap the diaper tightly. B) Clean with warm water with each diaper change. C) Apply gentle pressure to the site with gauze. D) Apply a new petroleum ointment gauze dressing.

Clinical risk factors for severe hyperbilirubinemia include which of the following? Select all that apply. A) African American ethnicity B) Female gender C) Cephalohematoma D) Bruising E) Assisted delivery with vacuum or forceps

C, D, E

A newborn is receiving phototherapy. Which intervention by the nurse would be most important? A) Measurement of head circumference B) Encouraging the mother to stop breastfeeding C) Stool blood testing D) Assessment of hydration status

A premature newborn is unable to suck at the breast. The nurse plans care for the mother, who is going to hand-express milk. Arrange the steps for milk expression in the correct order. 1. Roll the thumb and fingers simultaneously forward. 2. Position the thumb at 12:00 and the forefinger and middle finger at 6:00 around the areola. 3. Repeat the sequence multiple times to completely drain the breasts. 4. Stretch the areola back toward the chest wall without lifting the fingers off the breast.

2, 4, 1, 3

The nurse is preparing to instruct the parents of a newborn on the care of the umbilical cord. In which order should the nurse provide these instructions? 1. Check the cord for color 2. Wash hands with soap and water 3. Fold diaper below umbilical cord 4. Clean cord and base of cord with cotton swab 5. Check the cord for odor or oozing of green material

2, 4, 1, 5, 3

Put the following components specific to a postpartum examination in the proper sequential order: 1. L-lochia 2. E-emotional 3. H-Homans'/hemorrhoids 4. B-breasts 5. E-episiotomy/lacerations

4, 1, 5, 3, 2

The nurse is reviewing the process of pumping the breasts with a new mother. In which order should the nurse provide this information? 1. Fill glass or bottles 3/4 full 2. Massage the breasts and relax 3. Sit up straight or lean forward 4. Wash hands with soap and water 5. Pump each breast for 10 to 20 minutes

4, 2, 3, 5, 1

The mother of a newly circumcised infant is concerned about caring for the infant at home. What should the nurse instruct the mother about the infant's care? Place the following actions in the order that should be instructed to the mother. 1. Pat dry 2. Rinse area with warm water 3. Fasten diaper snuggly over the penis 4. Apply small amount of petroleum jelly 5. Squeeze water over the circumcision site

5, 2, 1, 4, 3

During an educational session the nurse learns that legislation was written to support breastfeeding mothers. In which order did the titles of this legislation occur? 1. Establish standards for safe and effective breast pumps 2. Include breastfeeding equipment as medical care for taxes 3. Require businesses with 50 or more employees to give lactating women breaks 4. Give tax incentives to businesses that establish a private place for breastfeeding 5. Protect lactating women from being fired or discriminated against in the workplace

5, 4, 1, 2, 3

The nurse is demonstrating to a patient the proper steps for breastfeeding a newborn. Put these steps in the logical order that would assist the patient in placing the newborn to her breast. 1. Tickle the newborn's lips with the nipple. 2. Allow the newborn to latch on to the nipple. 3. The newborn opens her mouth wide. 4. Have the newborn face the mother tummy to tummy. 5. Position the newborn so the nose is at the level of the nipple.

5, 4, 1, 3, 2

The mother of a 2-day-old male has been informed that her child has sepsis. The mother is distraught and says, "I should have known that something was wrong. Why didn't I see that he was so sick?" What is the nurse's best reply? A) "Newborns have immature immune function at birth, and illness is very hard to detect." B) "Your mothering skills will improve with time. You should take the newborn class." C) "Your baby didn't get enough active acquired immunity from you during the pregnancy." D) "The immunity your baby gets in utero doesn't start to function until he is 4 to 8 weeks old."

The nurse is completing the discharge teaching of a young first-time mother. Which statement by the mother requires immediate intervention? A) "I will put my baby to bed with his bottle so he doesn't get hungry during the night." B) "My baby will probably have a bowel movement each breastfeeding, and will wet often." C) "Nursing every 2 to 3 hours is normal, for a total of 8 to 12 feedings every day." D) "I will drink fenugreek tea from my grandmother to prevent my milk from coming in."

The nurse is observing a student nurse who is caring for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? A) Urine specific gravity is assessed at each voiding. B) Eye coverings are left off to help keep the baby calm. C) Temperature is checked every 6 hours. D) The infant is taken out of the isolette for diaper changes.

The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate? A) Place a gloved finger in the newborn's mouth. B) Take the vital signs. C) Wait until the newborn stops crying. D) Place a hot water bottle in the isolette.

The student nurse notices that a newborn weighs less today compared with the newborn's birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following? A) A shift of intracellular water to extracellular spaces. B) Loss of meconium stool. C) A shift of extracellular water to intracellular spaces. D) The sleep-wake cycle.

What condition is due to poor peripheral circulation? A) Acrocyanosis B) Mottling C) Harlequin sign D) Jaundice

Which of the following is a localized, easily identifiable soft area of the infant's scalp, generally resulting from a long and difficult labor or vacuum extraction? A) Caput succedaneum B) Cephalohematoma C) Molding D) Depressed fontanelles

In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include which of the following? Select all that apply. A) Volume of urine output B) Weight C) Blood p H D) Head circumference E) Bowel sounds

A, B

A newborn who has not voided by 48 hours after birth should be assessed for which of the following? Select all that apply. A) Restlessness B) Pain C) Kidney distention D) Adequacy of fluid intake E) Lethargy

A, B, D

Marked changes that occur in the cardiopulmonary system at birth include which of the following? Select all that apply. A) Closure of the foramen ovale B) Closure of the ductus venosus C) Mean blood pressure of 31 to 61 m m H g in full-term resting newborns D) Increased systemic vascular resistance and decreased pulmonary vascular resistance E) Opening of the ductus arteriosus

A, B, D

The nurse tells a mother that the doctor is preparing to circumcise her newborn. The mother expresses concern that the infant will be uncomfortable during the procedure. The nurse explains that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure include which of the following? Select all that apply. A) Providing a pacifier B) Stroking the head C) Restraining both arms and legs D) Talking to the infant E) Giving the infant a sedative before the procedure

A, B, D

The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Select all that apply. A) The medication should be instilled in the lower conjunctival sac of each eye. B) The eyelids should be massaged gently to distribute the ointment. C) The medication must be given immediately after delivery. D) The medication does not cause any discomfort to the infant. E) The medication can interfere with the baby's ability to focus.

A, B, E

Which statements by a breastfeeding class participant indicate that teaching by the nurse was effective? Select all that apply. A) "Breastfed infants get more skin-to-skin contact and sleep better." B) "Breastfeeding raises the level of a hormone that makes me feel good." C) "Breastfeeding is complex and difficult, and I probably won't succeed." D) "Breastfeeding is worthwhile, even if it costs more overall." E) "Breastfed infants have fewer digestive and respiratory illnesses."

A, B, E

Which of the following are important behaviors to assess in the neurologic assessment? Select all that apply. A) State of alertness B) Active posture C) Quality of muscle tone D) Cry E) Motor activity

A, C, D, E

The newborn's cry should have which of the following characteristics? Select all that apply. A) Medium pitch B) Shrillness C) Strength D) High pitch E) Lusty

A, C, E

A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalohematoma based on which characteristics? Select all that apply. A) The mass appeared on the second day after birth. B) The mass appears larger when the newborn cries. C) The head appears asymmetrical. D) The mass appears on only one side of the head. E) The mass overrides the suture line.

A, D

The nurse is caring for a postpartum client who is experiencing afterpains following the birth of her third child. Which comfort measure should the nurse implement to decrease her pain? Select all that apply. A) Offer a warm water bottle for her abdomen. B) Call the physician to report this finding. C) Inform her that this is not normal, and she will need an oxytocic agent. D) Administer a mild analgesic to help with breastfeeding. E) Administer a mild analgesic at bedtime to ensure rest.

A, D, E

Which of the following are potential disadvantages to breastfeeding? Select all that apply. A) Pain with breastfeeding B) Leaking milk C) Equal feeding responsibilities with fathers D) Vaginal wetness E) Embarrassment

A,B,E

A 38-week newborn is found to be small for gestational age (S G A). Which nursing intervention should be included in the care of this newborn? A) Monitor for feeding difficulties. B) Assess for facial paralysis. C) Monitor for signs of hyperglycemia. D) Maintain a warm environment.

The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? A) The new nurse holds the infant after giving a gavage feeding. B) The new nurse provides skin-to-skin care. C) The new nurse provides care when the baby is awake. D) The new nurse gives the feeding with room-temperature formula.

The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about? A) Neonatal jaundice B) Neonatal hypothermia C) Neonatal hyperthermia D) Respiratory distress

The nurse caring for a postterm newborn would not perform what intervention? A) Providing warmth B) Frequently monitoring blood glucose C) Observing respiratory status D) Restricting breastfeeding

The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information? A) "The baby should be in the back seat." B) "Newborns must be in rear-facing car seats." C) "We need instruction on how to use the car seat before installing it." D) "We can bring the baby home from the hospital without a car seat, as it is only a short drive."

To assess the healing of the uterus at the placental site, what does the nurse assess? A) Lab values B) Blood pressure C) Uterine size D) Type, amount, and consistency of lochia

A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse anticipate? A) Delivery of the neonate on its side with head up, to facilitate drainage of secretions. B) Direct tracheal suctioning by specially trained personnel. C) Preparation for the immediate use of positive pressure to expand the lungs. D) Suctioning of the oropharynx when the newborn's head is delivered.

A mother who is H I V-positive has given birth to a term female. What plan of care is most appropriate for this infant? A) Test with an H I V serologic test at 8 months. B) Begin prophylactic A Z T (Zidovudine) administration. C) Provide 4 to 5 large feedings throughout the day. D) Encourage the mother to breastfeed the child.

A new mother is holding her 2-hour-old son. The delivery occurred on the due date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurse's best response? A) "Don't worry. Babies go through a lot of these little phases." B) "Your son is in the sleep phase. He'll wake up soon." C) "Your son is exhausted from being born, and will sleep 6 more hours." D) "Your breastfeeding efforts have caused excessive fatigue in your son."

A new mother who is breastfeeding tells the nurse that her infant is spitting up frequently, has very loose stools and copious gas, and feeds for only short periods of time. The nurse suspects a feeding intolerance and, after questioning the mother about her diet, suggests that she do which of the following? A) Stop breastfeeding and switch to formula. B) Eliminate dairy products from her diet. C) Supplement breastfeeding with a soy-based formula. D) Offer the baby water between feedings.

At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborn's weight is which of the following? A) Excessive B) Within normal limits C) Less than expected D) Unusual

The nurse expects an initial weight loss for the average postpartum client to be which of the following? A) 5 to 8 pounds B) 10 to 12 pounds C) 12 to 15 pounds D) 15 to 20 pounds

The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement by a parent indicates that teaching was effective? A) "My baby will be able to focus on my face when she is about a month old." B) "My baby might startle a little if a loud noise happens near him." C) "Newborns prefer sour tastes." D) "Our baby won't have a sense of smell until she is older."

The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 m g/d L to 16.6 m g/d L in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn? A) Continue to observe B) Begin phototherapy C) Begin blood exchange transfusion D) Stop breastfeeding

The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Select all that apply. A) "We should keep our home air-conditioned so the baby doesn't overheat." B) "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." C) "When we change the baby's diaper, we should change any wet clothing or blankets, too." D) "If the baby's body temperature gets too low, he will warm himself up without any shivering." E) "Our baby will have a much faster rate of breathing if he is not dressed warmly enough."

B, C, D, E

A N I C U nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a N I C U? Select all that apply. A) Schedule care throughout the day. B) Silence alarms quickly. C) Place a blanket over the top portion of the incubator. D) Do not offer a pacifier. E) Dim the lights.

B,C,E

1) The nurse is making an initial assessment of the newborn. The findings include a chest circumference of 32.5 c m and a head circumference of 33.5 c m. Based on these findings, which action should the nurse take first? A) Notify the physician. B) Elevate the newborn's head. C) Document the findings in the chart. D) Assess for hypothermia immediately.

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

1) The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following? A) Increased blood pressure B) Hypoglycemia C) Postpartum hemorrhage D) Postpartum infection

A 2-day-old newborn is asleep, and the nurse assesses the apical pulse to be 88 beats/min. What would be the most appropriate nursing action based on this assessment finding? A) Call the physician. B) Administer oxygen. C) Document the finding. D) Place the newborn under the radiant warmer.

A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best? A) Begin chest compressions. B) Begin direct tracheal suctioning. C) Begin bag-and-mask ventilation. D) Obtain a blood pressure reading.

During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. The nurse documents this finding as which of the following? A) Nevus vasculosus B) Nevus flammeus C) Telangiectatic nevi D) A Mongolian spot

The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse? A) Occasional watery stools B) Spitting up after feeding C) Jitteriness and irritability D) Nasal stuffiness

The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention? A) Increased skin temperature and respirations B) Blood glucose level of 45 C) Room-temperature I V running D) Positioned under radiant warmer

The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states which of the following? A) "My baby might open her arms wide and pull her legs up to her tummy if she is passing gas." B) "When I hold my baby upright with one of his feet on the floor, his feet will automatically remain still." C) "When I put my finger in the palm of my daughter's hand, she will curl her fingers and hold on." D) "I can get my baby to turn his head toward the right if I lift his right arm over his head."

The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding? A) A mother with a poorly balanced diet B) A mother who is overweight C) A mother who is H I V positive D) A mother who has twins

The postpartum client is about to go home. The nurse includes which subject in the teaching plan? A) Replacement of fluids B) Striae C) Diastasis of the recti muscles D) R E E D A scale

Which of the following is the primary carbohydrate in the breastfeeding newborn? A) Glucose B) Fructose C) Lactose D) Maltose

Which statement by a new mother 1 week postpartum indicates maternal role attainment? A) "I don't think I'll ever know what I'm doing." B) "This baby feels like a real stranger to me." C) "It works better for me to undress the baby and to nurse in the chair rather than the bed." D) "My sister took to mothering in no time. Why can't I?"

The nurse is preparing to provide a newborn with an injection of vitamin K. In which order should the nurse complete the following steps? 1. Cleanse skin with alcohol and allow to dry 2. Aspirate and then inject the medication slowly 3. Insert a 25-gauge 5/8 inch needle at a 90 degree angle 4. Remove the needle and massage with an alcohol swab 5. Bunch skin over mid-anterior lateral aspect of the thigh

1, 5, 3, 2, 4

The nurse is preparing to gavage-feed a preterm infant. Put the steps in the order in which the nurse should provide this feeding. 1. Check p H of the gastric aspirate 2. Elevate the syringe 6-8 inches above the infant's head 3. Measure from the tip of the nose to the earlobe to the xiphoid process 4. Clear the tubing with 2-3 m L of air 5. Lubricate the tube by dipping it into sterile water

3, 5, 1, 2, 4

At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight? A) This weight loss is excessive. B) This weight loss is within normal limits. C) This weight gain is excessive. D) This weight gain is within normal limits.

A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. The nurse explains to the parents that due to oxygen therapy, their infant is at a greater risk for which of the following? A) Visual impairment B) Hyperthermia C) Central cyanosis D) Sensitive gag reflex

A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following? A) "A quick cool bath will help wake up my son for feedings." B) "I can check my son's temperature under his arm." C) "My baby should be dressed warmly, with a hat." D) "Cuddling my son will help to keep him warm."

A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth? A) Arm recoil B) Square window sign C) Scarf sign D) Popliteal angle

A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, what does the nursing instructor tell the student do? A) Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood. B) Use a previous puncture site. C) Cool the heel prior to obtaining blood. D) Use a sterile needle and aspirate.

A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurse's best response? A) "Take your newborn to the pediatrician." B) "Cover the cord stump with gauze." C) "Apply Betadine around the cord stump." D) "This is normal during healing."

A postpartum client has inflamed hemorrhoids. Which nursing intervention would be appropriate? A) Encourage sitz baths. B) Position the client in the supine position. C) Avoid stool softeners. D) Decrease fluid intake.

During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations? A) The rise and fall of the chest B) Sudden wakefulness C) Urinary output D) Adequate thermoregulation

In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? A) Eye prophylaxis medication B) Drying the newborn C) Vital signs D) Vitamin K injection

In planning care for the fetal alcohol syndrome (F A S) newborn, which intervention would the nurse include? A) Allow extra time with feedings. B) Assign different personnel to the newborn each day. C) Place the newborn in a well-lit room. D) Monitor for hyperthermia.

The community nurse is working with a client from Southeast Asia who has delivered her first child. Her mother has come to live with the family for several months. The nurse understands that the main role of the grandmother while visiting is to do which of the following? A) Help the new mother by allowing her to focus on resting and caring for the baby. B) Teach her son-in-law the right way to be a father because this is his first child. C) Make sure that her daughter does not become abusive towards the infant. D) Pass on cultural values and beliefs to the newborn grandchild.

The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse? A) "The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion." B) "The infant received too many red blood cells after delivery because the cord was not clamped immediately." C) "The yellow color of your baby's skin indicates that you are breastfeeding too often." D) "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should."

The mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate? A) "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth." B) "Bring your infant to the clinic immediately." C) "This is due to overriding of the cranial bones during labor." D) "Your baby must be dehydrated."

The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health? A) The infant's mother has group B streptococcal (G B S) disease. B) The infant's mother had an I V of lactated Ringer's solution. C) The infant's mother had a labor that lasted 12 hours. D) The infant's mother had a cesarean birth with her last child.

The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother? A) Physiologic jaundice is normal, and peaks at this age. B) The newborn's liver is not working as well as it should. C) The baby is yellow because the bowels are not excreting bilirubin. D) The yellow color indicates that brain damage might be occurring.

The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurse's best response? A) "Most newborns are nose breathers." B) "The tube will elicit the sucking reflex." C) "A smaller catheter is preferred for feedings." D) "Most newborns are mouth breathers."

The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice? A) Cephalohematoma B) Mongolian spots C) Telangiectatic nevi D) Molding

The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following? A) A normal position B) A possible chromosomal abnormality C) Facial paralysis D) Prematurity

The nurse has completed a community education session on growth patterns of infants. Which statement by a participant indicates that additional teaching is needed? A) "Newborns should regain their birth weight by 1 week of age." B) "Breastfed and formula-fed babies have different growth rates." C) "Formula-fed infants regain their birth weight earlier than breastfed infants." D) "Healthcare providers consider breastfeeding to be the 'gold standard' for neonatal nutrition."

The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first? A) Mother of a 2-week-old infant who doesn't make eye contact when talked to B) Father of a 1-week-old infant who sleeps through the noise of an older sibling C) Father of a 6-day-old infant who responds more to mother's voice than to father's voice D) Mother of a 3-week-old infant who has begun to suck on the fingers of the right hand

The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority? A) Obtain a blood calcium level. B) Take the newborn's temperature. C) Obtain a bilirubin level. D) Place a pulse oximeter on the newborn.

The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? A) 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory B) 23-year-old of low socioeconomic status, unmarried C) 16-year-old who began prenatal care at 30 weeks D) 28-year-old with a history of gestational diabetes

The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 m g/d L. What should the nurse include in the plan of care for this newborn? A) Offer early feedings with formula or breast milk. B) Provide glucose water exclusively. C) Evaluate blood glucose levels at 12 hours after birth. D) Assess for hyperthermia.

The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurse's plan of care for this newborn? A) Offer early feedings. B) Administer an intravenous infusion of glucose. C) Assess for hypercalcemia. D) Assess for hyperbilirubinemia immediately after birth.

The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern? A) Large amounts of uric acid crystals in the first days of life B) At least 6 to 10 wet diapers a day after the first few days of life C) 1 to 2 stools a day for a formula-fed baby D) Urine that is straw to amber color without foul smell

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? A) Chest circumference 31.5 c m, head circumference 33.5 c m B) Chest circumference 30 c m, head circumference 29 c m C) Chest circumference 38 c m, head circumference 31.5 c m D) Chest circumference 32.5 c m, head circumference 36 c m

The nurse is performing an assessment on an infant whose mother states that she feeds the infant in a supine position by propping the bottle. Based on this information, what would the nurse include in the assessment? A) Otoscopic exam of the eardrum B) Bowel sounds C) Vital signs D) Skin assessment

The nurse is preparing a class on breastfeeding for pregnant women in their first trimester. The women are from a variety of cultural backgrounds, and all speak English well. Which statement should the nurse include in this presentation? A) "Although some cultures believe colostrum is not good for the baby, it provides protection from infections and helps the digestive system to function." B) "Some women are uncomfortable with exposing their breasts to nurse their infant, but it really isn't a big deal. You will get used to it." C) "No religion prescribes a feeding method, so you all can choose whatever method makes the most sense to you." D) "In most cultures, it is culturally acceptable to speak about intimate matters in front of their families."

The nurse is preparing new parents for discharge with their newborn. The father asks the nurse why the baby's head is so pointed and puffy-looking. What is the best response by the nurse? A) "His head is molded from fitting through the birth canal. It will become more round." B) "We refer to that as 'cone head,' which is a temporary condition that goes away." C) "It might mean that your baby sustained brain damage during birth, and could have delays." D) "I think he looks just like you. Your head is much the same shape as your baby's."

The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or younger. Which statement should the nurse include? A) "Your baby will respond to you the most if you look directly into his eyes and talk to him." B) "Each baby is different. Don't try to compare your infant's behavior with any other child's behavior." C) "If the sound level around your baby is high, the baby will wake up and be fussy or cry." D) "If your baby is a cuddler, it is because you rocked and talked to her during your pregnancy."

The nurse is teaching a prenatal class about feeding methods. A father-to-be asks the nurse which method, breast or formula, leads to the fastest infant growth and weight gain. Which response by the nurse is best? A) "In the first 3 to 4 months breastfed babies tend to gain weight faster." B) "In the first 3 to 4 months there is no difference in weight gain." C) "In the first 3 to 4 months bottle-fed babies grow faster." D) "In the first 3 to 4 months growth isn't as important as your comfort with the method."

The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. What information does teaching include? A) Specially prepared formulas B) Cataract problems C) Low glucose concentrations D) Administration of thyroid medication

The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require which of the following? A) Initial resuscitation B) Vigorous stimulation at birth C) Phototherapy immediately D) An initial feeding of iron-enriched formula

The nurse wishes to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use? A) Brazelton Neonatal Behavioral Assessment Scale B) New Ballard Score C) Dubowitz gestational age scale D) Ortolani maneuver

The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus? A) Methylergonovine maleate (Methergine) B) Rh immune globulin (R h o G A M) C) Terbutaline (Brethine) D) Docusate (Colace)

The parents of a newborn are receiving discharge teaching. The nurse explains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary? A) "Our baby was born with kidneys that are too small." B) "A baby's kidneys don't concentrate urine well for several months." C) "Feeding our baby frequently will help the kidneys function." D) "Kidney function in an infant is very different from that in an adult."

The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents do not seem to understand the explanation given by the physician. What statement by the nurse is best? A) "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." B) "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder." C) "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart." D) "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal."

The pediatric clinic nurse is reviewing lab results with a 2-month-old infant's mother. The infant's hemoglobin has decreased since birth. Which statement by the mother indicates the need for additional teaching? A) "My baby isn't getting enough iron from my breast milk." B) "Babies undergo physiologic anemia of infancy." C) "This results from dilution because of the increased plasma volume." D) "Delaying the cord clamping did not cause this to happen."

The pregnant client at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best? A) "Babies can develop postmaturity syndrome, which refers to a number of complications that can occur after 42 weeks of pregnancy." B) "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." C) "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." D) "The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger."

Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn? A) Jitteriness B) Sucking on fingers C) Lusty cry D) Axillary temperature of 98°F

Which nonspecific immune mechanism helps the ability of antibodies and phagocytic cells to clear pathogens from an organism? A) Complement B) Coagulation C) Inflammatory response D) Phagocytosis

Which of the following behaviors noted in the postpartum client would require the nurse to assess further? A) Responds hesitantly to infant cries. B) Expresses satisfaction about the sex of the baby. C) Friends and family visit the client and give advice. D) Talks to and cuddles with the infant frequently.

Which of the following conditions would predispose a client for thrombophlebitis? A) Severe anemia B) Cesarean delivery C) Anorexia D) Hypocoagulability

Which of the following is a benefit of delayed umbilical cord clamping for the preterm infant? A) Fewer infants require blood transfusion for anemia B) Fewer infants require blood transfusion for high blood pressure C) Increase in the incidence of intraventricular hemorrhage D) Increase in incidence of infant breastfeeding

To maintain a healthy temperature in the newborn, which of the following actions should be taken? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Keep the newborn's clothing and bedding dry. B) Reduce the newborn's exposure to drafts. C) Do not use the radiant warmer during procedures. D) Do not wrap the newborn. E) Encourage the mother to snuggle with the newborn under blankets.

A, B, E

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? Select all that apply. 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

The nurse encourages a new mother to feed the newborn as soon as the newborn shows interest. The nurse bases this recommendation on which benefits of early feedings? Select all that apply. A) Early feedings stimulate peristalsis. B) Colostrum is thinner than mature milk. C) Early feedings enhance maternal-infant bonding. D) Early feedings promote the passage of meconium. E) Colostrum contains a high number of calories.

A, C, D

The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing which of the following? Select all that apply. A) Respiratory rate B) Skin texture C) Airway clearance D) Ability to feed E) Head weight

A, C, D

The nurse is teaching the parents of a newborn who has been exposed to H I V how to care for the newborn at home. Which instructions should the nurse emphasize? Select all that apply. A) Use proper hand-washing technique. B) Provide three feedings per day. C) Place soiled diapers in a sealed plastic bag. D) Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. E) Take the temperature rectally.

A, C, D

The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? Select all that apply. A) Hyperirritability B) Decreased muscle tone C) Exaggerated reflexes D) Low pitched cry E) Transient tachypnea

A,C,E

Many newborns exposed to H I V/A I D S show signs and symptoms of disease within days of birth that include which of the following? Select all that apply. A) Swollen glands B) Hard stools C) Smaller than average spleen and liver D) Rhinorrhea E) Interstitial pneumonia

A,D,E

Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Select all that apply. A) Obtain skin cultures. B) Restrict parental visits. C) Evaluate bilirubin levels. D) Administer oxygen as ordered. E) Observe for signs of hypoglycemia.

A, C, D, E

The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs? Select all that apply. A) Continual rise in temperature B) Decreased frequency of stools C) Absence of breathing longer than 20 seconds D) Lethargy E) Refusal of two feedings in a row

A, C, D, E

The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? Select all that apply. A) Physiologic jaundice occurs after 24 hours of age. B) Pathologic jaundice occurs after 24 hours of age. C) Phototherapy increases serum bilirubin levels. D) The need for phototherapy depends on the bilirubin level and age of the infant. E) Kernicterus causes irreversible neurological damage.

A, E

The nurse is cross-training maternal-child health unit nurses to provide home-based care for parents after discharge. Which statements indicate that additional teaching is required? Select all that apply. A) "The behavioral assessment should be done as soon after birth as possible." B) "The behavioral assessment can be performed without input from parents." C) "The behavioral assessment might be incomplete in a 1-hour home visit." D) "The behavioral assessment includes orientation and motor activity." E) "The behavioral assessment can detect neurological impairments."

A,B

A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Select all that apply. A) Gently massage the site after injection. B) Use a 22-gauge, 1-inch needle. C) Inject in the vastus lateralis muscle. D) Cleanse the site with alcohol prior to injection. E) Inject at a 45-degree angle.

A,C,D

A new mother is concerned because the anterior fontanelle swells when the newborn cries. Explaining normal findings concerning the fontanelles, the nurse states which of the following? Select all that apply. A) The fontanelles can swell with crying. B) The fontanelles might be depressed. C) The fontanelles can pulsate with the heartbeat. D) The fontanelles might bulge. E) The fontanelles can swell when stool is passed.

A,C,E

A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first? A) Stool characteristics B) Fluid intake C) Skin color D) Bilirubin level

Which of the following would be considered normal newborn urinalysis values? Select all that apply. A) Color bright yellow B) Bacteria 0 C) Red blood cells (R B C) 0 D) White blood cells (W B C) more than 4-5/h p f E) Protein less than 5-10 m g/d L

B, C, E

A nurse is evaluating the diet plan of a breastfeeding mother, and determines that her intake of fruits and vegetables is inadequate. The nurse explains that the nutritional composition of the mother's breast milk can be adversely affected by this nutritional inadequacy. Which strategy should the nurse recommend to the mother? A) Stop breastfeeding B) Provide newborn supplements to the newborn C) Offer whole milk D) Supplement with skim milk

A nurse is evaluating the diet plan of a breastfeeding mother. Which beverage is most likely to cause intolerance in the infant? A) Orange juice B) Milk C) Decaffeinated tea D) Water

A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurse's best response? A) "I will call your pediatrician immediately." B) "Passage of the first stool within 48 hours is normal." C) "Your newborn might not have a stool until the third day." D) "Your newborn must be dehydrated."

An H I V-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care for the newborn at home. Which instructions should the nurse include? A) Do not add food supplements to the baby's diet. B) Place soiled diapers in a sealed plastic bag. C) Wash soiled linens in cool water with bleach. D) Shield the baby's eyes from bright lights.

Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. What action should the nurse take? A) Answer questions quickly and try to divert her attention to other subjects. B) Review the documentation of the birth experience and discuss it with her. C) Contact the physician to warn him the client might want to file a lawsuit, based on her preoccupation with the birth experience. D) Submit a referral to Social Services because of possible obsessive behavior.

Mild or chronic anemia in an infant may be treated adequately by which of the following? A) Transfusions with O-negative or typed and cross-matched packed red cells B) Iron supplements or iron-fortified formulas C) Steroid therapy D) Antibiotics or antivirals

One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate? A) Meticulous hand washing and antibiotic eye ointment administration. B) Intravenous acyclovir (Zovirax) and contact precautions. C) Cultures of blood and C S F and serial chest x-rays every 12 hours. D) Parental rooming-in and four intramuscular injections of penicillin.

Placing the baby at mother's breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated? A) 6 to 12 hours after birth B) Within 1 hour of birth C) 24 hours after birth D) 48 hours after birth

The client with blood type O R h-negative has given birth to an infant with blood type O R h-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse? A) "The R h o G A M you received at 28 weeks' gestation did not prevent alloimmunization." B) "Your body has made antibodies against the baby's blood that are destroying her red blood cells." C) "The red blood cells of your baby are breaking down because you both have type O blood." D) "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."

The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues? A) "I am so happy and blessed to have my new baby." B) "One minute I'm laughing and the next I'm crying." C) "My husband is helping out by changing the baby at night." D) "Breastfeeding is going quite well now that the engorgement is gone."

The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be which of the following? A) Temperature 97.9°F B) Respirations 68 breaths/minute C) Stable vital signs 45 minutes ago D) Heart rate 156 beats/min

The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data? A) Heart rate 120 B) Temperature 96.8°F C) Respiratory rate 50 D) Temperature 99.6°F

The nurse has received the end-of-shift report on the postpartum unit. Which client should the nurse see first? A) Woman who is 2nd day post-cesarean, moderate lochia serosa B) Woman day of delivery, fundus firm 2 c m above umbilicus C) Woman who had a cesarean section, 1st postpartum day, 4 c m diastasis recti abdominis D) Woman who had a cesarean section, 1st postpartum day, hypoactive bowel sounds all quadrants

The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition? A) Meconium aspiration syndrome B) Transient tachypnea of the newborn C) Respiratory distress syndrome D) Prematurity of the neonate

The nurse is assisting a mother to bottle-feed her newborn, who has been crying. The nurse suggests that prior to feeding, the mother should do which of the following? A) Offer a pacifier B) Burp the newborn C) Unwrap the newborn D) Stroke the newborn's spine and feet

The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? A) Eyes are covered, no clothing on, diaper in place B) Axillary temperature 99.7°F C) Infant removed from the isolette for breastfeeding D) Loose bowel movement

The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? A) Keep the infant N P O for 4 hours following the procedure. B) Observe for urine output. C) Wrap dry gauze tightly around the penis. D) Clean with cool water with each diaper change.

The nurse is completing the gestational age assessment on a newborn while in the mother's postpartum room. During the assessment, the mother asks what aspects of the baby are being checked. What is the nurse's best response? A) "I'm checking to make sure the baby has all of its parts." B) "This assessment looks at both physical aspects and the nervous system." C) "This assessment checks the baby's brain and nerve function." D) "Don't worry. We perform this check on all the babies."

The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following? A) A history of obsessive-compulsive disorder (O C D) B) Chlamydia C) Delivered six other children by cesarean section D) A urinary tract infection (U T I)

The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parent indicates that teaching was effective? A) "This condition occurs more frequently among Japanese people." B) "We must be very careful to avoid most proteins to prevent brain damage." C) "Carbohydrates can cause our baby to develop cataracts and liver damage." D) "Our baby's thyroid gland isn't functioning properly."

The nurse is teaching a new mother how to encourage a sleepy baby to breastfeed. Which of the following instructions would not be included in that teaching? A) Providing skin-to-skin contact B) Swaddling the newborn in a blanket C) Unwrapping the newborn D) Allowing the newborn to feel and smell the mother's breast

The nurse is working with a mother who has just delivered her third child at 33 weeks' gestation. The mother says to the nurse, "This baby doesn't turn her head and suck like the older two children did. Why?" What is the best response by the nurse? A) "Every baby is different. This is just one variation of normal that we see on a regular basis." B) "This baby might not have a rooting or sucking reflex because she is premature." C) "When she is wide awake and alert, she will probably root and suck even if she is early." D) "She might be too tired from the birthing process and need a couple of days to recover."

The nurse is working with a new mother who delivered yesterday. The mother has chosen to breastfeed her infant. Which demonstration of skill is the best indicator that the client understands breastfeeding? A) She puts the infant to breast when he is asleep to help wake him up. B) She takes off her gown to achieve skin-to-skin contact. C) She leans toward the infant so that he turns his head to access the nipple. D) The infant is crying when he is brought to the breast.

The nurse suspects clubfoot in the newborn and assesses for the condition by doing which of the following? A) Adducting the foot and listening for a click. B) Moving the foot to midline and determining resistance. C) Extending the foot and observing for pain. D) Stimulating the sole of the foot.

The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction? A) "The en face position promotes bonding and attachment." B) "Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed." C) "In reciprocity, the interaction of mother and infant is mutually satisfying and synchronous." D) "The needs of the mother and of her infant are balanced during the phase of mutual regulation."

The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected? A) "If I had taken better care of myself, this wouldn't have happened." B) "I've been sleeping very well since I had the baby." C) "This is probably the doctor's fault." D) "If I hadn't seen our baby's birth, I wouldn't believe she is ours."

The student nurse has performed a gestational age assessment of an infant, and finds the infant to be at 32 weeks. On which set of characteristics is the nurse basing this assessment? A) Lanugo mainly gone, little vernix across the body B) Prominent clitoris, enlarging minora, anus patent C) Full areola, 5 to 10 m m bud, pinkish-brown in color D) Skin opaque, cracking at wrists and ankles, no vessels visible

The student nurse notices that the newborn seems to focus on the mother's eyes. The nursing instructor explains that this newborn behavior is which of the following? A) Habituation B) Orientation C) Self-quieting D) Reactivity

The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them? A) "Jaundice is uncommon in newborns." B) "Some newborns require phototherapy." C) "Jaundice is a medical emergency." D) "Jaundice is always a sign of liver disease."

To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following? A) Keep the baby in the room at all times. B) Check the identification of all personnel who transport the newborn. C) Place a "No Visitors" sign on the door. D) Keep the baby in the nursery at all times.

What indications would lead the nurse to suspect sepsis in a newborn? A) Respiratory distress syndrome developing 48 hours after birth B) Temperature drops from 97.4°F to 97.0 2°F hours after 2 hours of warming. C) Irritability and flushing of the skin at 8 hours of age D) Bradycardia and tachypnea developing when the infant is 36 hours old

What is the primary carbohydrate in mammalian milk that plays a crucial role in the nourishment of the newborn? A) Colostrum B) Lactose C) Lactoferrin D) Secretory I g A

The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal? Select all that apply. A) Respiratory rate of 66 breaths per minute B) Periodic breathing with pauses of 25 seconds C) Synchronous chest and abdomen movements D) Grunting on expiration E) Nasal flaring

B, D, E

The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likely to be observed? Select all that apply. A) Lanugo abundant over shoulders and back B) Plantar creases over entire sole C) Pinna of ear springs back slowly when folded. D) Vernix well distributed over entire body E) Testes are pendulous, and the scrotum has deep rugae

B, E

Nursing interventions that foster the process of becoming a mother include which of the following? Select all that apply. A) Encouraging detachment from the nurse-patient relationship B) Promoting maternal-infant attachment C) Building awareness of and responsiveness to infant interactive capabilities D) Instruct about promoting newborn independence E) Preparing the woman for the maternal social role

B,C,E

During the first several postpartum weeks, the new mother must accomplish certain physical and developmental tasks, including which of the following? Select all that apply. A) Establish a therapeutic relationship with her physician B) Adapt to altered lifestyles and family structure resulting from the addition of a new member C) Restore her intellectual abilities D) Restore physical condition E) Develop competence in caring for and meeting the needs of her infant

B,D,E

A 7 pound 14 ounce girl was born to an insulin-dependent type Ⅱ diabetic mother 2 hours ago. The infant's blood sugar is 47 m g/d L. What is the best nursing action? A) To recheck the blood sugar in 6 hours B) To begin an I V of 10% dextrose C) To feed the baby 1 ounce of formula D) To document the findings in the chart

A client from Mexico has just delivered a son, and the nurse offers to assist in putting the baby to breast. Although the client indicated before the birth that she wanted to breastfeed, she is very hesitant, and says she would like to bottle-feed for the first few days. After talking to her, the nurse understands that her primary reason for wanting to delay breastfeeding is based on what cultural belief? A) Breast milk causes skin rashes. B) It is harmful to breastfeed immediately. C) Colostrum is bad for the baby. D) Thin milk causes diarrhea.

A mother states that her breasts leak between feedings. Which of the following can contribute to the letdown reflex in breastfeeding mothers? A) Pain with breastfeeding B) Number of hours passed since last feeding C) The newborn's cry D) Maternal fluid intake

A new father asks the nurse to describe what his baby will experience while sleeping and awake. What is the best response? A) "Babies have several sleep and alert states. Keep watching and you'll notice them." B) "You might have noticed that your child was in an alert awake state for an hour after birth." C) "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." D) "Birth is hard work for babies. It takes them a week or two to recover and become more awake."

A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? A) "I can't believe he can already digest fats, carbohydrates, and proteins." B) "It is amazing that his whole digestive tract can move things along at birth." C) "Incredibly, his stomach capacity was already a cupful when he was born." D) "He will lose some weight but then miraculously regain it by about 10 days."

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (R D S). Which of the following signs and symptoms would not be characteristic of R D S? A) Grunting respirations B) Nasal flaring C) Respiratory rate of 40 during sleep D) Chest retractions

A nurse is caring for several postpartum clients. Which client is demonstrating a problem attaching to her newborn? A) The client who is discussing how the baby looks like her father B) The client who is singing softly to her baby C) The client who continues to touch her baby with only her fingertips D) The client who picks her baby up when the baby cries

Approximately what percentage of the newborn's body weight is water? A) 5% to 10% B) 90% to 95% C) 70% to 75% D) 50% to 60%

During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following? A) Place the newborn in a prone position. B) Limit feedings to three a day to decrease diarrhea. C) Place the infant supine and operate a home apnea-monitoring system. D) Wean the newborn off the pacifier.

New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant? A) The foreskin will be retractable at 2 months. B) Retract the foreskin and clean thoroughly. C) Avoid retracting the foreskin. D) Use soap and Betadine to cleanse the penis daily.

On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to which of the following? A) The taking-hold phase B) Postpartum hemorrhage C) The taking-in period D) Epidural anesthesia

Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do? A) Enable T or B cells to respond to antigens B) Repress responses to specific B or T lymphocytes to antigens C) Kill foreign or virus-infected cells D) Remove pathogens and cell debris

The community nurse is working with a client whose only child is 8 months old. Which statement does the nurse expect the mother to make? A) "I have a lot more time to myself than I thought I would have." B) "My confidence level in my parenting is higher than I anticipated." C) "I am constantly tired. I feel like I could sleep for a week." D) "My baby likes everyone, and never fusses when she's held by a stranger."

The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. Which of the following assessment findings is not congruent with prematurity? A) Cry is weak and feeble B) Clitoris and labia minora are prominent C) Strong sucking reflex D) Lanugo is plentiful

The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following? A) Ortolani maneuver B) Palmar grasping reflex C) Clavicle D) Tonic neck reflex

The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do? A) Document the findings. B) Catheterize the client. C) Massage the uterine fundus until it is firm. D) Call the physician immediately.

The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what? A) Hold the newborn in an upright position. B) Massage the hands and feet. C) Swaddle the newborn in a blanket. D) Make eye contact while talking to the newborn.

The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart? A) Preterm appropriate for gestational age, symmetrical I U G R B) Term small for gestational age, symmetrical I U G R C) Preterm small for gestational age, asymmetrical I U G R D) Preterm appropriate for gestational age, asymmetrical I U G R

The nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within how long? A) 2 days B) 10 days C) 8 days D) 14 days

The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse? A) Asking the client to void and donning clean gloves B) Listening to bowel sounds and then asking when her last bowel movement occurred C) Offering the patient pre-medication 2 hours before the assessment D) Completing the assessment and explaining the results to the client

The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is most important to include in the presentation? A) Conjugated bilirubin is eliminated in the conjugated state. B) Unconjugated bilirubin is neurotoxic, and cannot cross the placenta. C) Total bilirubin is the sum of the direct and indirect levels. D) Hyperbilirubinemia is a decreased total serum bilirubin level.

The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement? A) "I should expect a lighter flow next week." B) "The flow will increase if I am too active." C) "My bleeding will remain red for about a month." D) "I will be able to use a pantiliner in a day or two."

The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed? A) "The white spots on my baby's nose are called milia, and are harmless." B) "The whitish cheeselike substance in the creases is vernix, and will be absorbed." C) "The red spots with a white center on my baby are abnormal acne." D) "Jaundice is a yellowish discoloration of skin that if noticed on the 1st day of life should be reported to the physician."

The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit which of the following? A) Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline B) Testes located in the upper scrotum, rugae covering the scrotum, vernix covering the entire body C) Ear cartilage folded over, lanugo present over much of the body, slow recoil time D) 1 c m breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension

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? A) The student nurse listens to bowel sounds, then assesses the head for skull consistency and size and tension of fontanelles. B) The student nurse checks for Ortolani's sign, then palpates the femoral pulse, then assesses respiratory rate. C) The student nurse determines skin color, then describes the shape of the chest and looks at structures and flexion of the feet. D) The student nurse counts the number of cord vessels, then assesses genitals, then sclera color and eyelids.

The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse? A) "Circumcision should be undertaken to prevent problems in the future." B) "Circumcision might decrease the child's risk of developing a urinary tract infection." C) "Circumcision can sometimes cause complications. What questions do you have?" D) "Circumcision is painful, and should be avoided unless you are Jewish."

The parents of a preterm newborn wish to visit their baby in the N I C U. A statement by the nurse that would not support the parents as they visit their newborn is which of the following? A) "Your newborn likes to be touched." B) "Stroking the newborn will help with stimulation." C) "Visits must be scheduled between feedings." D) "Your baby loves her pink blanket."

When a breastfeeding mother complains that her breasts are leaking milk, the nurse can offer which effective intervention? A) Decrease the number of minutes the newborn is at the breast per feeding. B) Decrease the mother's fluid intake. C) Place absorbent pads in the bra. D) Administer oxytocin.

When is breastfeeding contraindicated? A) Infant has hypertension B) Mother has a history of treated tuberculosis C) Mother is H I V positive or has A I D S D) Mother has a history of treated herpes

The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statement(s) by the parents indicate that additional teaching is needed? Select all that apply. A) "Our baby will be in an incubator to keep him warm." B) "Breathing might be harder for our baby because he is early." C) "The growth of our baby will be faster than if he were term." D) "Tube feedings will be required because his stomach is small." E) "Because he came early, he will not produce urine for 2 days."

C, D, E

What should the healthcare provider consider when prescribing a medication to a woman who is breastfeeding? Select all that apply. A) Drug's potential effect on hormone production B) Amount of drug excreted into the mother's blood C) Drug's potential adverse effects to the infant D) Infant's age and health E) Mother's need for the medication

C, D, E

The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock? Select all that apply. A) Increased pulse B) High blood pressure C) Tachycardia D) Bradycardia E) Capillary filling time greater than 3 seconds

C, E

The nurse is preparing a class for mothers who have just recently delivered and their partners. One topic of the class is infant attachment. Which statement by a participant indicates an understanding of this concept? Select all that apply. A) "We should avoid holding the baby too much." B) "Looking directly into the baby's eyes might frighten him." C) "Talking to the baby is good because he'll recognize our voices." D) "Holding the baby so we have direct face-to-face contact is good." E) "We should only touch the baby with our fingertips for the first month."

C,D

The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate? A) Encourage the new mother, saying, "It will happen soon." B) Instruct the client to eat a low-fiber diet. C) Decrease fluid intake. D) Obtain an order for a stool softener.

A client at 20 weeks' gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the client indicate that the teaching was successful? A) "Formula-feeding gives the baby protection from infections." B) "Breast milk cannot be stored; it has to be thrown away after pumping." C) "Breastfeeding is more expensive than formula-feeding." D) "My baby will have a lower risk of food allergies if I breastfeed."

A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long? A) 2 months B) 2 weeks C) 1 year D) 4 months

A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (R D S). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment? A) Decreased urine output B) Pulmonary vascular resistance increases C) Increased P C O2 D) Increased urination

A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurse's best response? A) "Take your newborn to the pediatrician." B) "There might be a possible food allergy." C) "Your newborn has diarrhea." D) "This is a normal occurrence."

Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following? A) Preeclampsia screening B) Congenital kidney disease screening C) Visual screening D) Hearing screening

During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up? A) Firm fundus B) Fundus at the umbilical level C) Moderate lochia rubra D) Steady trickle of blood

How does the nurse assess for Homans' sign? A) Extending the foot and inquiring about calf pain. B) Extending the leg and inquiring about foot pain. C) Flexing the knee and inquiring about thigh pain. D) Dorsiflexing the foot and inquiring about calf pain.

Parents have been told their child has fetal alcohol syndrome (F A S). Which statement by a parent indicates that additional teaching is required? A) "Our baby's heart murmur is from this syndrome." B) "He might be a fussy baby because of this." C) "His face looks like it does due to this problem." D) "Cuddling and rocking will help him stay calm."

The client delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an I V of lactated Ringer's solution running at 100 m L/h r. Her fundus is firm and to the right of midline. What is the best nursing action? A) To massage the fundus vigorously B) To assess the client's pain level C) To increase the rate of the I V D) To assist the client to the bathroom

The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse? A) 60 breaths per minute B) 70 breaths per minute C) 64 breaths per minute D) 20 breaths per minute

The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect? A) Apical heart rate of 140 beats per minute B) Respiratory rate of 40 C) Temperature of 36.5°C D) Visible, blue discoloration of the skin

The nurse is analyzing various strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement? A) Select videos on various topics of newborn care. B) Organize a class that includes first-time mothers only. C) Have mothers return in 1 week, when they feel more rested. D) Schedule time for one-to-one teaching in the mother's room.

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? A) Respiratory rate 60 and irregular in depth and rhythm B) Pulse rate 145, cardiac murmur heard C) Mean blood pressure 55 m m H g D) Pauses in respiration lasting 30 seconds

The nurse is beginning the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important? A) Describe the likely reaction of siblings to the new baby. B) Discuss adaptation to grandparenthood by her parents. C) Determine whether father-infant attachment is taking place. D) Assist the mother in identifying the baby's behavior cues.

The nurse is caring for a client who recently emigrated from a Southeast Asian country. The mother has been resting since the birth, while her sister has changed the diapers and fed the infant. What is the most likely explanation for this behavior? A) The client is not attaching to her infant appropriately. B) The client is not going to be a good mother, and the baby is at risk. C) The client has no mother present to role-model behaviors. D) The client is exhibiting normal behavior for her culture.

The nurse is caring for a new breastfeeding mother who is from Pakistan. The nurse plans her care so that the newborn is offered the breast on which of the following? A) Day of birth B) First day after birth C) Second day after birth D) Third to fourth day after birth

The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with which of the following? A) Omphalocele B) Gastroschisis C) Diaphragmatic hernia D) Myelomeningocele

The nurse is caring for a premature infant in the N I C U, and is going to attempt a bottle feeding with thawed breast milk. How long can thawed breast milk be stored in the refrigerator before the nurse must discard it? A) 4 hours B) 8 hours C) 12 hours D) 24 hours

The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching? A) "Call your pediatrician if the baby's temperature is below 98.6°F axillary." B) "Your baby's stools will change to a greenish color when your milk comes in." C) "You can wipe away any eye drainage that might form." D) "Your infant should wet a diaper at least 6 times per day."

The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful? A) "I should avoid looking directly into the baby's eyes to prevent frightening the baby." B) "My baby will be very sleepy immediately after birth and should go to the nursery." C) "Newborns cannot focus their eyes, so it doesn't matter how I hold my new baby." D) "Giving my baby his first bath can really give me a chance to get to know him."

The nurse is explaining the nutritional differences between breast milk and formula to an expectant couple. The mother-to-be asks whether breast milk is nutritionally superior to formula. What should the nurse reply? A) The vitamins and minerals in formula are more bioavailable to the infant. B) There is no cholesterol in breast milk. C) The only carbohydrate in breast milk is lactose. D) The ratio of whey to casein proteins in breast milk changes to meet the nutritional needs of the growing infant.

The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. What is the nurse's best response? A) "We see this from time to time. It's not a big deal." B) "The gush is an indication that your fundus isn't contracting." C) "Don't worry. I'll make sure everything is fine." D) "Blood pooled in the vagina while you were in bed."

The nurse is planning visits to the homes of new parents and their newborns. Which client should the nurse see first? A) 3-day-old male who received hepatitis B vaccine prior to discharge B) 4-day-old female whose parents are both hearing-impaired C) 5-day-old male with light, sticky, yellow drainage on the circumcision site D) 6-day-old female with greenish discharge from the umbilical cord site

The nurse is preparing to assess a newborn's neurological status. Which finding would require an immediate intervention? A) At rest, the infant has partially flexed arms and the legs drawn up to the abdomen. B) When the corner of the mouth is touched, the infant turns the head that direction. C) The infant blinks when the exam light is turned on over the face and body. D) The right arm is flaccid while the infant brings the left arm and fist upward to the head.

The nurse is teaching a group of new parents about newborn behavior. Which statement made by a parent would indicate a need for additional information? A) "Sleep and alert states cycle throughout the day." B) "We can best bond with our child during an alert state." C) "About half of the baby's sleep time is in active sleep." D) "Babies sleep during the night right from birth."

The nurse is working with a client from Southeast Asia. The client tells the nurse that she should not put the baby to breast until her milk comes in and her breasts are warm, because "cold milk" (colostrum) is bad for the baby. After the nurse explains the benefits of colostrum, the client still insists that "cold milk" is bad. Which response by the nurse is best? A) "What kind of formula would you like to use?" B) "That idea is folklore. Colostrum is good for the baby." C) "Now that you are here, you need to feed your baby the right way." D) "Let's give the baby formula after you breastfeed."

The nurse is working with an adolescent mother who tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." What is the best response by the nurse? A) "You are very young, and parenting will be a challenge for you." B) "Your mother was probably right. Be very careful with your baby." C) "Mothers have instincts that kick in when they get their babies home." D) "We can give the baby a bath together. I'll help you learn how to do it."

The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn? A) "You appear to be Muslim. Do you want your son circumcised?" B) "Let me explain newborn care here in the United States." C) "Your baby is a United States citizen. You must be very happy about that." D) "Could you explain your preferences regarding childrearing?"

The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best? A) "I'll bring you to your baby and then leave so you can have some privacy." B) "Your baby is on a ventilator with 50% oxygen, and has an umbilical line." C) "I am so sorry this has all happened. I know how stressful this can be." D) "Your baby is working hard to breathe and lying quite still, and has an I V."

The parents of a newborn comment to the nurse that their infant seems to enjoy being held, and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents' learning. Which statement indicates that teaching was effective? A) "Some babies are easier to deal with than others." B) "We are lucky to have a baby with a calm disposition." C) "Our baby spends more time in the active alert phase." D) "Cuddliness is a social behavior that some babies have."

Which of the following is a sign of dehydration in the newborn? A) Slow, weak pulse B) Soft, loose stools C) Light colored, concentrated urine D) Depressed fontanelles

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.

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