NU 150- MT- 6 chapters

The NICU nurse begins her shift by assessing one of the preterm infants assigned to her care. The infant's color is pale, his O2 saturation has decreased, and he is grimacing. This infant is displaying common signs of ____.

ANS: Pain

25. According to Beck's studies, what risk factor for postpartum depression (PPD) is likely to have the greatest effect on the woman's condition? a. Prenatal depression b. Single-mother status c. Low socioeconomic status d. Unplanned or unwanted pregnancy

ANS: A Feedback A Depressive symptoms during pregnancy or previous ppd are strong predictors for subsequent episodes of PPD. B Single-mother status is a small-relation predictor for PPD. C Low socioeconomic status is a small-relation predictor for PPD. D An unwanted pregnancy may contribute to the risk for PPD; however, it does not pose as great an effect as prenatal depression.

3. Of all pregnant women being treated for depression, approximately one-third have a first occurrence during pregnancy. All pregnant and postpartum women should be screened for perinatal mood disorders by using the _________ Postnatal Depression Scale.

ANS: Edinburgh The 10-item Edinburgh Postnatal Depression Scale accurately identifies depression in pregnant and postpartum women.

2. _______________ is the most common postpartum infection.

ANS: Endometritis Endometritis usually begins as a localized infection at the placental site; however, can spread to involve the entire endometrium. Assessment for signs of endometritis may reveal a fever, elevated pulse, chills, anorexia, fatigue, pelvic pain, uterine tenderness or foul-smelling profuse lochia.

20. Which measure may prevent mastitis in the breastfeeding mother? a. Initiating early and frequent feedings b. Nursing the infant for 5 minutes on each breast c. Wearing a tight-fitting bra d. Applying ice packs before feeding

ANS: A Feedback A Early and frequent feedings prevent stasis of milk, which contributes to engorgement and mastitis. B Five minutes does not adequately empty the breast. This will produce stasis of the milk. C A firm-fitting bra will support the breast, but not prevent mastitis. The breast should not be bound. D Warm packs before feeding will increase the flow of milk.

14.A newborn, at 5 hours old, wakes from a sound sleep and becomes very active and begins to cry. Which of the following signs if exhibited by this newborn would indicate expected adaptation to extrauterine life? (Circle all that apply.) a. Increased mucus production b. Passage of meconium c. Heart rate of 160 beats per minute d. Respiratory rate of 24 breaths per minute and irregular e. Retraction of sternum with inspiration f. Expiratory grunting with nasal flaring

14. a, b, and c; the newborn at 5 hours old is in the second period of reactivity, during which tachycardia, tachypnea, increased muscle tone, skin color changes, increased mucus production, and passage of meconium are normal findings; temperature should range between 36.5° and 37.2° C, and respiratory rate should range between 30 and 60 BPM; expiratory grunting and nasal flaring and retractions of the sternum are signs of respiratory distress.

15. When assessing a newborn boy at 12 hours of age, the nurse notes a rash on his abdomen and thighs composed of reddish macules, papules, and small vesicles. The nurse would: a. document the finding as erythema toxicum. b. isolate the newborn and his mother until infection is ruled out. c. apply an antiseptic ointment to each lesion. d. request nonallergenic linen from the laundry.

15. a; the rash described is erythema toxicum; it is an inflammatory response that has no clinical significance and requires no treatment because it will disappear spontaneously.

16. A breastfed full-term newborn girl is 12 hours old and is being prepared for early discharge. Which of the following assessment findings, if present, could delay discharge? a. Dark green-black stool, tarry in consistency b. Yellowish tinge in sclera and on face c. Swollen breasts with a scant amount of thin discharge d. Blood-tinged mucoid vaginal discharge

16. b; physiologic jaundice does not appear until 24 hours after birth; further investigation would be needed if it appears during the first 24 hours, because that would be consistent with pathologic jaundice; a, c, and d are all expected findings.

17. As part of a thorough assessment, the newborn should be checked for hip dislocation and dysplasia. Which of the following techniques would be used? a. Check for syndactyly bilaterally b. Stepping or walking reflex c. Magnet reflex d. Ortolani's maneuver

17. d; b and c are common newborn reflexes used to assess integrity of neuromuscular system; syndactyly refers to webbing of the finger

18. When assessing a newborn after birth, the nurse notes flat, irregular, pinkish marks on the bridge of the nose, nape of neck, and over the eyelids. The areas blanch when pressed with a finger. The nurse would document this finding as: a. milia. b. nevus vasculosus. c. telangiectatic nevi. d. nevus flammeus.

18. c; telangiectatic nevi (nevus simplex) are also known as stork bite marks and can also appear on the eyelids; milia are plugged sebaceous glands and appear like white pimples; nevus vasculosus or a strawberry mark is a raised, sharply demarcated, bright or dark red swelling; nevus flammeus is a port-wine, flat red to purple lesion that does not blanch with pressure.

Early signs of infection are often subtle and could indicate other conditions. One of the frequent signs is A. temperature instability. B. seizure activity. C. decreased pulse rate. D. ruddy skin color.

A Signs of infection include temperature instability, respiratory problems, and changes in feeding habits or behavior not seizure activity, and decreased pulse rate. Ruddy skin color is usually a sign of a high hematocrit.

As the nurse is assessing a 2-day-old newborn, jaundice is noted on the face only. The nurse can anticipate a bilirubin level of about A. 5 mg/dL. B. 10 mg/dL. C. 15 mg/dL. D. 20 mg/dL.

A When the bilirubin level reaches 5 to 7 mg/dL, jaundice is visible in the newborn's face. It moves down the body as bilirubin levels continue to rise.

What intervention would make phototherapy most effective in reducing the indirect bilirubin in an affected newborn? A. Expose as much skin as possible. B. Increase oral intake of water between and before feedings. C. Place eye patches on the newborn. D. Wrap the infant in triple blankets to prevent cold stress.

A With bili lights, the infant wears only a diaper to ensure maximal exposure of the skin. The eyes are closed and patches placed over them to prevent injury. However, this is not what affects the bilirubin levels. The infant can be placed in an incubator or under a radiant warmer to maintain heat.

The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States? a. Alcohol b. Marijuana c. Tobacco d. Heroin

A Alcohol abuse during pregnancy is recognized as one of the leading causes of cognitive impairment in the United States.

An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which highly technical method of treatment may be necessary for an infant who does not respond to conventional treatment? a. Extracorporeal membrane oxygenation b. Respiratory support with a ventilator c. Insertion of a laryngoscope and suctioning of the trachea d. Insertion of an endotracheal tube

A Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, thus allowing the infant's lungs to rest and recover. The infant is likely to have been first connected to a ventilator. Laryngoscope insertion and tracheal suctioning are performed after birth before the infant takes the first breath. An endotracheal tube will be in place to facilitate deep tracheal suctioning and ventilation.

Which infant would be more likely to have Rh incompatibility? a. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor b. Infant who is Rh negative and whose mother is Rh negative c. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor d. Infant who is Rh positive and whose mother is Rh positive

A If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the children will be Rh positive. Only Rh-positive children of an Rh-negative mother are at risk for Rh incompatibility. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, there is a 50% chance that each infant born of the union will be Rh positive and a 50% chance that each will be born Rh negative.

With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: a. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. b. Erb palsy is damage to the lower plexus. c. Parents of children with brachial palsy are taught to pick up the child from under the axillae. d. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

A If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start.

An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action would be to: a. Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. b. Continue to observe and make no changes until the saturations are 75%. c. Continue with the admission process to ensure that a thorough assessment is completed. d. Notify the parents that their infant is not doing well.

A Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained above 92%. Oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determination of fetal status.

1. The nurse is in the process of assessing the comfort level of her postpartum patient. Excess bleeding is not obvious; however, the new mother complains of deep, severe pelvic pain. The registered nurse (RN) has noted both skin and vital sign changes. This patient may have formed a(n) ________.

ANS: hematoma Hematomas occur as a result of bleeding into loose connective tissue while the overlying tissue remains intact. A hematoma can develop after either a spontaneous or an instrumental vaginal delivery when blood vessels are injured. They are most likely to occur in the vulvar, vaginal, or retroperitoneal areas. The nurse should examine the vulva for a bulging mass or skin discoloration and intervene as necessary.

A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. The nurse caring for the infant after birth should anticipate: a. Meconium aspiration, hypoglycemia, and dry, cracked skin. b. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome. c. Golden yellow- to green stained-skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat. d. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance.

A Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome would be consistent with a very premature infant. The skin may be meconium stained, but the infant would most likely have longer hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST would indicate hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

A careful review of the literature on the various recreational and illicit drugs reveals that: a. More longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs. b. Heroin and methadone cross the placenta; marijuana, cocaine, and phencyclidine (PCP) do not. c. Mothers should discontinue heroin use (detox) any time they can during pregnancy. d. Methadone withdrawal for infants is less severe and shorter than heroin withdrawal.

A Studies on the effects of marijuana and cocaine use by mothers are somewhat contradictory. More long-range studies are needed. Just about all these drugs cross the placenta, including marijuana, cocaine, and PCP. Drug withdrawal is accompanied by fetal withdrawal, which can lead to fetal death. Therefore, detoxification from heroin is not recommended, particularly later in pregnancy. Methadone withdrawal is more severe and more prolonged than heroin withdrawal.

A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents? a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b. "The drug keeps your baby from requiring too much sedation." c. "Surfactant is used to reduce episodes of periodic apnea." d. "Your baby needs this medication to fight a possible respiratory tract infection."

A Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With administration of artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with respiratory distress syndrome (RDS) is to stimulate production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol b. Heroin c. Cocaine d. Marijuana

A The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction. The infant may have a shrill cry and sleep cycle disturbances and present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.

In the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect: a. Hypovolemia and/or shock. b. Central nervous system injury. c. A nonneutral thermal environment. d. Pending renal failure.

A The nurse should suspect hypovolemia and/or shock. Other symptoms could include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary.

During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurse's best response would be: a. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." b. "You and your baby can be exposed to the human immunodeficiency virus (HIV) in your cats' feces." c. "It's just gross. You should make your husband clean the litter boxes." d. "Cat feces are known to carry Escherichia coli, which can cause a severe infection in both you and your baby."

A Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. About 30% of women who contract toxoplasmosis during gestation transmit the disease to their children. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. HIV is not transmitted by cats. Although suggesting that the woman's husband clean the litter boxes may be a valid statement, it is not appropriate, does not answer the client's question, and is not the nurse's best response. E. coli is found in normal human fecal flora. It is not transmitted by cats.

The most important nursing action in preventing neonatal infection is: a. Good handwashing. b. Separate gown technique. c. Isolation of infected infants. d. Standard Precautions.

A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting go b. Taking hold c. Taking in d. Taking on

ANS: A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. During the taking-hold phase the mother assumes responsibility for her own care and shifts her attention to the infant. In the taking-in phase the mother is primarily focused on her own needs. There is no taking-on phase of maternal adjustment.

Risk factors associated with necrotizing enterocolitis (NEC) include (Select all that apply): a. Polycythemia. b. Anemia. c. Congenital heart disease. d. Bronchopulmonary dysphasia. e. Retinopathy.

A, B, C Risk factors for NEC include asphyxia, respiratory distress syndrome, umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus, congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection. Bronchopulmonary dysphasia and retinopathy are not associated with NEC.

Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (Select all that apply): a. Amphetamine. b. Heroin. c. Nicotine. d. PCP. e. Morphine.

A, B, C, D Amphetamine, heroin, nicotine, and PCP are contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication that often is used to treat neonatal abstinence syndrome.

Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for (Select all that apply): a. Problems with thermoregulation b. Cardiac distress c. Hyperbilirubinemia d. Sepsis e. Hyperglycemia

A, C, D Thermoregulation problems, hyperbilirubinemia, and sepsis are all conditions related to immaturity and warrant close observation. After discharge the infant is at risk for rehospitalization related to these problems. AWHONN launched the Near-Term Infant Initiative to study the problem and ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications. Late-preterm infants are also at increased risk for respiratory distress and hypoglycemia.

17. The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by a. Subinvolution of the uterus b. Defective vascularity of the decidua c. Cervical lacerations d. Coagulation disorders

ANS: A Feedback A Late PPH may be the result of subinvolution of the uterus. Recognized causes of subinvolution included retained placental fragments and pelvic infection. B Although defective vascularity of the decidua may cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments. C Although cervical lacerations may cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments. D Although coagulation disorders may cause PPH, late PPH typically results from subinvolution of the uterus, pelvic infection, or retained placental fragments.

12. The nurse should expect medical intervention for subinvolution to include a. Oral methylergonovine maleate (Methergine) for 48 hours b. Oxytocin intravenous infusion for 8 hours c. Oral fluids to 3000 mL/day d. Intravenous fluid and blood replacement

ANS: A Feedback A Methergine provides long-sustained contraction of the uterus. B Oxytocin provides intermittent contractions. C There is no correlation between dehydration and subinvolution. D There is no indication that excessive blood loss has occurred.

5. Early postpartum hemorrhage is defined as a blood loss greater than a. 500 mL in the first 24 hours after vaginal delivery b. 750 mL in the first 24 hours after vaginal delivery c. 1000 mL in the first 48 hours after cesarean delivery d. 1500 mL in the first 48 hours after cesarean delivery

ANS: A Feedback A The average amount of bleeding after a vaginal birth is 500 mL. B The average amount of bleeding after a vaginal birth is 500 mL. C Early postpartum hemorrhage occurs in the first 24 hours, not 48 hours. Blood loss after a cesarean averages 1000 mL. D Early postpartum hemorrhage is within the first 24 hours. Late postpartum hemorrhage is 48 hours and later.

2. The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is a. Uterine atony b. Uterine inversion c. Vaginal hematoma d. Vaginal laceration

ANS: A Feedback A Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage. B Uterine inversion may lead to hemorrhage, but it is not the most likely source of this patient's bleeding. Furthermore, if the woman was experiencing a uterine inversion, it would be evidenced by the presence of a large, red, rounded mass protruding from the introitus. C A vaginal hematoma may be associated with hemorrhage. However, the most likely clinical finding would be pain, not the presence of profuse bleeding. D A vaginal laceration may cause hemorrhage; however, it is more likely that profuse bleeding would result from uterine atony. A vaginal laceration should be suspected if vaginal bleeding continues in the presence of a firm, contracted uterine fundus.

13. A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" The nurse's best response is: a. "That's meconium, which is your baby's first stool. It's normal." b. "That's transitional stool." c. "That means your baby is bleeding internally." d. "Oh, don't worry about that. It's okay."

ANS: A "That's meconium, which is your baby's first stool. It's normal" is an accurate statement and the most appropriate response. Transitional stool is greenish brown to yellowish brown and usually appears by the third day after initiation of feeding. "That means your baby is bleeding internally" is not accurate. "Oh, don't worry about that. It's okay" is not an appropriate statement. It is belittling to the father and does not educate him about the normal stool patterns of his daughter.

12. A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is: a. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." b. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." c. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." d. "Your baby will get cold stressed easily and needs to be bundled up at all times."

ANS: A "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him" is an accurate statement. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is loss of heat that occurs when a liquid is converted into a vapor. In the newborn heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss, but this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infant's temperature.

20. As related to the normal functioning of the renal system in newborns, nurses should be aware that: a. The pediatrician should be notified if the newborn has not voided in 24 hours. b. Breastfed infants likely will void more often during the first days after birth. c. "Brick dust" or blood on a diaper is always cause to notify the physician. d. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.

ANS: A A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants void less during this time because the mother's breast milk has not come in yet. Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if there is no apparent cause of bleeding. Weight loss from fluid loss may take 14 days to regain.

7. A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called: a. Acrocyanosis. c. Harlequin color. b. Erythema neonatorum. d. Vernix caseosa.

ANS: A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and appears intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.

In providing support to a new mother who must return to full-time employment 6 weeks after a vaginal delivery, which action by the nurse is best? a. Allow her to express her positive and negative feelings freely. b. Reassure her that she'll get used to leaving her baby. c. Discuss child care arrangements with her. d. Allow her to solve the problem on her own.

ANS: A Allowing the patient to express feelings will provide positive support in her process of maternal adjustment. Simply reassuring the mother blocks further communication and belittles her feelings. Discussing child care arrangements should wait until she has expressed herself. She should be instrumental in solving the problem; however, allowing her time to express her feelings and talk the problem over will assist her in making this decision.

Rho immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh-, baby Rh+ b. Mother Rh-, baby Rh- c. Mother Rh+, baby Rh+ d. Mother Rh+, baby Rh-

ANS: A An Rh- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. The other blood type combinations would not necessitate the use of Rhogam.

34. The nurse should immediately alert the physician when: a. The infant is dusky and turns cyanotic when crying. b. Acrocyanosis is present at age 1 hour. c. The infant's blood glucose level is 45 mg/dL. d. The infant goes into a deep sleep at age 1 hour.

ANS: A An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. Acrocyanosis is an expected finding during the early neonatal life. This is within normal range for a newborn. Infants enter the period of deep sleep when they are about 1 hour old.

31. 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.

ANS: A Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces.

29. A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: a. May occur with spontaneous vaginal birth. b. Happens only as the result of a forceps or vacuum delivery. c. Is present immediately after birth. d. Will gradually absorb over the first few months of life.

ANS: A Bleeding may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. The soft, irreducible fullness does not pulsate or bulge when the infant cries. Low forceps and other difficult extractions may result in bleeding. However, cephalhematomas can also occur spontaneously. The swelling may appear unilaterally or bilaterally and is usually minimal or absent at birth. It increases over the first 2 to 3 days of life. Cephalhematomas disappear gradually over 2 to 3 weeks. A less common condition results in calcification of the hematoma, which may persist for months.

A newborn assessment finding that would support the nursing diagnosis of postmaturity would be: a. loose skin. b. ruddy skin color. c. presence of vernix. d. absence of lanugo.

ANS: A Decreased placental function because of a prolonged pregnancy results in loss of subcutaneous tissue in the neonate, which is evidenced by loose skin. Ruddy skin color, presence of vernix, and absence of lanugo do not indicate a postmature infant.

2. 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.

ANS: A In normal infant respiration the chest and abdomen rise synchronously, and breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths are not deep with a regular rhythm.

The mother-baby nurse is able to recognize reciprocal attachment behavior. What does this refer to? a. The positive feedback an infant exhibits toward parents during the attachment process b. Behavior during the sensitive period when the infant is in the quiet alert stage c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d. Behavior by the infant during the sensitive period to elicit feelings of "falling in love" from the parents

ANS: A In this definition, reciprocal refers to the feedback from the infant during the attachment process.

11. Nurses can help parents deal with the issue and fact of circumcision if they explain a. the pros and cons of the procedure during the prenatal period. b. that the American Academy of Pediatrics (AAP) recommends that all newborn males be routinely circumcised. c. that circumcision is rarely painful and that any discomfort can be managed without medication. d. that the infant will likely be alert and hungry shortly after the procedure.

ANS: A Parents need to make an informed choice regarding newborn circumcision based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families should provide factual, unbiased information regarding circumcision and give parents opportunities to discuss the risks and benefits of the procedure. The AAP and other professional organizations note the benefits but stop short of recommendation for routine circumcision. Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures. Infants may or may not be alert and hungry after the procedure.

The most important reason to protect the preterm infant from cold stress is that: a. it could make respiratory distress syndrome worse. b. shivering to produce heat may use up too many calories. c. a low temperature may make the infant less able to digest nutrients. d. cold decreases circulation to the extremities.

ANS: A Rationale: A. Cold stress may interfere with the production of surfactant, making respiratory distress syndrome worse. B. Preterm infants do not shiver to produce heat. C. Cold stress does interfere with ability to eat, but not with the ability to digest the nutrients. D. Decrease circulation is not the top priority in caring for an infant with cold stress.

39. 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 c. Stepping b. Tonic neck d. Plantar grasp

ANS: A 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.

Which woman is most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Woman who is bottle-feeding her first child c. Primipara who delivered a 7-lb boy d. Woman who has started to breastfeed

ANS: A The discomfort of after pains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. After pains are particularly severe during breastfeeding, not bottle-feeding. The uterus of a primipara tends to remain contracted. The breastfeeding woman may have increased pain due to engorgement, but the multipara probably will have the most severe afterbirth pains.

16. 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.

ANS: A 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.

Which finding 12 hours after birth requires further assessment? a. The fundus is palpable two fingerbreadths above the umbilicus. b. The fundus is palpable at the level of the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: A The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The nurse needs to make further assessments. The other findings are within normal limits for the time period.

15. Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct? a. Ideally the visit is scheduled between 24 and 72 hours after discharge. b. Home visits are available in all areas. c. Visits are completed within a 30-minute time frame. d. Blood draws are not a part of the home visit.

ANS: A The home visit is ideally scheduled during the first 24 to 72 hours after discharge. This timing allows early assessment and intervention for problems with feedings, jaundice, newborn adaptation, and maternal-infant interaction. Because home visits are expensive, they are not available in all geographic areas. Visits are usually 60 to 90 minutes in length to allow enough time for assessment and teaching. When jaundice is found, the nurse can discuss the implications and check the transcutaneous bilirubin level or draw blood for testing.

27. The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is: a. Vision. c. Smell. b. Hearing. d. Taste.

ANS: A The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.

23. The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called: a. Vernix caseosa. c. Caput succedaneum. b. Surfactant. d. Acrocyanosis.

ANS: A This protection, vernix caseosa, is needed because the infant's skin is so thin. Surfactant is a protein that lines the alveoli of the infant's lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet that results in a blue coloring.

A woman's chart indicates she has a second-degree laceration. When assessing this patient, the nurse plans to observe which of the following structures? (Select all that apply.) a. Vaginal mucosa b. Perineal skin c. Peritoneal muscle d. Anus e. Rectum

ANS: A, B, C A second-degree perineal laceration includes vaginal mucosa, perineal skin, and peritoneal muscle. A third-degree laceration involves the anus, while a fourth-degree laceration includes the rectum.

1. Nurses use many different nonpharmacologic methods of pain management. Examples of nonpharmacologic pain management techniques include which of the following? (Select all that apply.) a. Swaddling b. Nonnutritive sucking (pacifier) c. Skin-to-skin contact with the mother d. Sucrose e. Acetaminophen

ANS: A, B, C, D These interventions are all appropriate nonpharmacologic techniques used to manage pain in neonates. Other interventions include soothing music, dim lighting and speaking to the infant in a quiet voice. Acetaminophen is a pharmacologic method of treating pain.

The nurse assesses a woman's episiotomy or perineal laceration using the acronym REEDA. What factors does this include? (Select all that apply.) a. Redness b. Edema c. Approximation d. Depth e. Discharge

ANS: A, B, C, E The acronym REEDA indicates redness, edema, ecchymosis or bruising, discharge, and approximation. Depth is not a consideration with this acronym.

1. Medications used to manage postpartum hemorrhage include (select all that apply) a. Pitocin b. Methergine c. Terbutaline d. Hemabate e. Magnesium sulfate

ANS: A, B, D Feedback Correct Pitocin, Methergine, and Hemabate are all used to manage PPH. Incorrect Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.

Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for which of the following? Select all that apply. a. Problems with thermoregulation b. Cardiac distress c. Hyperbilirubinemia d. Sepsis e. Hyperglycemia

ANS: A, C, D

3. Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics. Reasons for having this testing performed include (Select all that apply.) a. To prevent or reduce developmental delay b. Reassurance for concerned new parents c. Early identification and treatment d. To help the child communicate better e. To achieve one of the Healthy People 2020 goals

ANS: A, C, D, E These are all appropriate reasons for auditory screening of the newborn. Infants who do not pass should be rescreened. If they still do not pass the test, they should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in early intervention by 6 months of age. New parents are often anxious about this test and the impending results; however, it is not the reason for the screening to be performed. Auditory screening is usually done before hospital discharge. It is important for the nurse to ensure that the infant receive the appropriate testing and that the test is fully explained to the parents. For infants who are referred for further testing and follow-up, it is important for the nurse to provide further explanation and emotional support.

Many women given up smoking during pregnancy to protect the health of the fetus. The majority of women resumed smoking within the first 6 months postpartum. Factors that increase the likelihood of relapse include (Select all that apply.) a. living with a smoker. b. returning to work. c. weight concerns. d. successful breastfeeding. e. failure to breastfeed.

ANS: A, C, E Living with a smoker, weight concerns, and failure to breastfeed are all associated with a higher relapse rate after smoking cessation during pregnancy.

Because late preterm infants are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these infants are at increased risk for which of the following? (Select all that apply.) a. Sepsis b. Hyperglycemia c. Hyperbilirubinemia d. Cardiac distress e. Problems with thermoregulation

ANS: A, C, E Sepsis, hyperbilirubinemia, and problems with thermoregulation are all conditions that are related to immaturity and warrant close observation. After discharge, the infant is at risk for rehospitalization related to these problems. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) has launched the Near-Term Infant Initiative to study the problem and determine ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications. These infants are at risk for respiratory distress and hypoglycemia

2. The nurse should model and teach practices used to prevent sudden infant death syndrome. Which of the following do these include? (Select all that apply.) a. Fully supine position for all sleep b. Side-sleeping position as an acceptable alternative c. "Tummy time" for play d. Placing the infant's crib in the parents' room e. A soft mattress

ANS: A, D The back to sleep position is now recommended as the only position for every sleep period. Ideally the infant's crib should be placed in the parents' room. Side sleeping is not an acceptable alternative because of the possibility the infant will roll to the prone position. Tummy time helps develop muscles and reduces plagiocephaly. Mattresses in cribs should be firm.

10. Which woman is at greatest risk for early postpartum hemorrhage? a. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress b. A woman with severe preeclampsia on magnesium sulfate whose labor is being induced c. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor d. A primigravida in spontaneous labor with preterm twins

ANS: B Feedback A Although many causes and risk factors are associated with PPH, this scenario does not pose risk factors or causes of early PPH. B Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. C Although many causes and risk factors are associated with PPH, this scenario does not pose risk factors or causes of early PPH. D Although many causes and risk factors are associated with PPH, this scenario does not pose risk factors or causes of early PPH.

3. The nurse knows that a measure for preventing late postpartum hemorrhage is to a. Administer broad-spectrum antibiotics. b. Inspect the placenta after delivery. c. Manually remove the placenta. d. Pull on the umbilical cord to hasten the delivery of the placenta.

ANS: B Feedback A Broad-spectrum antibiotics will be given if postpartum infection is suspected. B If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage. C Manual removal of the placenta increases the risk of postpartum hemorrhage. D The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord. That can cause uterine inversion.

6. A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? a. Call for help. b. Assess the fundus for firmness. c. Take her blood pressure. d. Check the perineum for lacerations.

ANS: B Feedback A The first action should be to assess the fundus. B Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. C Assessing blood pressure is an important assessment with a bleeding patient, but the top priority is to control the bleeding. This is done by first assessing the fundus for firmness. D If bleeding continues in the presence of a firm fundus, lacerations may be the cause.

7. A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests a. Uterine atony b. Lacerations of the genital tract c. Perineal hematoma d. Infection of the uterus

ANS: B Feedback A The fundus is not firm with uterine atony. B Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. C A hematoma would be internal. Swelling and discoloration would be noticed, but bright bleeding would not be. D With an infection of the uterus there would be an odor to the lochia and systemic symptoms such as fever and malaise.

9. What instructions should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications? a. Palpate the fundus daily to ensure that it is soft. b. Notify the physician of any increase in the amount of lochia or a return to bright red bleeding. c. Report any decrease in the amount of brownish red lochia. d. The passage of clots as large as an orange can be expected.

ANS: B Feedback A The fundus should stay firm. B An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication. C The lochia should decrease in amount. D Large clots after discharge are a sign of complications and should be reported.

22. If the nurse suspects a uterine infection in the postpartum patient, she should assess the a. Pulse and blood pressure b. Odor of the lochia c. Episiotomy site d. Abdomen for distention

ANS: B Feedback A The pulse may be altered with an infection, but the odor of the lochia will be an earlier sign and more specific. B An abnormal odor of the lochia indicates infection in the uterus. C The infection may move to the episiotomy site if proper hygiene is not followed. D The abdomen becomes distended usually because of a decrease of peristalsis, such as after cesarean section.

4. A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000 g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. The nurse should a. Continue to massage the fundus. b. Notify the physician. c. Recheck vital signs. d. Insert a Foley catheter.

ANS: B Feedback A The uterine muscle can be overstimulated by massage, leading to uterine atony and rebound hemorrhage. B Treatment of excessive bleeding requires the collaboration of the physician and the nurses. Do not leave the patient alone. C The nurse should call the clinician while a second nurse rechecks the vital signs. D The woman has voided successfully, so a Foley catheter is not needed at this time.

18. The patient who is being treated for endometritis is placed in Fowler's position because it a. Promotes comfort and rest b. Facilitates drainage of lochia c. Prevents spread of infection to the urinary tract d. Decreases tension on the reproductive organs

ANS: B Feedback A This may not be the position of comfort, but it does allow for drainage. B Lochia and infectious material are eliminated by gravity drainage. C Hygiene practice aids in preventing the spread of infection to the urinary tract. D The position is to aid in the drainage of lochia and infectious material.

8. A postpartum patient is at increased risk for postpartum hemorrhage if she delivers a(n) a. 5-lb, 2-oz infant with outlet forceps b. 6.5-lb infant after a 2-hour labor c. 7-lb infant after an 8-hour labor d. 8-lb infant after a 12-hour labor

ANS: B Feedback A This woman is at risk for lacerations because of the forceps. B A rapid (precipitous) labor and delivery may cause exhaustion of the uterine muscle and prevent contraction. C This is a normal labor progression. Less than 3 hours is rapid and can produce uterine muscle exhaustion. D This is a normal labor progression. Less than 3 hours is a rapid delivery and can cause the uterine muscles not to contract.

41. Plantar creases should be evaluated within a few hours of birth because: a. The newborn has to be footprinted. b. As the skin dries, the creases will become more prominent. c. Heel sticks may be required. d. Creases will be less prominent after 24 hours.

ANS: B As the infant's skin begins to dry, the creases will appear more prominent, and the infant's gestation could be misinterpreted. Footprinting will not interfere with the creases. Heel sticks will not interfere with the creases. The creases will appear more prominent after 24 hours.

9. The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them: a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better."

ANS: B "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns" is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. Infants prefer low illumination and withdraw from bright light.

5. 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. Keep the infant in the nursery for the next 4 hours. d. Assess for other signs of inaccurate gestational age.

ANS: B A cap will prevent further heat loss from the head, and having the mother place the infant skin-to-skin should increase the infant's temperature. Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary. A slightly decreased temperature can be treated in the mother's room. This would be an excellent time for parent teaching on prevention of cold stress. There is no need for another gestational age assessment.

During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant? a. Anticipatory b. Formal c. Informal d. Personal

ANS: B A major task of the formal stage of role attainment is getting acquainted with the infant. The anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes. The informal stage begins once the parents have learned appropriate responses to their infant's cues. The personal stage is attained when parents feel a sense of harmony in their role.

When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is a. rectal suppositories. b. early and frequent ambulation. c. tightening and relaxing abdominal muscles. d. providing carbonated beverages.

ANS: B Activity can aid the movement of accumulated gas in the gastrointestinal tract so early, and frequent ambulation is the best option. Rectal suppositories can be helpful after distention occurs but do not prevent it. Tightening and relaxing the abdominal muscles is not related. Carbonated beverages may increase distention.

The preterm infant who should receive gavage feedings instead of being given a bottle is one who: a. Sometimes gags when a feeding tube is inserted. b. Has a sustained respiratory rate of 70 breaths/minute. c. Sucks on a pacifier during gavage feedings. d. Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/minute.

ANS: B An infant with an elevated respiratory rate may aspirate if fed by nipple.

To assess fundal contraction 6 hours after cesarean delivery, the nurse should a. palpate forcefully through the abdominal dressing. b. gently palpate, applying the same technique used for vaginal deliveries. c. place hands on both sides of the abdomen and press downward. d. rely on assessment of lochial flow rather than palpating the fundus.

ANS: B Assessment of the fundus is the same for both vaginal and cesarean deliveries; however, palpation should be gentle due to increased discomfort caused by the uterine incision. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. The fundus should be palpated and massaged to prevent bleeding.

To promote bonding and attachment immediately after delivery, what action by the nurse is most important? a. Allow the mother quiet time with her infant. b. Assist the mother in assuming an en face position with her newborn. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in feeding her baby.

ANS: B Assisting the mother in assuming an en face position with her newborn will support the bonding process. Quiet time with the infant is helpful but not as important as en face positioning. The mother has just delivered and is more focused on the infant; she will not be receptive to teaching at this time. This is a good time to initiate breastfeeding, but this is not as specific to bonding and attachment as the en face position.

A man calls the nurse's station stating that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, "She was never like this before the baby was born." What response by the nurse is best? a. Tell him to ignore the mood swings, as they will go away. b. Reassure him that this behavior is normal. c. Advise him to get immediate psychological help for her. d. Instruct him in the signs, symptoms, and duration of postpartum blues.

ANS: B Before providing further instructions, inform family members of the fact that postpartum blues are a normal process to allay anxieties and increase receptiveness to learning. Telling him the mood swings will go away is belittling his concerns. Postpartum blues are a normal process that is short lived; no medical intervention is needed. Client teaching is important; however, his anxieties need to be allayed before he will be receptive to teaching.

40. Infants in whom cephalhematomas develop are at increased risk for: a. Infection. c. Caput succedaneum. b. Jaundice. d. Erythema toxicum.

ANS: B Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalhematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas.

14. The transition period between intrauterine and extrauterine existence for the newborn: a. Consists of four phases, two reactive and two of decreased responses. b. Lasts from birth to day 28 of life. c. Applies to full-term births only. d. Varies by socioeconomic status and the mother's age.

ANS: B Changes begin right after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. The transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition regardless of age or type of birth. Although stress can cause variation in the phases, the mother's age and wealth do not disturb the pattern.

38. The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as: a. Enterohepatic circuit. c. Unconjugation of bilirubin. b. Conjugation of bilirubin. d. Albumin binding.

ANS: B Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. This is the route by which part of the bile produced by the liver enters the intestine, is reabsorbed by the liver, and then is recycled into the intestine. Unconjugated bilirubin is fat soluble. Albumin binding is to attach something to a protein molecule.

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

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

7. What action by the nurse is most important to prevent the kidnapping of newborns from the hospital? a. Instruct the mother not to give her infant to anyone except the one nurse assigned to her that day. b. Question anyone who is seen walking in the hallways carrying an infant. c. Allow no visitors in the maternity area except those who have identification bracelets. d. Restrict the amount of time infants are out of the nursery.

ANS: B Infants should be transported in the hallways only in their cribs. It is impossible for one nurse to be on call for one mother and baby for the entire shift, so the parents need to be able to identify the nurses who are working on the unit. Limiting visitors may cut the new family off from vital support. Infants should be with their parents the majority of the time.

Following a traumatic birth of a 10-pound infant, the nurse should assess: a. gestational age status. b. flexion of both upper extremities. c. infant's percentile on growth chart. d. blood sugar to detect hyperglycemia.

ANS: B Large infants are at risk for shoulder dystocia, which may result in clavicle fracture or damage to the brachial plexus. Gestational age or the infant's growth chart percentile will not provide data about potential injuries from a traumatic birth. A large infant is at risk for hypoglycemia.

4. 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. c. Tachycardia. b. Cold stress. d. Vasoconstriction.

ANS: B Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat warmer. Cold stress results in an increased respiratory rate and vasoconstriction.

Which of the following is most helpful in preventing premature birth? a. High socioeconomic status b. Adequate prenatal care c. Aid to Families With Dependent Children d. Women, Infants, and Children nutritional program

ANS: B Prenatal care is vital in identifying possible problems.

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

ANS: B ROP is thought to occur as a result of high levels of oxygen in the blood

Following the vaginal delivery of a macrosomic infant, the nurse should assess the infant for: a. Hyperglycemia. b. Clavicle fractures. c. Hyperthermia. d. An increase in red blood cells.

ANS: B Rationale: A. LGA infants are prone to hypoglycemia. B. Macrosomic infants may have a complicated delivery and are susceptible to birth injuries such as fractured clavicles, cephalohematomas, and brachial palsy. C. Hyperthermia is usually caused by inappropriate monitoring of infants under radiant heaters. D. An increase in RBCs is not an expected occurrence with LGA infants.

The postpartum woman who continually repeats the story of her labor, delivery, and recovery experiences is a. providing others with her knowledge of events. b. making the birth experience "real." c. taking hold of the events leading to her labor and delivery. d. accepting her response to labor and delivery.

ANS: B Reliving the birth experience makes the event real and helps the mother realize that the pregnancy is over and that the infant is born and is now a separate individual. She is in the taking-in phase, trying to make the birth experience seem real. This process meets her needs, not those of others.

25. An examiner who discovers unequal movement or uneven gluteal skin folds during the Ortolani maneuver would then: a. Tell the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. b. Alert the physician that the infant has a dislocated hip. c. Inform the parents and physician that molding has not taken place. d. Suggest that, if the condition does not change, surgery to correct vision problems may be needed.

ANS: B The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.

18. By knowing about variations in infants' blood count, nurses can explain to their clients that: a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord. b. The early high white blood cell (WBC) count is normal at birth and should decrease rapidly. c. Platelet counts are higher than in adults for a few months. d. Even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly.

ANS: B The WBC count is high the first day of birth and then declines rapidly. Delayed clamping of the cord results in an increase in hemoglobin and the red blood cell count. The platelet count essentially is the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the vitamin K deficiency is significant.

1. A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: a. Transition period. c. Organizational stage. b. First period of reactivity. d. Second period of reactivity.

ANS: B The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. The transition period is the phase between intrauterine and extrauterine existence. There is no such phase as the organizational stage. The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.

2. A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the ophthalmic ointment is to a. destroy an infectious exudate caused by Staphylococcus that could make the infant blind. b. prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. c. prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. d. prevent the infant's eyelids from sticking together and help the infant see.

ANS: B The ointment is used to prevent potential gonorrheal and chlamydial infection of the infant's eyes.

16. A nurse is observing a student nurse apply erythromycin ophthalmic ointment. What action by the student requires the nurse to intervene? a. Applies ointment in thin ribbon b. Applies ointment from outer canthus to inner canthus. c. Holds the tube horizontally while applying ointment d. Wipes excess ointment away after 1 minute.

ANS: B The ointment should be applied from inner to outer canthus. When the student does this incorrectly, the nurse should intervene. The other actions are appropriate.

If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the patient has a. been lying on her right side too long. b. a distended bladder. c. stretched ligaments that are unable to support the uterus. d. a normal involution.

ANS: B The presence of a full bladder will displace the uterus. This finding does not signify a problem with positioning or ligaments, nor is it an expected finding.

17. A student nurse is preparing an injection of vitamin K (aquaMEPHYTON). What action by the student shows good understanding of this procedure? a. Draws up 1.5 mg of solution b. Protects solution from light c. Finds landmark for subQ injection d. Administers directly after circumcision

ANS: B The solution of vitamin K is light-sensitive, so it should be protected from light. The dose is 0.5 to 1 mg. It is given IM and should be administered prior to a circumcision.

13. An unfortunate but essential role of the nurse is protecting the infant from abduction. Which statement regarding the profile of a potential abductor is the most accurate? a. Male gender b. A young woman who has had a previous pregnancy loss c. A middle-aged woman past childbearing age d. A female with a number of children of her own

ANS: B The woman is usually of childbearing age and may have had a previous pregnancy loss or has been unable to have a child of her own. She may want an infant to solidify the relationship with her husband or boyfriend and may have pretended to be pregnant. The women are usually familiar with the facility and its routines.

A nurse is examining a woman 2 months after delivery. The woman has lost 25 pounds. What action by the nurse is best? a. Counsel her on other weight loss measures. b. Ask her for a dietary recall for 3 days. c. Instruct her on exercises for faster loss. d. Explain that her weight loss is affecting her breast milk.

ANS: B This woman has lost too much weight for being 8 weeks postpartum. Gradual weight loss is recommended, so the nurse should first assess the woman's eating habits by conducting a nutrition history. From that information the nurse can help the woman plan a safer weight loss plan. She does not need to lose weight faster, so counseling her on weight loss measures or more exercise is not beneficial. Telling her she is harming her baby is not therapeutic and may make her less likely to listen to the nurse.

An infant delivered preterm at 28 weeks' gestation weighs 1200 g. Based on this information, the infant is designated as: a. SGA. b. VLBW. c. ELBW. d. Low birth weight at term.

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

33. Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: a. Increased pressure in the right atrium. b. Increased pressure in the left atrium. c. Decreased blood flow to the left ventricle. d. Changes in the hepatic blood flow.

ANS: B With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The pressure in the right atrium decreases at birth. It is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale.

42. 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.

Nurses must be aware of the conditions that increase the risk of hemorrhage, one of the most common complications of the puerperium. What are these conditions? (Select all that apply.) a. Primipara b. Rapid or prolonged labor c. Overdistention of the uterus d. Uterine fibroids e. Preeclampsia

ANS: B, C, D, E Rapid or prolonged labor, overdistention of the uterus, uterine fibroids, and preeclampsia are all risk factors for postpartum hemorrhage. Being a primipara is not a risk factor.

Infant Jill is preterm and on a respirator, with intravenous lines and much equipment around her when her parents come to visit for the first time. It is important for the nurse to: a. Suggest that the parents visit for only a short time to reduce their anxieties. b. Reassure the parents that the baby is progressing well. c. Encourage the parents to touch Jill. d. Discuss the care they will give Jill when she goes home.

ANS: C Touching the infant will increase the development of attachment.

24. When a woman is diagnosed with postpartum psychosis, one of the main concerns is that she may a. Have outbursts of anger b. Neglect her hygiene c. Harm her infant d. Lose interest in her husband

ANS: C Feedback A Although outbursts of anger is a symptom is attributable to PPD, the major concern would be the potential of harm to herself or to her infant. B Neglect of personal hygiene is symptom is attributable to PPD; however, the major concern would be the potential of harm to herself or to her infant. C Thoughts of harm to one's self or the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. D Although this patient is likely to lose interest in her spouse, the major concern is the potential of harm to herself or to her infant.

27. To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) a. Is the "baby blues" plus the woman has a visit with a counselor or psychologist b. Is more common among older, Caucasian women because they have higher expectations c. Is distinguished by pervasive sadness that lasts at least 2 weeks d. Will disappear on its own without outside help

ANS: C Feedback A PPD is more serious and persistent than postpartum baby blues. B PPD is more common among younger mothers and African-American mothers. C PPD is characterized by a persistent depressed state. The woman is unable to feel pleasure or love although she is able to care for her infant. She often experiences generalized fatigue, irritability, little interest in food and sleep disorders. D Most women need professional help to get through PPD, including pharmacologic intervention.

26. Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is a. A phobia b. Panic disorder c. Posttraumatic stress disorder (PTSD) d. Obsessive-compulsive disorder (OCD)

ANS: C Feedback A Phobias are irrational fears that may lead a person to avoid certain objects, events, or situations. B Panic disorders include episodes of intense apprehension, fear, and terror. Symptoms may manifest themselves as palpitations, chest pain, choking, or smothering. C In PTSD, women perceive childbirth as a traumatic event. They have nightmares and flashbacks about the event, anxiety, and avoidance of reminders of the traumatic event. D OCD symptoms include recurrent, persistent, and intrusive thoughts. The mother may repeatedly check and recheck her infant once he or she is born, even though she realizes that this is irrational. OCD is best treated with medications.

15. Which nursing measure is appropriate to prevent thrombophlebitis in the recovery period after a cesarean birth? a. Roll a bath blanket and place it firmly behind the knees. b. Limit oral intake of fluids for the first 24 hours. c. Assist the patient in performing gentle leg exercises. d. Ambulate the patient as soon as her vital signs are stable.

ANS: C Feedback A The blanket behind the knees will cause pressure and decrease venous blood flow. B Limiting oral intake will produce hemoconcentration, which may lead to thrombophlebitis. C Leg exercises and passive range of motion promote venous blood flow and prevent venous stasis while the patient is still on bed rest. D The patient may not have full return of leg movements, and ambulating is contraindicated.

21. A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that a. The infant is protected from infection by immunoglobulins in the breast milk. b. The infant is not susceptible to the organisms that cause mastitis. c. The organisms that cause mastitis are not passed to the milk. d. The organisms will be inactivated by gastric acid.

ANS: C Feedback A The mother is just producing the immunoglobulin from this infection, so it is not available for the infant. B Because of an immature immune system, infants are susceptible to many infections. However, this infection is in the breast tissue and is not excreted in the breast milk. C The organisms are localized in the breast tissue and are not excreted in the breast milk. D The organism will not get into the infant's gastrointestinal system.

19. Nursing measures that help prevent postpartum urinary tract infection include a. Promoting bed rest for 12 hours after delivery b. Discouraging voiding until the sensation of a full bladder is present c. Forcing fluids to at least 3000 mL/day d. Encouraging the intake of orange, grapefruit, or apple juice

ANS: C Feedback A The woman should be encouraged to ambulate early. B With pain medications, trauma to the area, and anesthesia, the sensation of a full bladder may be decreased. She needs to be encouraged to void frequently. C Adequate fluid intake of 2500 to 3000 ml/day prevents urinary stasis, dilutes urine, and flushes out waste products. D Juices such as cranberry juice can discourage bacterial growth.

14. The mother-baby nurse must be able to recognize what sign of thrombophlebitis? a. Visible varicose veins b. Positive Homans' sign c. Local tenderness, heat, and swelling d. Pedal edema in the affected leg

ANS: C Feedback A Varicose veins may predispose the woman to thrombophlebitis, but are not a sign. B A positive Homans' sign may be caused by a strained muscle or contusion. C Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of the inflammation. D Edema may be more involved than pedal.

Which of the following is a characteristic of a postterm infant who weighs 7 lb, 12 oz? a. A hematocrit level of 55%. b. Soft and supple skin. c. Lack of subcutaneous fat. d. An abundance of vernix caseosa.

ANS: C Rationale: A. The nails are usually long. B. The skin is wrinkled, cracked, and peeling. C. This postterm infant actually lost weight in utero, which is seen as loss of subcutaneous fat. D. There is no vernix caseosa.

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

ANS: C All three of these complications are common in LGA infants.

21. With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that: a. The newborn's cheeks are full because of normal fluid retention. b. The nipple of the bottle or breast must be placed well inside the baby's mouth because teeth have been developing in utero, and one or more may even be through. c. Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head. d. Bacteria are already present in the infant's GI tract at birth because they traveled through the placenta.

ANS: C Avoiding overfeeding can also reduce regurgitation. The newborn's cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices.

A nurse has taught a woman and partner about measures to improve sexuality after childbirth. Which statement by the partner demonstrates a need for further teaching? a. "We will use water-soluble lubricant before intercourse." b. "We can try having sex in the morning when we are rested." c. "Breastfeeding before sex will increase vaginal lubrication." d. "My wife will be more comfortable if she is on top."

ANS: C Breastfeeding just prior to intercourse may allow uninterrupted time while the baby sleeps afterward, although it will not increase vaginal lubrication. It also decreases the chance of leaking milk. The other statements show good understanding.

What is the best way for the nurse to promote and support the maternal-infant bonding process? a. Help the mother identify her positive feelings toward the newborn. b. Encourage the mother to provide all newborn care. c. Assist the family with rooming-in. d. Return the newborn to the nursery during sleep periods.

ANS: C Close and frequent interaction between mother and infant, which is facilitated by rooming-in, is important in the bonding process. This is often referred to as the mother-baby care or couplet care. Having the mother express her feelings is important, but it is not the best way to promote bonding. The mother needs time to rest and recuperate; she should not be expected to do all of the care. The mother needs to observe the infant during all stages so she will be aware of what to expect when they go home

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

ANS: C Crust is a normal part of healing and should not be removed. The diaper should be fastened loosely to prevent rubbing or pressure on the incision site. The normal yellowish exudate that forms over the site should be differentiated from the purulent drainage of infection. The only contraindication for petroleum jelly is the use of a PlastiBell.

A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurse's best response is a. "You have pitting edema in your ankles." b. "You have deep tendon reflexes rated 2+." c. "You have calf pain when I flexed your foot." d. "You have a 'fleshy' odor to your vaginal drainage."

ANS: C Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein thrombosis. It does not indicate edema, rate deep tendon reflexes, or describe the odor of lochia.

A nurse observes a mother on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. What action by the nurse is best? a. Realize that this situation is perfectly acceptable. b. Offer to hand the baby to the woman. c. Hand the baby to the woman. d. Explain "taking in" to the woman.

ANS: C During the "taking-in" phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. While acceptable, the nurse can still facilitate infant bonding. The woman is dependent and passive at this stage and may have difficulty making a decision so offering her the baby is not the best option. Women learn best in the taking-hold phase.

11. While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should: a. Notify the physician immediately. b. Move the newborn to an isolation nursery. c. Document the finding as erythema toxicum. d. Take the newborn's temperature and obtain a culture of one of the vesicles.

ANS: C Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites. This is a normal finding that does not require notification of the physician, isolation of the newborn, or any additional interventions.

10. With regard to lab tests and diagnostic tests in the hospital after birth, nurses should be aware that a. all states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b. federal law prohibits newborn genetic testing without parental consent. c. if genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. d. hearing screening is now mandated by federal law.

ANS: C If testing is done prior to 24 hours of age, genetic screening should be repeated when the infant is 1 to 2 weeks old. States all test for PKU and hypothyroidism, but other genetic defects are not universally covered. Federal law mandates newborn genetic screening; however, parents can decline testing. A waiver should be signed and a notation made in the infant's medical record. Federal law does not mandate screening for hearing problems; however, the majority of states have enacted legislation mandating newborn hearing screening. In the United States the majority (95%) of infants is screened for hearing loss prior to discharge from the hospital.

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

ANS: C In asymmetric intrauterine growth retardation, the head is normal in size but appears large because the infant's body is long and thin due to lack of subcutaneous fat.

8. The nurse administers vitamin K to the newborn for what 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.

ANS: C In order to promote clotting, vitamin K is necessary. However, the bacteria that synthesize vitamin K are not present in the newborn's intestinal tract, so the nurse administers it via injection. The maternal diet has no bearing on the amount of vitamin K found in the newborn. It is not involved in the synthesis of prothrombin. By day 8, normal newborns are able to produce their own vitamin K.

Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Postpartum hemorrhage and eclampsia b. Fever and increased blood pressure c. Postpartum hemorrhage and urinary tract infection d. Urinary tract infection and uterine rupture

ANS: C Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and eclampsia, blood pressure, or fever. The risk of uterine rupture decreases after the birth.

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

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

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

ANS: C Low body temperature indicates that additional calories are needed to maintain body temperature.

If the patient's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, the nurse should a. tell the physician immediately. b. have the laboratory draw blood for reanalysis. c. recognize that this is an acceptable range at this point. d. begin antibiotic therapy immediately.

ANS: C Marked leukocytosis occurs with WBC counts increasing to as high as 30,000/mm3 during labor and the immediate postpartum period. The WBC falls to normal within 6 days postpartum. No action is necessary.

37. A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is: a. Seen at age 3 days. b. The residue of a milk curd. c. Passed in the first 12 hours of life. d. Lighter in color and looser in consistency.

ANS: C Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, obstruction is suspected. Meconium stool is the first stool of the newborn and is made up of matter remaining in the intestines during intrauterine life. Meconium is dark and sticky.

A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after delivery because of a. increased estrogen. b. increased progesterone. c. decreased melanocyte-stimulating hormone. d. decreased human placental lactogen.

ANS: C Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after delivery. The linea nigra will eventually fade away for most women. Estrogen and progesterone levels decrease after delivery. Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation.

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

ANS: C Parents should be taught these signs of overstimulation so they will learn to adapt their care to the needs of their infant.

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

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

24. What marks on a baby's skin may indicate an underlying problem that requires notification of a physician? a. Mongolian spots on the back b. Telangiectatic nevi on the nose or nape of the neck c. Petechiae scattered over the infant's body d. Erythema toxicum anywhere on the body

ANS: C Petechiae (bruises) scattered over the infant's body should be reported to the pediatrician because they may indicate underlying problems. Mongolian spots are bluish-black spots that resemble bruises but fade gradually over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum is an appalling-looking rash, but it has no clinical significance and requires no treatment.

32. A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. d. This condition is also known as "breast milk jaundice."

ANS: C Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greater, which occurs when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice occurs during the first 24 hours of life. Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocytes, and must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids.

Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? a. Estrogen b. Progesterone c. Prolactin d. Human placental lactogen

ANS: C Prolactin levels in the blood increase progressively throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth. Estrogen and progesterone levels decrease markedly after expulsion of the placenta, reaching their lowest levels 1 week into the postpartum period. Human placental lactogen levels dramatically decrease after expulsion of the placenta.

Decreased surfactant production in the preterm lung is a problem because surfactant: a. Causes increased permeability of the alveoli. b. Provides transportation for oxygen to enter the blood supply. c. Keeps the alveoli open during expiration. d. Dilates the bronchioles, decreasing airway resistance.

ANS: C Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing.

6. 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. c. Hip dysplasia. b. Clubfoot. d. Webbing

ANS: C The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.

3. While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: a. 80 to 100 beats/min. c. 120 to 160 beats/min. b. 100 to 120 beats/min. d. 150 to 180 beats/min.

ANS: C The average infant heart rate while awake is 120 to 160 beats/min. The newborn's heart rate may be about 85 to 100 beats/min while sleeping. The infant's heart rate typically is a bit higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant cries.

35. While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: a. 80 to 100 beats/min. c. 120 to 160 beats/min. b. 100 to 120 beats/min. d. 150 to 180 beats/min.

ANS: C The average infant heart rate while awake is 120 to 160 beats/min. The newborn's heart rate may be about 85 to 100 beats/min while sleeping. The infant's heart rate typically is a bit higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant cries.

36. 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.

ANS: C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is necessary to activate blood clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors.

What documentation on a woman's chart on postpartum day 14 indicates a normal involution process? a. Moderate bright red lochial flow b. Breasts firm and tender c. Fundus below the symphysis and not palpable d. Episiotomy slightly red and puffy

ANS: C The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. The lochia should be changed by this day to serosa. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage.

3. When instructing parents on the correct use of a bulb syringe it is important include what information? a. Avoid suctioning the nares. b. Insert the compressed bulb into the center of the mouth. c. Suction the mouth first. d. Remove the bulb syringe from the crib when finished.

ANS: C The mouth should be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. The nasal passages should be suctioned one nostril at a time. The mouth should always be suctioned first. After compression of the bulb it should be inserted into one side of the mouth. If it is inserted into the center of the mouth, the gag reflex is likely to be initiated. The bulb syringe should remain in the crib so that it is easily accessible if needed again.

17. With regard to the newborn's developing cardiovascular system, nurses should be aware that: a. The heart rate of a crying infant may rise to 120 beats/min. b. Heart murmurs heard after the first few hours are cause for concern. c. The point of maximal impulse (PMI) often is visible on the chest wall. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).

ANS: C The newborn's thin chest wall often allows the PMI to be seen. The normal heart rate for infants who are not sleeping is 120 to 160 beats/min. However, a crying infant temporarily could have a heart rate of 180 beats/min. Heart murmurs during the first few days of life have no pathologic significance; an irregular heart rate past the first few hours should be evaluated further. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

To determine a preterm infant's readiness for nipple feeding, the nurse should assess the: a. Skin turgor. b. Bowel sounds. c. Current weight. d. Respiratory rate

ANS: D Coordination of suck, swallow, and breathing is a common task for preterm infants. The infant must have a respiratory rate less than 60 breaths/min before nipple feeding can be implemented; skin turgor, bowel sounds, and current weight are not indications for nipple feeding.

9. The student nurse asks why gloves are needed when handling a newborn because the newborn "hasn't been exposed to anything." What response by the nurse is best? a. It is part of standard precautions. b. It is hospital policy. c. Amniotic fluid and maternal blood pose risks to us. d. We are protecting the infant from our bacteria.

ANS: C With the possibility of transmission of viruses such as HBV and HIV through maternal blood and amniotic fluid, the newborn must be considered a potential contamination source until proved otherwise. As part of standard precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing. While this may be policy and is part of standard precautions, simply stating these facts does not convey any detailed information. The nurses are not protecting the infant from themselves.

The nurse explains to the nursing student that one mechanism for the diaphoresis and diuresis experienced during the early postpartum period is which of the following? a. Elevated temperature caused by postpartum infection b. Increased basal metabolic rate after giving birth c. Loss of increased blood volume associated with pregnancy d. Increased venous pressure in the lower extremities

ANS: C Within 12 hours of birth, women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid. An elevated temperature causes chills and may cause dehydration, not diaphoresis and diuresis. Diaphoresis and diuresis are not caused by an increase in the basal metabolic rate. Postpartal diuresis may be caused by the removal of increased venous pressure in the lower extremities

14. When the nurse is in the process of health teaching it is very important that he or she consider the family's cultural beliefs regarding child care. One of these beliefs includes that a. Arab women are anxious to breastfeed while still in the hospital. b. it is important to complement Asian parents about their new baby. c. women from India tie a black thread around the infant's waist. d. in the Korean culture the patient's mother is the primary caregiver of the infant.

ANS: C Women from India may tie a black thread around the infant's wrist, ankle, or waist to ward off evil spirits. This thread should not be removed by the nurse. Arab women are hesitant to breastfeed in the birth facility and wish to wait until they are home and their milk comes in. Asian parents may be uneasy when caregivers are too complementary about the baby or casually touch the infant's head. In the Korean culture, the husband's mother is the primary caregiver for the infant and the mother during the early weeks.

28. With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or postpartum depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent postpartum depression. The most accurate statement as related to these activities is to a. Stay home and avoid outside activities to ensure adequate rest. b. Be certain that you are the only caregiver for your baby in order to facilitate infant attachment. c. Keep feelings of sadness and adjustment to your new role to yourself. d. Realize that this is a common occurrence that affects many women.

ANS: D Feedback A Although it is important for the mother to obtain enough rest, she should not distance herself from family and friends. Her spouse or partner can communicate the best visiting times so that the new mother can obtain adequate rest. It is also important that she not isolate herself at home by herself during this time of role adjustment. B Even if breastfeeding, other family members can participate in the infant's care. If depression occurs, the symptoms can often interfere with mothering functions and this support will be essential. C The new mother should share her feelings with someone else. It is also important that she not overcommit herself or feel as though she has to be "superwoman." A telephone call to the hospital warm line may provide reassurance with lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary. D Should the new mother experience symptoms of the baby blues, it is important that she be aware that this is nothing to be ashamed of.

1. Which statement by a postpartum woman indicates that further teaching is not needed regarding thrombus formation? a. "I'll stay in bed for the first 3 days after my baby is born." b. "I'll keep my legs elevated with pillows." c. "I'll sit in my rocking chair most of the time." d. "I'll put my support stockings on every morning before rising."

ANS: D Feedback A As soon as possible, the woman should ambulate frequently. B The mother should avoid knee pillows because they increase pressure on the popliteal space. C Sitting in a chair with legs in a dependent position causes pooling of blood in the lower extremities. D Venous congestion begins as soon as the woman stands up. The stockings should be applied before she rises from the bed in the morning.

16. One of the first symptoms of puerperal infection to assess for in the postpartum woman is a. Fatigue continuing for longer than 1 week b. Pain with voiding c. Profuse vaginal bleeding with ambulation d. Temperature of 38° C (100.4° F) or higher on 2 successive days starting 24 hours after birth

ANS: D Feedback A Fatigue is a late finding associated with infection. B Pain with voiding may indicate a UTI, but it is not typically one of the earlier symptoms of infection. C Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection. D Postpartum or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or higher on 2 successive days of the first 10 postpartum days, starting 24 hours after birth.

13. If nonsurgical treatment for late postpartum hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a. Hysterectomy b. Laparoscopy c. Laparotomy d. D&C

ANS: D Feedback A Hysterectomy is not indicated for this condition. A hysterectomy is the removal of the uterus. B Laparoscopy is not indicated for this condition. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity. C Laparotomy is not indicated for this condition. A laparotomy is a surgical incision into the peritoneal cavity to explore the peritoneal cavity. D D&C allows examination of the uterine contents and removal of any retained placental fragments or blood clots.

23. Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? a. Postpartum depression b. Postpartum psychosis c. Postpartum bipolar disorder d. Postpartum blues

ANS: D Feedback A Postpartum depression is not the normal worries (blues) that many new mothers experience. Many caregivers believe that postpartum depression is underdiagnosed and underreported. B Postpartum psychosis is a rare condition that usually surfaces within 3 weeks of delivery. Hospitalization of the woman is usually necessary for treatment of this disorder. C Bipolar disorder is one of the two categories of postpartum psychosis, characterized by both manic and depressive episodes. D Postpartum blues or "baby blues" is a transient self-limiting disease that is believed to be related to hormonal fluctuations after childbirth.

11. When caring for a postpartum woman experiencing hypovolemic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is a. Absence of cyanosis in the buccal mucosa b. Cool, dry skin c. Diminished restlessness d. Decreased urinary output

ANS: D Feedback A The assessment of the buccal mucosa for cyanosis can be subjective in nature. B The presence of cool, pale, clammy skin is an indicative finding associated with hypovolemic shock. C Hypovolemic shock is associated with lethargy, not restlessness. D Hemorrhage may result in hypovolemic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised, and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion.

5. An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called: a. Lanugo. c. Nevus flammeus. b. Vascular nevi. d. Mongolian spots.

ANS: D A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair seen on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port-wine stain, is most frequently found on the face.

28. 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 c. Thermal b. Mechanical d. Psychologic

ANS: D A psychologic factor is not one of the essential factors in the initiation of breathing; the fourth factor is sensory. The sensory factors include handling by the provider, drying by the nurse, lights, smells, and sounds. Chemical factors are essential for the initiation of breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations. Prostaglandins are known to inhibit breathing, and clamping of the cord results in a drop in the level of prostaglandins. Mechanical factors also are necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. With birth the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. This also contributes to the initiation of breathing.

4. In providing and teaching cord care, what is an important principle? a. Cord care is done only to control bleeding. b. Alcohol is the only agent used for cord care. c. It takes a minimum of 24 days for the cord to separate. d. The process of keeping the cord dry will decrease bacterial growth.

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

In caring for the postterm infant, thermoregulation can be a concern, especially in an infant who also has a(n): a. Hematocrit level of 58%. b. WBC count of 15,000 cells/mm3. c. RBC count of 5 million. d. Blood glucose level of 25 mg/dl.

ANS: D Because glucose is necessary to produce heat, the infant who is also hypoglycemic will not be able to produce enough body heat.

The nurse caring for the postpartum woman understands that breast engorgement is caused by a. overproduction of colostrum. b. accumulation of milk in the lactiferous ducts and glands. c. hyperplasia of mammary tissue. d. congestion of veins and lymphatics.

ANS: D Breast engorgement is caused by the temporary congestion of veins and lymphatics, not overproduction of colostrum, accumulation of milk, or hyperplasia.

22. Which statement describing physiologic jaundice is incorrect? a. Neonatal jaundice is common, but kernicterus is rare. b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c. Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help. d. Breastfed babies have a lower incidence of jaundice.

ANS: D Breastfeeding is associated with an increased incidence of jaundice. Neonatal jaundice occurs in 60% of newborns; the complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to know how to assess for jaundice in their newborn.

6. When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to a. keep the state records updated. b. allow accurate statistical information. c. document the number of births. d. recognize and treat newborn disorders early.

ANS: D Early treatment of disorders will prevent morbidity associated with inborn errors of metabolism or other genetic conditions. Keeping and updating records are not the reasons for the testing.

Which maternal event is abnormal in the early postpartum period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

ANS: D For the first 3 days after childbirth, lochia is mostly red and is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume after birth. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days after birth, leading to flatulence and constipation. The new mother is hungry and thirsty because of energy used in labor and thirsty because of fluid restrictions during labor.

Which condition seen in the postpartum period is likely to require careful medical assessment? a. Varicosities of the legs b. Carpal tunnel syndrome c. Periodic numbness and tingling of the fingers d. Headaches

ANS: D Headaches in the postpartum period can have a number of causes, some of which deserve medical attention. Varicosities are common. Carpal tunnel syndrome is relieved in childbirth when the compression on the median nerve is lessened. Periodic numbness of the fingers usually disappears after birth unless carrying the baby aggravates the condition.

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

ANS: D Rationale: A. SGA infants are defined as below the 10th percentile in growth compared with other infants of the same gestational age. It is not defined by weight. B. Infants born prior to 38 weeks are defined as preterm. C. There are many causes of SGA babies. D. SGA infants are defined as below the 10th percentile in growth compared with other infants of the same gestational age.

A postpartum woman is unable to empty her bladder. What intervention would the nurse try last? a. Pouring water from a squeeze bottle over the woman's perineum b. Providing hot tea c. Asking the physician to prescribe analgesics d. Inserting a sterile catheter

ANS: D Invasive procedures usually are the last to be tried, especially with so many other simple methods available. Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early on. Hot tea or other fluids ad lib is an easy, noninvasive strategy that should be tried early on. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means could be tried first, but medications still come before insertion of a catheter.

A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As the nurse prepares her for discharge, she begins to cry. What action should the nurse take first? a. Assess her for pain. b. Point out how lucky she is to have a healthy baby. c. Explain that she is experiencing postpartum blues. d. Allow her time to express her feelings.

ANS: D Many women experience transient postpartum blues and need assistance in expressing their feelings. This condition affects 70% to 80% of new mothers. The nurse should allow time for the new mother to express herself. The nurse should not assume she is in pain at this point. Pointing out how lucky she is belittles her feelings. Patient teaching can be done later.

If rubella vaccine is indicated for a postpartum patient, instructions to the patient should include a. drinking plenty of fluids to prevent fever. b. no specific instructions. c. recommending that she stop breastfeeding for 24 hours after injection. d. explaining the risks of becoming pregnant within 1 month after injection.

ANS: D Potential risks to the fetus can occur if pregnancy results within 28 days after rubella vaccine administration. Drinking fluids will not prevent a fever. Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding.

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

ANS: D Rationale: A. Respiratory distress syndrome is seen in preterm infants. B. Dehydration is a concern for all infants and not specific for SGA. C. Promoting bonding is a concern for all infants and not specific for SGA. D. SGA infants have poor glycogen stores and are subject to hypoglycemia.

In comparison with the term infant, the preterm infant has: a. Few blood vessels visible though the skin. b. More subcutaneous fat. c. Well-developed flexor muscles. d. Greater surface area in proportion to weight.

ANS: D Rationale: A. This is an indication of a more mature infant. B. This is an indication of a more mature infant. C. This is an indication of a more mature infant. D. Preterm infants have greater surface area in proportion to their weight.

10. 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. c. Babinski reflex. b. Glabellar (Myerson) reflex. d. Moro reflex.

ANS: D The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar reflex is elicited by tapping on the infant's head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.

30. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

ANS: D The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. This is a particularly common condition for infants delivered by cesarean section. Surfactant is produced by the lungs, so aspiration is not a concern.

15. Which statement describing the first phase of the transition period is inaccurate? a. It lasts no longer than 30 minutes. b. It is marked by spontaneous tremors, crying, and head movements. c. It includes the passage of meconium. d. It may involve the infant's suddenly sleeping briefly.

ANS: D The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase. The first phase is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. In the first phase the newborn also produces saliva.

12. A nurse is responsible for teaching new parents about the hygienic care of their newborn. What information does the nurse include? a. Avoid washing the head for at least 1 week to prevent heat loss. b. Sponge bathe only until the cord has fallen off. c. Cleanse the ears and nose with cotton-tipped swabs, such as Q-tips. d. Water temperature should be at least 38° C.

ANS: D The ideal temperature of the bath water should be at least 38° C, or 100.4° F. The head can be washed. Tub baths may be initiated from birth. Ensure that the infant is fully immersed. Q-tips should not be used, because they may cause injury. A corner of a moistened washcloth should be twisted into shape so that it can be used to cleanse the ears and nose.

8. 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.

ANS: D The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes markedly after birth as a result of fetal respiration, which reduces pulmonary vascular resistance to the pulmonary blood flow and initiates a chain of cardiac changes that support the cardiovascular system. The infant relies on passive immunity received from the mother for the first 3 months of life. After the establishment of respirations, heat regulation is critical to newborn survival.

19. What infant response to cool environmental conditions is either not effective or not available to them? a. Constriction of peripheral blood vessels b. Metabolism of brown fat c. Increased respiratory rates d. Unflexing from the normal position

ANS: D The newborn's flexed position guards against heat loss because it reduces the amount of body surface exposed to the environment. The newborn's body is able to constrict the peripheral blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may rise to stimulate muscular activity, which generates heat.

A new father states, "I know nothing about babies," but he seems to be interested in learning. What action by the nurse is best? a. Continue to observe his interaction with the newborn. b. Tell him when he does something wrong. c. Show no concern, as he will learn on his own. d. Include him in teaching sessions.

ANS: D The nurse must be sensitive to the father's needs and include him whenever possible. As fathers take on care new role, the nurse should praise every attempt even if his early care is awkward. It is important to note the bonding process of the mother and the father, but that does not satisfy the expressed needs of the father. He should be encouraged by pointing out the correct procedures he does. Criticizing him will discourage him. The nurse should be sure to include him in all teaching sessions.

A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old brother is punching his mother on the back. What action by the nurse is best? a. Report the incident to the social services department. b. Advise the parents that the toddler needs to be reprimanded. c. Report to oncoming staff that the mother is not a good disciplinarian. d. Realize that this is a normal family adjusting to family change.

ANS: D The observed behaviors are normal variations of families adjusting to change. The nurse could provide suggestions on managing the adjustments. There is no need to report this one incident. The child does not need to be reprimanded, however; when the family is receptive the nurse could provide anticipatory guidance for this situation and help them problem solve. The nurse should avoid labeling the parents.

A postpartum patient asks, "Will these stretch marks go away?" The nurse's best response is a. "They will fade and be gone by your 6-week checkup." b. "No, unfortunately they will never fade away." c. "Yes, eventually they will totally disappear." d. "They will fade to silvery lines but won't disappear completely."

ANS: D The stretch marks will fade to silvery lines but will not disappear completely.

26. One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the: a. Incompletely developed neuromuscular system. b. Primitive reflex system. c. Presence of various sleep-wake states. d. Cerebellum growth spurt.

ANS: D The vulnerability of the brain likely is to the result of the cerebellum growth spurt. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant. The various sleep-wake states are not relevant.

A nurse has taught a woman how to do Kegel exercises. What statement by the patient shows good understanding? a. "I contract my thighs, buttocks, and abdomen." b. "I do 10 of these exercises every day." c. "I stand while practicing this new exercise routine." d. "I pretend that I am trying to stop the flow of urine midstream."

ANS: D The woman can pretend that she is attempting to stop the passing of gas, or the flow of urine midstream. This will replicate the sensation of the muscles drawing upward and inward. Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. Guidelines suggest that these exercises should be done 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. The best position to learn Kegel exercises is to lie supine with knees bent. A secondary position is on the hands and knees.

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? a. The woman is a gravida 2, para 2. b. The woman had a vacuum-assisted birth. c. The woman received epidural anesthesia. d. The woman has an episiotomy.

ANS: D These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which indicates these interventions, but that is not the only situation in which an episiotomy would be used, so this is not the best answer. Use of epidural anesthesia has no correlation with these orders.

A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse's most appropriate response is to ask the woman a. "Didn't you like your lunch?" b. "Does your doctor know that you are planning to eat that?" c. "What is that anyway?" d. "I'll warm the soup in the microwave for you."

ANS: D This statement shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. Asking if the provider knows she is eating this soup is insensitive.

Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the provider of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder.

ANS: D Urinary retention can cause overdistention of the urinary bladder, which lifts and displaces the uterus. Nursing actions need to be implemented before notifying the provider. Blood pressure, pulse, and lochia are important to assess, but first the nurse assesses the bladder so corrective action can be taken if needed.

1. Should a postpartum complication such as hemorrhage occur, the nursing staff will spring into action to ensure that patient safety needs are met. This level of activity is very reassuring to both the new mother and her family members as they can see that the patient is receiving the best care. Is this statement true or false?

ANS: F On the contrary, the unusual activity of the hospital staff may make the mother and her family very anxious. Keeping the family informed is one of the most effective ways of reducing unnecessary anxiety. A comment such as, "I know that all of this activity must be frightening. She is bleeding a little more than we would like, and we are doing several things at once" would be very helpful.

2. Pulmonary embolism (PE) is a serious complication of deep vein thrombosis (DVT) and the leading cause of maternal mortality. As many as 15% to 25% of all DVTs lead to PEs if not recognized and treated. Is this statement true or false?

ANS: T This statement is correct. PE occurs with fragments of a blood clot dislodge and are carried to the lungs. Treatment is aimed at dissolving the clot and maintaining pulmonary circulation. Oxygen is used to decrease hypoxia, and narcotic analgesics are given to reduce pain and apprehension.

What are appropriate nursing measures to help relieve a preterm infants pain during a painful procedure? (CHOOSE ALL THAT APPLY.) A. Swaddling the infant B. Use a pacifier dipper in sucrose C. Administering a prescribed sedative D. Keeping a hand near the face to be used for sucking

Answer: A, B, & D

The nurse is aware that because of excess blood loss during delivery, the woman is at risk for hypovolemic shock. What is one of the earliest signs that shock is occuring? A. Woman is anxious and confused B. Decrease in urinary output C. Tachycardia D. Increase in respirations

Answer: C Rationale: A. This is a later sign. B. This is a later sign. C. Tachycardia is one of the earliest signs of shock as the circulating blood decreases. Even gradual increases in pulse rates should be noted. D. This is a later sign.

A sign of thrombophlebitis is A. Visible varicose veins B. Negative Homan's sign C. Local tenderness, warmth, and redness D. Pedal edema in the affected leg

Answer: C Rationale: A. Varicose veins will put the woman at high risk for developing thrombophlebitis, but they are not a sign. B. A positive Homan's sign can be a screening test for the possibility of thrombophlebitis. C. These characteristics are classic signs of thrombophlebitis that appear at the site of the inflammation. D. Edema will occur with thrombophlebitis, but answer choice "C" is a more complete answer.

The nurse knows that late postpartum hemorrhage can be prevented by A. Administering broad-spectrum antibiotics B. Inspecting the placenta after delivery C. Manually removing the placenta D. Pulling on the umbilical cord to hasten the delivery of the the placenta

Answer: B Rationale: A. Broad-spectrum antibiotics will be given if postpartum infection is suspected. B. If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage. C. Manual removal of the placenta increases the risk of postpartum hemorrhage. D. The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord, which can cause uterine inversion.

A preterm infant with respiratory difficulties should be placed in which position to facilitate drainage? A. Supine B. Prone C. Trendelenburg D. Fowler's

Answer: B Rationale: A. Supine position can be used later as the infant matures and has improved respiratory efforts. B. The prone position is not recommended for normal newborn infants, because it is associated with an increased incidence of sudden infant death syndrome. However, the prone position for a preterm infant can facilitate drainage of respiratory secretions and regurgitated feedings. Prone positions also increase oxygenation and lung compliance and reduce energy expenditure. C. Trendelenburg position would increase the energy expenditure by making it more difficult for the infant to breath. D. Fowler's position would not assist with the drainage of secretions.

A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000-gram infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find and the rubra lochia remains heavy. The nurse should A. continue to massage the fundus B. notify the physician C. recheck vital signs D. insert a Foley catheter

Answer: B Rationale: A. The uterine muscle can be overly stimulated by massage, leading to uterine atony and rebound hemorrhage. B. Treatment of excessive bleeding requires the collaboration of the physician and the nurses. The nurse should call the clinician while a second nurse rechecks the vital signs. Do not leave the patient alone. C. Vital signs need to be rechecked. One nurse should call the clinician while a second nurse rechecks the vital signs. D. The woman has voided successfully, so a Foley catheter is not needed at this time.

The nurse is assessing a woman that delivered 1 hour ago. She noted the uterus is boggy. What should the first interventions be for this woman? A. Notify the nurse-midwife B. Massage the uterus until firm C. Administer Pitocin D. Have the woman void

Answer: B Rationale: A. If massage is not successful, then the primary care given should be notified. B. To manage uterine atony, the first intervention should be to massage the uterus. C. Prescribed Pitocin may be given if the nurse is unsuccessful in firming the uterus by massage. D. If the uterus was displaced and there were signs of a full bladder, then emptying the bladder may be the proper intervention. The question did not give enough information to choose this answer.

One technique to measure a preterm infants output is to A. Attach a plastic bag to the perineum to collect the urine B. Lay a diaper under the infant and weigh the diaper when changing C. Weigh the diaper when changed D. Insert a Foley catheter

Answer: C Rationale: A. Attaching a bag to the perineum can cause skin breakdown and the potential for infection. B. Laying the diaper under the infant may not collect all of the urine. C. The diaper is weighed prior to putting it on the infant and when it is taken off. The fluid loss is 1 mL = 1 g of weight. D. Foley catheters will increase the risk of infections.

Which nursing measure is appropriate to prevent thrombophlebitis in the recovery period following a c-section birth? A. Roll a bath blanket and place it firmly behind the knees B. Limit oral intake of fluids for the first 24 hours C. Assist woman in performing leg exercises every 2 hours D. Ambulate the woman as soon as her vital signs are stable

Answer: C Rationale: A. The blanket behind the knees will cause pressure and decrease venous blood flow. B. Limiting oral intake will produce hemoconcentration that may led to thrombophlebitis. C. Leg exercises promote venous blood flow and prevent venous stasis while the woman is still on bed rest. D. The woman may not have full return of leg movements and ambulating is contraindicated.

Which woman is at greater risk for early postpartum hemorrhage? A. Gravida 1 who delivered a 7-pound baby boy B. Gravida 3 who delivered a 5-pound baby girl C. Gravida 1 who delivered mature twins D. Gravida 2 who delivered a premature baby girl

Answer: C Rationale: A. Overdistention of the uterus is a major predisposing factor in early postpartum hemorrhage. A 7-pound baby does not normally overdistend the uterus. B. Overdistention of the uterus is a major predisposing factor in early postpartum hemorrhage. This baby is not considered large enough to overdistend the uterus. C. Overdistention of the uterus is a major predisposing factor in early postpartum hemorrhage. D. Overdistention of the uterus is a major predisposing factor in early postpartum hemorrhage. A preterm baby is not normally considered large enough to overdistend the uterus.

What temperature indicates the presence of postpartum infection? A. 99.6 F in the first 48 hours B. 100 F in 2 days postpartum C. 100.4 in the first 24 hours D. 100.8 F on the 2nd and 3rd postpartum days

Answer: D Rationale: A. A temperature elevation greater than 100.4 °F on 2 postpartum days, not including the first 24 hours, meets the criteria for infection. B. A temperature elevation greater than 100.4 °F on 2 postpartum days, not including the first 24 hours, meets the criteria for infection. C. A temperature elevation greater than 100.4 °F on 2 postpartum days, not including the first 24 hours, meets the criteria for infection. D. A temperature elevation greater than 100.4 °F on 2 postpartum days, not including the first 24 hours, meets the criteria for infection.

The name of the transient, self-limiting, mood disorder that affects new mothers after childbirth is ________.

Answer: Postpartum blues

Infants born before surfactant production are at risk for _________.

Answer: Respiratory distress syndrome

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests _________.

Answer: lacerations of the genital tract

ABO incompatibility also causes pathologic jaundice in the newborn. Mothers with what blood type have natural antibodies to types A and B blood? A. It does not matter what blood type the mother is B. Type O C. Type A D. Type B

B ABO incompatibility also causes pathologic jaundice. Mothers with type O blood have natural antibodies to types A and B blood. The antibodies cross the placenta and cause hemolysis of fetal red blood cells. However, the destruction is much less severe than with Rh incompatibility and causes milder signs.

The nurse is monitoring the feedings of the infant with hyperbilirubinemia. The purpose of ensuring that the infant receives feedings every 2 to 3 hours, whether by breast or bottle is to A. prevent hyperglycemia. B. provide fluids and protein. C. decrease gastrointestinal motility. D. prevent rapid emptying of the bilirubin from the bowel.

B Frequent feedings prevent hypoglycemia, provide protein to maintain the albumin level in the blood, and promote gastrointestinal motility and prompt removal of bilirubin in the stools.

The goal of treatment of the infant with phenylketonuria (PKU) is to: a. Cure mental retardation. b. Prevent central nervous system (CNS) damage, which leads to mental retardation. c. Prevent gastrointestinal symptoms. d. Cure the urinary tract infection

B CNS damage can occur as a result of toxic levels of phenylalanine. No known cure exists for mental retardation. Digestive problems are a clinical manifestation of PKU. PKU does not involve any urinary problems.

To care adequately for infants at risk for neonatal bacterial infection, nurses should be aware that: a. Congenital infection progresses more slowly than does nosocomial infection. b. Nosocomial infection can be prevented by effective handwashing; early-onset infections cannot. c. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher. d. The clinical sign of a rapid, high fever makes infection easier to diagnose.

B Handwashing is an effective preventive measure for late-onset (nosocomial) infections because these infections come from the environment around the infant. Early-onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract and progress more rapidly than do nosocomial (late-onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Clinical signs of neonatal infection are nonspecific and are similar to those of noninfectious problems, thus making diagnosis difficult.

An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: a. Birth injury. b. Hypoglycemia. c. Hypocalcemia. d. Seizures.

B Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.

With regard to small for gestational age (SGA) infants and intrauterine growth restrictions (IUGR), nurses should be aware that: a. In the first trimester diseases or abnormalities result in asymmetric IUGR. b. Infants with asymmetric IUGR have the potential for normal growth and development. c. In asymmetric IUGR weight is slightly more than SGA, whereas length and head circumference are somewhat less than SGA. d. Symmetric IUGR occurs in the later stages of pregnancy.

B IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th percentile. Infants with asymmetric IUGR have the potential for normal growth and development

To provide optimal care of infants born to mothers who are substance abusers, nurses should be aware that: a. Infants born to addicted mothers are also addicted. b. Mothers who abuse one substance likely will use or abuse another, thus compounding the infant's difficulties. c. The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself. d. No laboratory procedures are available that can identify the intrauterine drug exposure of the infant.

B Multiple substance use (even just alcohol and tobacco) makes it difficult to assess the problems of the exposed infant, particularly with regard to withdrawal manifestations. Infants of substance-abusing mothers may have some of the physiologic signs but are not addicted in the behavioral sense. "Drug-exposed newborn" is a more accurate description than "addict." The NNNS is designed to assess the neurologic, behavioral, and stress/abstinence function of the neonate. Newborn urine, hair, or meconium sampling may be used to identify an infant's intrauterine drug exposure.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: a. Hypertonia, tachycardia, and metabolic alkalosis. b. Abdominal distention, temperature instability, and grossly bloody stools. c. Hypertension, absence of apnea, and ruddy skin color. d. Scaphoid abdomen, no residual with feedings, and increased urinary output.

B Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.

A newborn was admitted to the neonatal intensive care unit after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurse's most appropriate action would be to: a. Wait quietly at the newborn's bedside until the parents come closer. b. Go to the parents, introduce himself or herself, and gently encourage the parents to come meet their infant; explain the equipment first, and then focus on the newborn. c. Leave the parents at the bedside while they are visiting so they can have some privacy. d. Tell the parents only about the newborn's physical condition, and caution them to avoid touching their baby.

B The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents "see" the infant, rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant's condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant's appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents only about the newborn's physical condition and cautioning them to avoid touching their baby is an inappropriate action.

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of: a. Gonorrhea. b. Congenital syphilis. c. Herpes simplex virus infection. d. Human immunodeficiency virus.

B The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities.

Meconium-stained amniotic fluid occurs in 10% to 15% of births. Meconium aspiration syndrome (MAS) is a condition in which there is obstruction, air trapping, and chemical pneumonitis caused by meconium in the infant's lungs. MAS develops in what percentage of those infants? A. 1% B. 5% C. 25% D. 50%

B. 5% MAS occurs in 5% of cases. It most often occurs when hypoxia causes increased peristalsis of the intestines and relaxation of the anal sphincter before or during labor. MAS develops when meconium in the amniotic fluid enters the lungs during fetal life or at birth.

Transitory tachypnea of the newborn (TTN) is thought to occur as a result of A. a lack of surfactant. B. hypoinflation of the lungs. C. delayed absorption of fetal lung fluid. D. a slow vaginal delivery associated with meconium-stained fluid.

C Delayed absorption of fetal lung fluid is thought to be the reason for TTN. A lack of surfactant is seen in preterm infants. Risk factors include cesarean birth without labor, precipitous delivery, male gender, perinatal asphyxia, and maternal diabetes or asthma. A slow vaginal delivery with meconium-stained fluid is not a risk factor for TTN.

Signs of newborn drug exposure in utero usually begin how soon after birth? A. 2 hours B. 12 hours C. 24 to 72 hours D. I week later

C Signs develop during the first 24 to 72 hours after birth, but may not occur for up to 4 weeks, depending on the specific drug and the time of the mother's last use.

Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC: a. Early enteral feedings b. Exchange transfusion c. Breastfeeding d. Prophylactic probiotics

C A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohn's disease, and celiac illness. The neonatal intensive care unit nurse can be very supportive of the mother in terms of providing her with equipment to pump breast milk, ensuring privacy, and encouraging skin-to-skin contact with the infant. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.

As related to central nervous system injuries that could occur to the infant during labor and birth, nurses should be aware that: a. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant. b. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia. c. In many infants signs of hemorrhage in a full-term infant are absent and are diagnosed only through laboratory tests. d. Spinal cord injuries almost always result from forceps-assisted deliveries.

C Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomography scan may reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants it is a result of hypoxia. Spinal cord injuries are almost always from breech births; they are rare today because cesarean birth often is used for breech presentation.

An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? a. Rapid bolusing of the entire amount in 15 minutes b. Warm cloths to the abdomen for the first 10 minutes c. Slow, small, warm bolus feedings over 30 minutes d. Cold, medium bolus feedings over 20 minutes

C Feedings by gravity are done slowly over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing of the entire amount in 15 minutes would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Warm cloths to the abdomen for the first 10 minutes would not be appropriate because it is not a thermoregulated environment. Additionally, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

The most common cause of pathologic hyperbilirubinemia is: a. Hepatic disease. b. Postmaturity. c. Hemolytic disorders in the newborn. d. Congenital heart defect.

C Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause. Prematurity would be a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.

As related to the eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that: a. Infants will stay in the neonatal intensive care unit (NICU) until they are ready to go home. b. Once discharged to home, the high risk infant should be treated like any healthy term newborn. c. Parents of high risk infants need special support and detailed contact information. d. If a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.

C High risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high risk infant should spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Just because high risk infants are discharged does not mean that they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

Infants of mothers with diabetes (IDMs) are at higher risk for developing: a. Anemia. c. Respiratory distress syndrome. b. Hyponatremia. d. Sepsis.

C IDMs are at risk for macrosomia, birth injury, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. They are not at risk for anemia, hyponatremia, or sepsis.

The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. This intervention: a. Is adopted from classical British nursing traditions. b. Helps infants with motor and central nervous system impairment. c. Helps infants to interact directly with their parents and enhances their temperature regulation. d. Gets infants ready for breastfeeding.

C Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent's bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits.

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: a. Pharmacologic treatment. b. Reduction of environmental stimuli. c. Neonatal abstinence syndrome scoring. d. Adequate nutrition and maintenance of fluid and electrolyte balance.

C Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates central nervous system (CNS), metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays CNS disturbances. Poor feeding is one of the gastrointestinal symptoms common to this client population. Fluid and electrolyte balance must be maintained and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.

For clinical purposes, preterm and post-term infants are defined as: a. Preterm before 34 weeks if appropriate for gestational age (AGA) and before 37 weeks if small for gestational age (SGA). b. Post-term after 40 weeks if large for gestational age (LGA) and beyond 42 weeks if AGA. c. Preterm before 37 weeks, and post-term beyond 42 weeks, no matter the size for gestational age at birth. d. Preterm, SGA before 38 to 40 weeks, and post-term, LGA beyond 40 to 42 weeks.

C Preterm and post-term are strictly measures of time—before 37 weeks and beyond 42 weeks, respectively—regardless of size for gestational age.

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

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

In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: a. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. b. Two thirds of newborns with fetal alcohol syndrome (FAS) are boys. c. Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. d. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

C Some learning problems do not become evident until the child is at school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.

An infant is being discharged from the neonatal intensive care unit after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infant's mother asks the nurse whether her baby will meet developmental milestones on time, as did her son who was born at term. The nurse's most appropriate response is: a. "Your baby will develop exactly like your first child did." b. "Your baby does not appear to have any problems at the present time." c. "Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing." d. "Your baby will need to be followed very closely."

C The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant's responses are evaluated accordingly against the norm expected for the corrected age of the infant. Although it is impossible to predict with complete accuracy the growth and development potential of each preterm infant, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. The growth and developmental milestones are corrected for gestational age until the child is approximately 2.5 years old. Stating that the baby does not appear to have any problems at the present time is inaccurate. Development will need to be evaluated over time.

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 The infant has minimal to no fat stores. During times of cold stress the skin will become mottled, and acrocyanosis will develop, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse's role is to observe the infant frequently to prevent heat loss and respond quickly if signs and symptoms occur. The respiratory rate increases followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.

A plan of care for an infant experiencing symptoms of drug withdrawal should include: a. Administering chloral hydrate for sedation. b. Feeding every 4 to 6 hours to allow extra rest. c. Swaddling the infant snugly and holding the baby tightly. d. Playing soft music during feeding.

C The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music) because this will increase activity and potentially increase CNS irritability.

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds: a. "It is an eye ointment to help your baby see you better." b. "It is to protect your baby from contracting herpes from your vaginal tract." c. "Erythromycin is given prophylactically to prevent a gonorrheal infection." d. "This medicine will protect your baby's eyes from drying out over the next few days."

C With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is not used for eye lubrication.

The infant of a diabetic mother is hypoglycemic. What type of feeding should be instituted first? A. Glucose water in a bottle B. D5W intravenously C. Formula via nasogastric tube D. Breastfeeding, or breast milk/formula in a bottle

D Breastfeeding or breast milk/formula by bottle should be given first to raise the blood glucose level not glucose water. Oral feedings are tried first, and intravenous lines may be initiated if the hypoglycemia continues. Formula would be administered via bottle, not by tube feeding.

Four hours after the delivery of a healthy neonate of an insulin-dependent diabetic mother, the baby appears jittery and has rapid respirations and poor muscle tone. Which nursing action has top priority? A. Start an intravenous line with D5W. B. Notify the clinician state. C. Document the event in the nurses' notes. D. Test for blood glucose level.

D These symptoms are signs of hypoglycemia in the newborn, and the nurse should first test the blood glucose level according to agency's policy, treat symptoms with standing orders protocol, and then notify the physician with the results.

On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask whether they can hold their infant during his next gavage feeding. Given that this newborn is physiologically stable, what response would the nurse give? a. "Parents are not allowed to hold infants who depend on oxygen." b. "You may hold only your baby's hand during the feeding." c. "Feedings cause more physiologic stress, so the baby must be closely monitored. Therefore, I don't think you should hold the baby." d. "You may hold your baby during the feeding."

D "You may hold your baby during the feeding" is an accurate statement. Parental interaction via holding is encouraged during gavage feedings so that the infant will associate the feeding with positive interactions. Nasal cannula oxygen therapy allows for easier feedings and psychosocial interactions. The parent can swaddle the infant during gavage feedings to help the infant associate the feeding with positive interactions. Some parents like to do kangaroo care while gavage feeding their infant. Swaddling or kangaroo care during feedings provides positive interactions for the infant.

With regard to hemolytic diseases of the newborn, nurses should be aware that: a. Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother. b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. c. Exchange transfusions frequently are required in the treatment of hemolytic disorders. d. The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.

D An indirect Coombs' test may be performed on the mother a few times during pregnancy. Only the Rh-positive child of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

When providing an infant with a gavage feeding, which of the following should be documented each time? a. The infant's abdominal circumference after the feeding b. The infant's heart rate and respirations c. The infant's suck and swallow coordination d. The infant's response to the feeding

D Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained before feeding. However, the infant's response to the feeding is more important. Some older infants may be learning to suck, but the important factor to document would be the infant's response to the feeding (including attempts to suck).

What bacterial infection is definitely decreasing because of effective drug treatment? a. Escherichia coli infection b. Candidiasis c. Tuberculosis d. Group B streptococcal infection

D Penicillin has significantly decreased the incidence of group B streptococcal infection. E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Tuberculosis is increasing in the United States and Canada. Candidiasis is a fairly benign fungal infection.

HIV may be perinatally transmitted: a. Only in the third trimester from the maternal circulation. b. From the use of unsterile instruments. c. Only through the ingestion of amniotic fluid. d. Through the ingestion of breast milk from an infected mother.

D Postnatal transmission of HIV through breastfeeding may occur. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. This is highly unlikely because most health care facilities must meet sterility standards for all instrumentation. Transmission of HIV may occur during birth from blood or secretions.

Human immunodeficiency virus (HIV) may be perinatally transmitted: a. Only in the third trimester from the maternal circulation. b. By a needlestick injury at birth from unsterile instruments. c. Only through the ingestion of amniotic fluid. d. Through the ingestion of breast milk from an infected mother.

D Postnatal transmission of HIV through breastfeeding may occur. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases.

When assessing the preterm infant the nurse understands that compared with the term infant, the preterm infant has: a. Few blood vessels visible through the skin. b. More subcutaneous fat. c. Well-developed flexor muscles. d. Greater surface area in proportion to weight.

D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.

While completing a newborn assessment, the nurse should be aware that the most common birth injury is: a. To the soft tissues. b. Caused by forceps gripping the head on delivery. c. Fracture of the humerus and femur. d. Fracture of the clavicle.

D The most common birth injury is fracture of the clavicle (collarbone). It usually heals without treatment, although the arm and shoulder may be immobilized for comfort.

Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a. Delayed growth and development b. Ineffective infant feeding pattern c. Ineffective thermoregulation d. Risk for infection

D The nurse needs to understand that decreased immune functioning increases the risk for infection. Growth and development, thermoregulation, and feeding may be affected, although only indirectly.

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborn's distress is most likely to be: a. Hypoglycemia. b. Respiratory distress syndrome. c. Phrenic nerve injury. d. Sepsis.

D The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis.

A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse's most appropriate action is to: a. Leave the infant in the room with the mother. b. Take the infant immediately to the nursery. c. Perform a gestational age assessment to determine whether the infant is large for gestational age. d. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.

D This infant is macrosomic (more than 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. Observation may occur in the nursery or in the mother's room, depending on the condition of the fetus. Regardless of gestational age, this infant is macrosomic.

Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are: a. Suffering from sleep or wakeful apnea. b. Experiencing severe swings in blood pressure. c. Trying to maintain a neutral thermal environment. d. Breathing in a respiratory pattern common to premature infants.

D This pattern is called periodic breathing and is common to premature infants. It may still require nursing intervention of oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. It should not be confused with periodic breathing.