OB exam #2 (chapters 17,18,23,24,15,16)

A client gives birth to a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings?a. The infant is displaying a state of alertness.b. The infant is attempting self-consoling maneuvers.c. The infant is in a state of hyperactivity.d. The infant is entering the habituation state.

b. The infant is attempting self-consoling maneuvers.

The nurse is visiting the parents of a newborn diagnosed with periventricular leukomalacia. Which statement indicates that the parents understand the newborn's health problem?

"We will need to plan for special care to help with learning disabilities."

A newborn has scheduled heel sticks for bilirubin checks every 4 hours. The mother asks the nurse "what can be done to calm my baby after those heel pricks?" What is the nurse's most appropriate response?

"You can give your baby a sucrose solution by bottle for pain relief."

measures to relieve engorment when breastfeeding

- frequent empying of breast by feeding or manual expression - warm showers

Encourage women to lose their pregnancy weight by ___ months postpartum, and refer those who don't to community weight-loss programs.

6

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?

Administer 0.5 ml/kg/hr of breast milk enterally.

Which of the following, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of a LGA newborn? A) Drug abuse B) Diabetes C) Preeclampsia D) Infection

B Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdates gestation, maternal obesity, male fetus, and genetics. Drug abuse is associated with SGA newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth.

After teaching a class about hepatic system adaptations after birth, the instructor determines that the teaching was successful when the class identifies which of the following as the process of changing bilirubin from a fat-soluble product to a water-soluble product? A) Hemolysis B) Conjugation C) Jaundice D) Hyperbilirubinemia

B The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is called conjugation. Hemolysis involves the breakdown of blood cells. In the newborn, hemolysis of the red blood cells is the principal source of bilirubin. Jaundice is the manifestation of increased bilirubin in the bloodstream. Hyperbilirubinemia refers to the increased level of bilirubin in the blood.

Engorgement of breasts

Temporary swelling or fullness of the breasts in response to increased blood flow when the milk begins to "come in". Usually on the second or third day after birth.

Kegel exercises

a series of pelvic muscle exercises used to strengthen the muscles of the pelvic floor to control urinary stress incontinence in women

When preparing to resuscitate a preterm newborn, the nurse would perform which action first? a) Administer epinephrine. b) Use positive-pressure ventilation. c) Place the newborn's head in a neutral position. d) Hyperextend the newborn's neck.

c) Place the newborn's head in a neutral position. When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation

The heart rate of the newborn in the first few minutes after birth will be in which range?a. 180 to 220 bpmb. 120 to 130 bpmc. 120 to 180 bpmd. 80 to 120 bpm

c. 120 to 180 bpm

The nurse is assessing the skin of a newborn and notes a rash on the newborn's face, and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as which of the following? A) Harlequin sign B) Nevus flammeus C) Erythema toxicum D) Port wine stain

c. Erythema toxicum

When assessing a newborn's reflexes, the nurse strokes the newborn's cheek and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive? A) Palmar grasp reflex B) Tonic neck reflex C) Moro reflex D) Rooting reflex

d. Rooting reflex

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client? a. increase in the body temperature b. increased appetite c. hyperglycemia d. lethargy and hypotonia

d. lethargy and hypotonia

Necrotizing Enterocolitis

disease of the bowel which can cause ischemic and necrotic injury in the gastrointestinal tract. * preterm * breast milk!

Commonly, an ___________ is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration.

ice pack

Which assessment finding by the nurse would indicate that a neonate is being comforted?

increased oxygen saturation

The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails

Analgesics such as acetaminophen and oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or __________ are prescribed to relieve mild postpartum discomfort

naproxen

To administer oxygen by bag and mask to a newborn, you would position the baby

on the back with the head slightly extended.

Afterpains are usually stronger during breast-feeding because ___________ released by the sucking reflex strengthens the contractions. Mild analgesics can reduce this discomfort.

oxytocin

nurse is caring for a newborn with meconium aspiration syndrome. Which intervention should the nurse perform when caring for this newborn?

place new born under radiant warmer oxygen therapy antibiotics

A client is at 23 weeks' gestation and was admitted for induction and birth after noting the infant was an intrauterine fetal death. The client had fallen 3 days prior to the diagnosis and landed on her side. What is the most likely attributable cause to the fetal death?

placental abruption The most common cause of fetal death after a trauma is placental abruption, where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion in the first trimester. The scenario does not indicate that there has been a premature rupture of membranes or the possibility of preeclamsia.

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant?

placental factors Assessment of the SGA infant begins by reviewing the maternal history to identify risk factors such as placental factors with abnormal umbilical cord insertion, chronic placental abruption, malformed and smaller placentas, with placental previa or placental insufficiency being the main placental causes. Blood group incompatibility, having many pregnancies, and being over the age of 30 will not cause an SGA infant.

A preterm infant receives surfactant by lung lavage. What intervention should the nurse perform immediately? Select all that apply.

placing the infant in an upright position not suctioning the airway

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings?

polycythemia

Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of ______________________

postpartum hemorrhage.

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate?

postterm

The nurse preceptor explains that several factors are involved with the "powers" that can cause dystocia. She focuses on the dysfunction that occurs when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This is known as which term?

precipitous labor When the expulsive forces of the uterus become dysfunctional, the uterus may either never fully relax (hypertonic contractions) placing the fetus in jeopardy, or relax too much (hypotonic contractions), causing ineffective contractions. Another dysfunction can occur when the uterus contracts so frequently and with such intensity that a very rapid birth will take place (precipitous labor).

A newborn with persistent pulmonary hypertension demonstrates _______ within 12 hours after birth

tachypnea, cyanosis, grunting, respiratory distress with tachypnea, and retractions.

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply. a) Offer early feedings b) Stop breastfeeding until jaundice resolves c) Increase the infant's hydration d) Initiate phototherapy e) Administer vitamin supplements

• Increase the infant's hydration • Offer early feedings • Initiate phototherapy

An infant that is diagnosed with meconium aspiration displays which symptom?

intercostal and substernal retractions

Failure to maintain and restore perineal muscular tone leads to ___________________ later in life for many women.

urinary incontinence

x

100 mm Hg

Which of the following is a consequence of hypothermia in a newborn? a) Respirations of 46 b) Heart rate of 126 c) Skin pink and warm d) Holds breath 25 seconds

Holds breath 25 seconds

A baby is born with congenital rubella. Which of the following would be an important assessment to be made before hospital discharge?

Hearing assessment

In an infant who has hypothermia, what would be an appropriate nursing diagnosis?

Impaired tissue perfusion

Which intervention should a nurse implement to promote thermal regulation in a preterm newborn?

Observe for clinical signs of cold stress such as weak cry.

A nurse is assessing the fluid status of a preterm newborn. Which parameter would be most appropriate for the nurse to assess?

fontanels

The nurse is assessing a postterm newborn. Which finding would the nurse be least likely to assess?

thick umbilical cord

The procedure for newborn resuscitation is easily remembered by the

"ABCDs" - airway, breathing, circulation, and drugs

Perinatal asphyxia risk factors:

- Trauma - Sepsis - Malformation - Hypovolemic shock - Medication

A client is Rh-negative and has given birth to a newborn who is Rh-positive. Within how many hours should Rh immunoglobulin be inject

72

What percentage of neonates require some type of assistance to transition to extrauterine life?

10%

The _____ score is used to evaluate newborns at 1 minute and 5 minutes after birth.

Apgar score

Second-degree laceration

extends through perineal muscles *episiotomy

A _________ is an involuntary muscular response to a sensory stimulus

reflex

A woman gives birth to a newborn at 39 weeks' gestation. The nurse classifies this newborn as:

term

BUBBLE-EE

B- breasts U- uterus B- bladder B- bowels L- lochia E- episiotomy/perineum/epidural site E- extremities E- emotional status

uterine atony

The most common cause of postpartum hemorrhage.

how to reduce bilirubin levels in newborn?

-Encourage early initiation of feedings to prevent hypoglycemia and provide protein to maintain the albumin levels to transport bilirubin to the liver. *every 2- 3 hours *phototherapy

nutrition for newborn with Necrotizing Enterocolitis

-If NEC is suspected, immediately STOP enteral feedings until a diagnosis is made. -Iv fluids -IV antibiotic

Heat loss mechanisms

radiation, conduction, convection, evaporation

Normal newborn weight range:

2500-4000 grams

atony

lack of muscle tone

A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements?

"Transverse lie is the same as when the fetal buttocks present to the birth canal." In most term pregnancies the fetus presents head down. In a breech presentation, the fetal buttocks, feet, or both present to the birth canal. Transverse lie is the same as shoulder presentation.

Diagnosis of fetal alcohol syndrome requires the presence of three findings:

1. Documentation of all three facial abnormalities 2. Documentation of growth deficits (height, weight, or both <10th percentile) 3. Documentation of CNS abnormalities (structural, neurologic, or functional)

Frequent voiding of small amounts (less than _____ mL) suggests urinary retention with overflow, and catheterization may be necessary to empty the bladder to restore tone.

150

__________ is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth.

Bonding

When assessing a postpartum woman, which of the following would lead the nurse to suspect postpartum blues? a. Panic attacks and suicidal thoughts b. Anger toward self and infant c. Periodic crying and insomnia D. Obsessive thoughts and hallucinations

C. Periodic crying and insomnia are characteristics of postpartum blues, in addition to mood changes, irritability, and increased sensitivity.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus.

neutral thermal environment

Environment in which body temperature is maintained without an increase in metabolic rate or oxygen use.

neonatal sepsis is caused by

GROUP B STREP

A nurse is explaining the benefits of breastfeeding to a client who has just delivered. Which statement correctly explains the benefits of breastfeeding to this mother?

Immunoglobulin IgA in breast milk boosts a newborn's immune system

A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism?a. evaporationb. convectionc. conductiond. radiation

c. conduction

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?

meconium stained fluids followed by tachypnea

Immediately after childbirth in the recovery area, the nurse observes the mother's partner's fascination and interest in the new son. This behavior is often termed:

partner's or significant others' developing bond with the newborn—a time of intense absorption, preoccupation, and interest—is called engrossment.

The small-for-gestational-age neonate is at increased risk for which complication during the transitional period?

polycythemia, probably due to chronic fetal hypoxia

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?

tea-colored urine

The nurse determines a newborn is small-for-gestational age based on which characteristics?

wasted appearance of extremities, thin umbilical cord, and reduced subcutaneous fat stores

An infant is born with respiratory depression. The provider begins actions to maintain effective ventilation. When would the nurse initiate chest compressions?

when the heart rate is less than 60 beats per minute

Which of the following would the nurse expect to find in a newborn who is considered small for gestational age? Select all that apply. a) Dry or thin umbilical cord b) Poor muscle tone over buttocks c) Sunken abdomen d) Increased subcutaneous fat stores e) Narrow skull sutures

• Sunken abdomen • Poor muscle tone over buttocks • Dry or thin umbilical cord

________________, more appropriately known as hypoxic-ischemic encephalopathy, is characterized by clinical and laboratory evidence of acute or subacute brain injury due to systemic hypoxemia or reduced cerebral blood flow

Perinatal asphyxia

engrossment

Paternal analogue of maternal emotional bonding; term used to describe fathers' fascination with their neonates, including their desire to touch, hold, caress, and talk to the newborn baby.

Normally, the fundus progresses downward at a rate of 1 fingerbreadth (or 1 cm) per day after childbirth and should be nonpalpable by ___ to ____ days postpartum.

10 to 14

Hypoglycemia in a mature infant is defined as a blood glucose level below which of the following? a) 30 mg/100 mL whole blood b) 100 mg/100 mL whole blood c) 40 mg/100 mL whole blood d) 80 mg/100 mL whole blood

40 mg/100 mL whole blood Explanation: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 mL whole blood is considered hypoglycemia

Anorectal Malformations

An imperforate anus is a gastrointestinal system malformation of the anorectal opening and is identified in the newborn period.

signs of Transient tachypnea of the newborn (TTN) improvement

As TTN resolves, the newborn's: * respiratory rate declines to 60 breaths per minute or less * the oxygen requirement decreases *the chest x-ray shows resolution of the perihilar streaking.

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth?

Assess uterine tone to determine fundal firmness. When caring for a client who has undergone a cesarean birth, the nurse should assess the client's uterine tone to determine fundal firmness. The nurse should assist with breastfeeding initiation and offer continued support. The nurse can also suggest alternate positioning techniques to reduce incisional discomfort while breastfeeding. Delaying breastfeeding may not be required. The nurse should encourage the client to cough, perform deep-breathing exercises, and use the incentive spirometer every 2 hours. The nurse should assist the client with early ambulation to prevent respiratory and cardiovascular problems.

What is the correct sequence of events in a neonatal resuscitation?

Dry the infant, establish an airway, expand the lungs, and initiate ventilation.

Three stage role development process

Expectations (they have a plan) Reality Transition to mastery

A client has delivered a small for gestation age (SGA) newborn. Which of the following would the nurse expect to assess? a) Protuberant abdomen b) Brown lanugo body hair c) Round flushed face d) Head larger than body

Head larger than body

which symptom would MOST accurately indicate that a newborn has experienced meconium aspiration during the delivery process?

Meconium stained fluids followed by tachypnea

What are the causes of postpartum stress?

Physical stress of pregnancy & birth, the required care-giving tasks assoc. w/the newborn, meeting the demands of other family members, and fatigue.

When caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant? a) Using minimal amount of tape b) Rocking and massaging c) Using distraction through objects d) Swaddling and positioning

Rocking and massaging

A danger sign is the reappearance of bright-red blood after lochia rubra has stopped. Reevaluation by a health care provider is essential if this occurs.

TRUE

A client's gestational age is 38 weeks and 6 days. If the baby is born today, which of the following terms accurately describes the gestational age of the newborn? a) Term. b) Premature. c) Postterm. d) Preterm.

Term. Correct Explanation: A term infant is born after the beginning of week 38 and before week 42 of pregnancy. Premature or preterm refers to the birth prior to 37 completed weeks. Postterm refers to birth beyond 42 weeks.

The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant?

To detect rebound hypoglycemia

A first time mother is nervous about breast feeding. which intervention would the nurse perform to reduce anxiety about breastfeeding? A. reassure the mother that some newborns latch and catch right away and some take more time to be patient. b. explain that breast feeding comes naturally to all mothers. c. tell her that breast feeding is a mechanical procedure that involves burping once in a while and she should try to finish quickly. d. ensure that the mother breast feeeds the newborn using the cradle method.

a

A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal?a. body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)b. positive Ortolani signc. heart rate of 90 to 100 bpmd. rounded, symmetrical abdomene. enlarged labia with pseudomenstruation

a. body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)

Respiratory Distress Syndrome medication

betamethasone stimulates the synthesis and release of surfactant (2), which lubricates the lungs, allowing the air sacs to slide against one another without sticking when the infant breathes. *surfactant replacement (minutes after birth)

The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the primary care provider. What does this finding indicate?

dehydration

An infant has a grade 3 intraventricular hemorrhage (IVH). The nurse monitors the infant for which complication?

hydrocephalus A grade 3 bleed causes enlargement of the ventricles. A long-term effect of hemorrhage may be the development of hydrocephalus. Encephalitis and meningitis are not complications of IVH. Intraparenchymal hemorrhage is seen in a grade 4 bleed.

Radiation heat loss

is the loss of heat from the body surface to COOLER SOLID SURFACES NOT in direct contact but in relative proximity

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?

undescended testes Some common physical characteristics of preterm infants include: undescended testes in the male; absent to a few creases in the soles and palms; breast and nipples not clearly delineated; and abundant vernix caseosa.

Milia

unopened sebaceous glands frequently found in newborn

An infant born 10 minutes prior was brought into the nursery for its exam. The nurse notices the infant's lip and palate are malformed. The father comes up to door and asks if the baby seems okay. What is the appropriate response by the nurse?

"Come on over and I will explain your infant's exam and findings." The nurse should include the parents and notify them of any visible anomalies right away. An in-depth discussion can take place later when the diagnosis is more definitive. Although the family may be in shock or denial, the nurse should give a realistic appraisal of the condition of their baby. Keeping communication lines open will lessen the family's feelings of helplessness and support their parental role.

While assessing a full-term neonate, which symptom would cause the nurse to suspect a neurologic impairment? a) A positive Babinski's reflex b) A positive rooting reflex c) A weak sucking reflex d) Startle reflex in response to a loud noise

A weak sucking reflex Correct Explanation: Normal neonates have a strong, vigorous sucking reflex. The rooting reflex is present at birth and disappears when the infant is between ages 3 and 4 months. A positive Babinski's reflex is present at birth and disappears by the time the infant is age 2. The startle reflex is present at birth and disappears when the infant is approximately age 4 months.

A prenatal client at 22 weeks gestation is scheduled for an amniocentesis. Which nursing action would apply to any client undergoing this procedure? Select all that apply. a)Assess for bleeding. b)Administer Rh immune globulin to the client. c)Cleanse skin with alcohol. d)Assess vital signs and fetal heart rate.

A, D The skin is cleaned with a betadine solution. The use of a local anesthesia at the needle insertion site is optional. A 22-gauge needle is then inserted into the uterine cavity and amniotic fluid is withdrawn. After 15-20 mL of fluid has been removed, the needle is withdrawn and the site is assessed for streaming (movement of fluid), which is an indication of bleeding. The fetal heart rate and maternal vital signs are then assessed. Rh immune globulin is given only to all Rh-negative women.

A nurse observes a 3-day-old term newborn that is starting to appear mildly jaundiced. What might explain this condition? a. Physiologic jaundice secondary to breast-feeding b. Hemolytic disease of the newborn due to blood incompatibility c. Exposing the newborn to high levels of oxygen d. Overfeeding the newborn with too much glucose water

A. Physiologic jaundice typically starts after 72 hours of breast-feeding. There is an enzyme in breast milk that inhibits the breakdown of bilirubin, and it is reflected on the newborn skin as jaundice.

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? a) An infant whose mother craved chocolate during pregnancy b) An infant whose labor began with ruptured membranes c) An infant who has marked acrocyanosis of his hands and feet d) An infant who had difficulty establishing respirations at birth

An infant who had difficulty establishing respirations at birth Explanation: Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.

When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure? A) Early parent-infant contact following birth B) Expert medical care for the labor and birth C) Good nutrition and prenatal care during pregnancy D) Grandparent involvement in infant care after birth

Ans: A Optimal bonding requires a period of close contact between the parents and newborn within the first few minutes to a few hours after birth. Expert medical care, nutrition and prenatal care, and grandparent involvement are not associated with the promotion of bonding.

A newborn's condition is not improving after intubation. What assessment by the nurse would identify a possible problem?

Auscultate breath sounds.

Identify a complication of the small-for-gestational-age newborn. a)Hyperglycemia b)Cognitive difficulties c)Leukocytosis d)Hyperthermia

B SGA newborns often subsequently exhibit learning disabilities. The disabilities are characterized by hyperactivity, short attention span, and poor fine motor coordination. Some hearing loss and speech defects also occur. The SGA newborn does not exhibit symptoms of high blood sugars, increased temperatures, and high white blood cell counts.

A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? A) "You are lucky to have given birth to a term newborn." B) "We still need to monitor him closely for problems." C) "How do you feel about delivering your baby at 36 weeks?" D) "Your baby is premature and needs monitoring in the NICU."

B A baby born at 36 weeks' gestation is considered a late-preterm newborn. These newborns face similar challenges as those of preterm newborns and require similar care. Telling the mother that close monitoring is necessary can prevent any misconceptions that she might have and prepare her for what might arise. The baby is not considered a term newborn, nor is the baby considered premature. The decision for care in the NICU would depend on the newborn's status. Asking the woman how she feels about the delivery demonstrates caring but does not address the woman's lack of understanding about her newborn.

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation? A) Respiratory rate of 54 breaths/minute B) Abdominal breathing C) Nasal flaring D) Acrocyanosis

C) Nasal flaring

Which of the following would alert the nurse to the possibility of respiratory distress in a newborn? A) Symmetrical chest movements B) Periodic breathing C) Respirations of 40 breaths/minute D) Sternal retractions

D Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life.

A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds, integrating understanding that this most likely is due to which of the following? A) Placing the newborn prone after feeding B) Limited ability of digestive enzymes C) Underdeveloped pyloric sphincter D) Relaxed cardiac sphincter

D The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in their ability to digest complex carbohydrates and fats; this results in fatty stools, not regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric contents.

A postpartum client comes to the clinic for her 6-week postpartum checkup. When assessing the client's cervix, the nurse would expect the external cervical os to appear: A) Shapeless B) Circular C) Triangular D) Slit-like

D The external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."

Which of the following would alert the nurse to suspect that a preterm newborn is in pain? A) Bradycardia B) Oxygen saturation level of 94% C) Decreased muscle tone D) Sudden high-pitched cry

D The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone.

The nurse is explaining to a postpartum woman 48 hours after her giving childbirth that the afterpains she is experiencing can be the result of which of the following? a. Abdominal cramping is a sign of endometriosis. b. A small infant weighing less than 8 pounds c. Pregnancies that were too closely spaced d. Contractions of the uterus after birth

D The direct cause of afterpains is uterine contractions

Because the newborn's red blood cells break down much sooner than those of an adult, what might result? a. Anemia b. Bruising c. Apnea d. Jaundice

D. since newborns produce bilirubin (red blood cell breakdown end product) at twice the rate of adults, their liver is not able to conjugate bilirubin as quickly as needed, this results in jaundice.

During assessment of the mother during postpartum period, what sign should alert the nurse that the client is likely experiencing uterine atony? A. fundus feels firm b. foul-smelling urine c. purulent vaginal discharge d. boggy or relaxed uterus

D. A boggy or relaxed uterus is sign of uterine atony. this can be result of bladder distention, which displaces the uterus upward and to the right, or retained placental fragments. Foul- smelling urine and purulent drainage are signs of infection but are not related to uterine atony. The firm fundus is normal.

Transient Tachypnea of the Newborn (TTN)

Mild respiratory distress; pulmonary liquid removed slowly or incompletely; resolution by 72 hours of age

A nurse is caring for an infant born after a prolonged and difficult maternal labor. What nursing intervention should the nurse perform when assessing for trauma and birth injuries in the newborn?

Note any absence of or decrease in deep tendon reflexes.

Which intervention should a nurse implement to promote thermal regulation in a preterm newborn? a) Observe for clinical signs of cold stress such as weak cry b) Check the blood pressure of the infant every 2 hours c) Assess the newborn's temperature every 8 hours until stable d) Set the temperature of the radiant warmer at a fixed level

Observe for clinical signs of cold stress such as weak cry

A nurse is caring for a client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. The nurse would be accurate in identifying which hormone as the cause of these after pains?

Oxytocin

Hyperbilirubinemia

a total serum bilirubin level above 5 mg/dL resulting from unconjugated bilirubin being deposited in the skin and mucous membranes *jaundice *preterm

A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment? a. Yellow sclera b. Abdominal distension c. Heart rate of 130 beats per minute d. Respiratory rate of 24

a. Yellow sclera

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem? a. apnea b. shivering c. hyperglycemia d. metabolic alkalosis

a. apnea

postmature babies

born after 42 weeks

Cephalhematoma

collection of blood between periosteum and skull bone that it covers does not cross suture line results from trauma during birth

How does the nurse position the infant experiencing respiratory difficulty?

on the back with the head elevated 15 degrees

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of:

very low birth weight.

Which factors could increase the risk of overheating in a newborn?

• Isolette that is too warm • Limited ability of diaphoresis

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8 degrees F, an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. Which nursing diagnosis takes highest priority? A) Hypothermia related to heat loss during birthing process B) Impaired parenting related to addition of new family member C) Risk for deficient fluid volume related to insensible fluid loss D) Risk for infection related to transition to extrauterine environment

A The newborn's heart rate is slightly below the accepted range of 120 to 160 beats/minute; the respiratory rate is at the high end of the accepted range of 30 to 60 breaths per minute. However, the newborn's temperature is significantly below the accepted range of 97.7 to 99.7 degrees F. Therefore, the priority nursing diagnosis is hypothermia. There is no information to suggest impaired parenting. Additional information is needed to determine if there is a risk for deficient fluid volume or a risk for infection.

When planning the care for a SGA newborn, which action would the nurse determine as a priority? A) Preventing hypoglycemia with early feedings B) Observing for respiratory distress syndrome C) Promoting bonding between the parents and the newborn D) Monitoring vital signs every 2 hours

A With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for respiratory distress, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn.

A nurse is teaching a group of student nurses about amniotic fluid. Which of the following statements by the student nurse reflects an understanding of the fetus's contribution to the quality of amniotic fluid? Select all that apply. a) "The fetus contributes to the volume of amniotic fluid by excreting urine." b) "Approximately 400 mL of amniotic fluid flows out of the fetal lungs each day." c) "The fetus swallows about 600 mL of the fluid in 24 hours." d) "A fetus can move freely and develop normally, even if there is no amniotic fluid."

A, B, C "The fetus contributes to the volume of amniotic fluid by excreting urine." Approximately 400 mL of amniotic fluid flows out of the fetal lungs each day. The fetus swallows about 600 mL of the fluid in 24 hours. A normal volume of amniotic fluid is necessary for good fetal movement. Normal movement is necessary for good musculoskeletal development.

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated?

Administer 0.5 ml/kg/hr of breast milk enterally. The nurse should administer 0.5 to 1 ml/kg/hr of breast milk enterally to induce surges in gut hormones that enhance maturation of the intestine. Administering vitamin D supplements, iron supplements, or intravenous dextrose will not significantly help the preterm newborn's gut overcome feeding difficulties.

A nurse is caring for a newborn with transient tachypnea. Which is the priority nursing intervention? a) Administer IV fluids; gavage feedings b) Perform gentle suctioning c) Monitor for signs of hypotonia d) Maintain adequate hydration

Administer IV fluids; gavage feedings

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate?

Administer dextrose intravenously.

sitz bath

After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids.

What factors influence the outcomes of the at-risk newborn? Select all that apply. a)Birth weight b)Gestational age c)Type and length of newborn illness d)Environmental factors e)Maternal factors

All are correct. Maternal factors such as age and parity, newborn weight, and gestational age also influence outcomes, as do environmental factors such as exposure to environmental dangers (toxic chemicals and illicit drugs). Evaluation; Physiological Integrity; Analysis

The nurse is assisting parents who have just experienced the death of their twin infants. What would be the most appropriate action for the nurse?

Allow the parents to be present at medical rounds and the resuscitation. In times of impending death and loss initiate spiritual comfort by calling the hospital clergy only if appropriate; offer to pray with the family only if appropriate. Have the parents participate in early and repeated care conferencing to reduce family stress. Allow the family to be present at both medical rounds and resuscitation; provide explanations of all procedures. Encourage the father to cry and grieve with his partner.

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? a) An infant whose labor began with ruptured membranes b) An infant whose mother craved chocolate during pregnancy c) An infant who had difficulty establishing respirations at birth d) An infant who has marked acrocyanosis of his hands and feet

An infant who had difficulty establishing respirations at birth

After teaching the parents of a newborn with retinopathy of prematurity (ROP) about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A) "Can we schedule follow-up eye examinations with the pediatric ophthalmologist now?" B) "We can fix the problem with surgery." C) "We'll make sure to administer eye drops each day for the next few weeks." D) "I'm sure the baby will grow out of it."

Ans: A Feedback: Parents of a newborn with suspected retinopathy of prematurity (ROP) should schedule follow-up vision screenings with a pediatric ophthalmologist every 2 to 3 weeks, depending on the severity of the findings at the initial examination.

The nurse is assessing a newborn and suspects that the newborn was exposed to drugs in utero because the newborn is exhibiting signs of neonatal abstinence syndrome. Which of the following would the nurse expect to assess? (Select all that apply.) A) Tremors B) Diminished sucking C) Regurgitation D) Shrill, high-pitched cry E) Hypothermia F) Frequent sneezing

Ans: A, C, D, F Feedback: Signs and symptoms of neonatal abstinence syndrome include tremors, frantic sucking, regurgitation or projectile vomiting, shrill high-pitched cry, fever, and frequent sneezing.

A newborn was diagnosed with a congenital heart defect and will undergo surgery at a later time. The nurse is teaching the parents about signs and symptoms that need to be reported. The nurse determines that the parents have understood the instructions when they state that they will report which of the following? (Select all that apply.) A) Weight loss B) Pale skin C) Fever D) Absence of edema E) Increased respiratory rate

Ans: A, C, E Feedback: Signs and symptoms that need to be reported include weight loss, poor feeding, cyanosis, breathing difficulties, irritability, increased respiratory rate, and fever.

A nurse is developing a plan of care for a preterm newborn to address the nursing diagnosis of risk for delayed development. Which of the following would the nurse include? (Select all that apply.) A) Clustering care to promote rest B) Positioning newborn in extension C) Using kangaroo care D) Loosely covering the newborn with blankets E) Providing nonnutritive sucking

Ans: A, C, E Feedback: The nurse would focus the plan of care on developmental care, which includes clustering care to promote rest and conserve energy, using flexed positioning to simulate in utero positioning, using kangaroo care to promote skin to skin sensations, swaddling with a blanket to maintain the flexed position, and providing nonnutritive sucking.

Which of the following, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of an LGA newborn? A) Drug abuse B) Diabetes C) Preeclampsia D) Infection

Ans: B Feedback: Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdated gestation, maternal obesity, male fetus, and genetics. Drug abuse is associated with SGA newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth.

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?

"A late preterm newborn may have more clinical problems compared with full-term newborns."

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply.

- Avoid coming to work when ill. - Use sterile gloves for an invasive procedure. - Initiate universal precautions when caring for the infant. To minimize the risk of infections, the nurse should avoid coming to work when ill, use sterile gloves for an invasive procedure, and initiate universal precautions. The nurse should remove all jewelry before washing hands, not cover the jewelry. The nurse should use disposable equipment rather than avoid it.

how to asses Apgar score?

- Determine the Apgar score at 1 and 5 minutes - if less than 7 at 5 minutes, repeat the assessment at 10 minutes of age. - If the initial assessment is poor, begin resuscitation measures until the Apgar score is above 7.

A client just gave birth to a preterm baby in the 30th week of gestation. Which nursing measures does the nurse acticipate for this newborn? Select all that apply.

- Dress the baby in a stockinette cap. - Place the baby under isolette care. - Estimate the urinary flow by weighing the diaper. The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature on a regular basis. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the newborn. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing.

uterine involution

- During the first few days after birth, the uterus typically descends from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day. - By 3 days, the fundus lies 2 to 3 fingerbreadths below the umbilicus (or slightly higher in multiparous women). - By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

The nurse assesses an infant's body temperature as 36.2°C during an extended resuscitation at birth. What consequence of a temperature of 36.2°C would the nurse anticipate? Select all that apply.

- Fetal shunts remain open. - Anaerobic glycolysis occurs. - Pulmonary perfusion decreases. - Metabolism increases. When the infant's body temperature is low, the fetal shunts remain open, anaerobic glycolysis occurs, pulmonary perfusion decreases, and metabolism increases. Immune function is not a consequence of body temperature.

A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? Select all that apply.

- Increase the infant's hydration. - Offer early feedings. - Initiate phototherapy. Hydration, early feedings, and phototherapy are measures that the nurse should take to reduce bilirubin levels in the newborn. Stopping breastfeeding or administering vitamin supplements will not help reduce bilirubin levels in the infant.

Meconium Aspiration Syndrome

- Intrauterine distress can cause passage into the amniotic fluid. - placental insufficiency - maternal hypertension - preeclampsia - fetal hypoxia - transient umbilical compression - oligohydramnios - maternal drug abuse - especially of tobacco -cocaine.

The nurse is concerned that a newborn is hypoglycemic. Which blood glucose level would support the nurse's suspicion?

30 mg/dL

The nurse is reviewing four prenatal charts. Which client would be an appropriate candidate for a contraction stress test (CST)? a)A client with intrauterine growth retardation b)A client with multiple gestation c)A client with an incompetent cervix d)A client with placenta previa

A A contraction stress test (CST) is indicated for a client with intrauterine growth retardation (IUGR), because it will assess the respiratory function of the placenta, which may be adversely affected by the conditions causing IUGR. The CST is contraindicated in third-trimester bleeding from placenta previa or marginal abruptio placentae, previous cesarean with classical incision (vertical incision in the fundus of the uterus), premature rupture of the membranes, incompetent cervix, anomalies of the maternal reproductive organs, history of preterm labor (if being done prior to term), or multiple gestation.

A nurse is counseling a mother about the immunologic properties of breast milk. The nurse integrates knowledge of immunoglobulins, emphasizing that breast milk is a major source of which immunoglobulin? A) IgA B) IgG C) IgM D) IgE

A A major source of IgA is human breast milk. IgG, found in serum and interstitial fluid, crosses the placenta beginning at approximately 20 to 22 weeks' gestation. IgM is found in blood and lymph fluid and levels are generally low at birth unless there is a congenital intrauterine infection. IgE is not found in breast milk and does not play a major role in defense in the newborn.

A woman who delivered a healthy newborn several hours ago asks the nurse, "Why am I perspiring so much?" The nurse integrates knowledge that a decrease in which hormone plays a role in this occurrence? A) Estrogen B) hCG C) hPL D) Progesterone

A Although hCG, hPL, and progesterone decline rapidly after birth, decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy.

A newborn is suspected of having fetal alcohol syndrome. Which of the following would the nurse expect to assess? A) Bradypnea B) Hydrocephaly C) Flattened maxilla D) Hypoactivity

Ans: C Feedback: A newborn with fetal alcohol syndrome exhibits characteristic facial features such as microcephaly (not hydrocephaly), small palpebral fissures, and abnormally small eyes, flattened or absent maxilla, epicanthal folds, thin upper lip, and missing vertical groove in the median portion of the upper lip. Bradypnea is not typically associated with fetal alcohol syndrome. Fine and gross motor development is delayed, and the newborn shows poor hand-eye coordination but not hypoactivity.

The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which of the following? A) Inability to clear fluids B) Immature respiratory control center C) Deficiency of surfactant D) Smaller respiratory passages

Ans: C Feedback: A preterm newborn is at increased risk for respiratory distress syndrome (RDS) most commonly because of a surfactant deficiency. Surfactant helps to keep the alveoli open and maintain lung expansion. With a deficiency, the alveoli collapse, predisposing the newborn to RDS. An inability to clear fluids can lead to transient tachypnea. Immature respiratory control centers lead to an increased risk for apnea. Smaller respiratory passages lead to an increased risk for obstruction.

The nurse is assessing a preterm newborn's fluid and hydration status. Which of the following would alert the nurse to possible overhydration? A) Decreased urine output B) Tachypnea C) Bulging fontanels D) Elevated temperature

Ans: C Feedback: Bulging fontanels in a preterm newborn suggest overhydration. Sunken fontanels, decreased urine output, and elevated temperature would suggest dehydration.

A group of students are reviewing information about the effects of substances on the newborn. The students demonstrate understanding of the information when they identify which drug as not being associated with teratogenic effects on the fetus? A) Alcohol B) Nicotine C) Marijuana D) Cocaine

Ans: C Feedback: Marijuana has not been shown to have teratogenic effects on the fetus. Alcohol, nicotine and cocaine do affect the fetus.

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Tachycardia b) Apnea c) Crying d) Sleepiness

Apnea

At 17 weeks pregnant, a mother asks the nurse questions about the development of her baby. The mother states that it may be too early to visualize any body structures via ultrasound. The nurse's best response in relation to fetal development at 17 weeks is: a) Myelination of the spinal cord has occurred. b) Differentiation of hard and soft palate can be seen. c) The earlobes are soft with little cartilage. d) Hard tissue (enamel) for teeth has developed.

B Differentiation of hard and soft palate are structures developed by 16 weeks gestation. Myelination of the spinal cord begins at 20 weeks gestation. Soft earlobes with little cartilage develop at 36 weeks gestation. Teeth form hard tissue (enamel) at 18 weeks gestation.

The nurse observes the stool of a newborn who has begun to breast-feed. Which of the following would the nurse expect to find? A) Greenish black, tarry stool B) Yellowish-brown, seedy stool C) Yellow-gold, stringy stool D) Yellowish-green, pasty stool

B After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. Meconium stool is greenish black and tarry. The last development in the stool pattern is the milk stool. Milk stools of the breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically sour-smelling. The milk stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.

After teaching a group of nursing students about a neutral thermal environment, the instructor determines that the teaching was successful when the students identify which of the following as the newborn's primary method of heat production? A) Convection B) Nonshivering thermogenesis C) Cold stress D) Bilirubin conjugation

B The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. Convection is a mechanism of heat loss. Cold stress results with excessive heat loss that requires the newborn to use compensatory mechanisms to maintain core body temperature. Bilirubin conjugation is a mechanism by which bilirubin in the blood is eliminated.

When to stop resuscitation

Continue resuscitation until the newborn has a pulse above 100 bpm, a good healthy cry, or good breathing efforts and a pink tongue.

When performing newborn resuscitation, which action would the nurse do first? A) Intubate with an appropriate-sized endotracheal tube. B) Give chest compressions at a rate of 80 times per minute. C) Administer epinephrine intravenously. D) Suction the mouth and then the nose.

D After placing the newborn's head in a neutral position, the nurse would suction the mouth and then the nose. This is followed by ventilation, circulation (chest compressions), and administration of epinephrine.

After teaching a group of nursing students about the process of involution, the instructor determines that additional teaching is needed when the students identify which of the following as being involved? A) Catabolism B) Muscle fiber contraction C) Epithelial regeneration D) Vasodilation

D Involution involves three retrogressive Process: contraction of muscle fibers to reduce those previously stretched during pregnancy; catabolism, which reduces enlarged myometrial cells; and regeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed during lochial discharge. Vasodilation is not involved.

A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure?

Ensure that the infant is kept warm.

After teaching a group of students about the effects of prematurity on various body systems, the instructor determines that the class was successful when the students identify which of the following as an effect of prematurity? a) Fragile cerebral blood vessels b) Enhanced ability to digest proteins c) Enlarged respiratory passages d) Rapid glomerular filtration rate

Fragile cerebral blood vessels Explanation: Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate.

The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which of the following? a) Hypoglycemia b) Polycythemia c) Asphyxia d) Meconium aspiration

Hypoglycemia

The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which of the following? a) Asphyxia b) Meconium aspiration c) Hypoglycemia d) Polycythemia

Hypoglycemia Correct Explanation: Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.

The nurse has been doing bag and mask resuscitation for over 2 minutes. What additional intervention will the nurse initiate?

Insert an orogastric tube.

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer?

Radiation

A nurse from the neonatal intensive care unit is called to the birth room for an infant requiring resuscitation. After placing the newborn in the sniffing position what would the nurse do next?

Suction the mouth then the nose.

While caring for a client following a lengthy labor & delivery, the nurse notes that the client repeatedly reviews her labor & delivery and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?

Taking-in; this phase occurs during the first 24-48 hours. The second phase is the taking-hold phase and usually lasts several weeks after delivery and is characterized by both dependent & independent behavior. The letting-go phase is when the mother re-establishes relationships with others and accepts her new role as a parent.

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded. The ear has a soft pinna that is flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.

Preterm infant deaths account for 80% to 90% of infant mortality in the first year of life. a) False b) True

True

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

Your infant cannot sustain respirations yet due to the lack of assistance from surfactant."

breast crawl

a newborns instinct to move up to mothers breast with leg and arm movement. once near breast baby will bounce head to find nipple and eventually latch

A nurse is assigned to care for a newborn with esophageal atresia. What priority preoperative nursing care is the priority for this newborn? a) Prevent aspiration by elevating the head of the bed and insert an NG tube to low suction b) Administer antibiotics and total parenteral nutrition as ordered c) Provide NG feedings only d) Document the amount and color of esophageal drainage

a. Prevent aspiration by elevating the head of the bed, and insert an NG tube to low suction.

A nurse is educating the mother of a new- born about feeding and burping. Which of the following strategies should the nurse offer to the mother regarding burping? a. Hold the baby upright with the baby's head on her mother's shoulder. b. Lay the baby on its back on its mother's lap. c. Gently rub the baby's abdomen while the baby is in a sitting position. d. Lay the baby on its mother's lap and give it frequent sips of warm water."

a. The nurse should ask the mother to hold the baby upright with the baby's head on her mother's shoulder. Alternatively, the nurse can also suggest the mother sit with the newborn on her lap with the newborn lying face down. Gently rubbing the baby's abdomen or giving frequent sips of warm water to the infant will not significantly induce burping; burping is induced by the newborn's position. Placing the baby on her back while trying to elicit burping after feeding may cause choking or aspiration."

A nurse is explaining the benefits of breastfeeding to a client who has just delivered. Which statement correctly explains the benefits of breastfeeding to this mother? a. Immunoglobulin IgA in breast milk boosts a newborn's immune system b. Breastfeeding provides more iron and calcium for the infant c. Mothers who breastfeed have increased breast size following nursing d. Breastfed infants gain weight faster than formula-fed infants after 6 months of age

a. Immunoglobulin IgA in breast milk boosts a newborn's immune system

A woman experiences an amniotic fluid embolism as the placenta is delivered. The nurse's first action would be to:

administer oxygen by mask. An amniotic embolism quickly becomes a pulmonary embolism. The woman needs oxygen to compensate for the sudden blockage of blood flow through her lungs.

A postterm newborn develops perinatal asphyxia. The nurse understands that this condition is most likely the result of:

aging placenta.

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?

apnea

A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication?

atelectasis

The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding?a. tan in color with a firm consistencyb. yellowy mustard color with seedy appearancec. greenish black with a tarry consistencyd. brownish black with a mucus-like appearance

b. yellowy mustard color with seedy appearance

a nurse has placed an infant with asphyxia on a radiant warmer. Which sign indicates that the resuscitation method have been successful? A. heart rate of 80 bpm B. jitteriness C. hypotonia D. strong cry

d

A nurse is caring for a full-term neonate who's receiving phototherapy for hyperbilirubinemia. Which finding should the nurse report immediately? a) Bronze-colored skin b) Greenish stool c) Maculopapular rash d) Absent Moro reflex

d) Absent Moro reflex An absent Moro reflex, lethargy, and seizures are symptoms of bilirubin encephalopathy, which can be life-threatening. A maculopapular rash, greenish stools, and bronzecolored skin are minor adverse effects of phototherapy that should be monitored but don't require immediate intervention

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? a) Gaze aversion b) Yawning c) Hiccups d) Quiet, alert state

d) Quiet, alert state When caring for neonates experiencing drug withdrawal, the nurse must be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet, alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate can't handle stimuli at that time

Hemolytic disease of the newborn typically shows within 24 hours after birth due to ______________

due to the different types of blood between mother and newborn.

Bilirubin is cleared from the body by:

liver

after birth the fundus should be________ and should feel firm.

midline

While in labor a woman with a prior history of cesarean birth reports light-headedness and dizziness. The nurse assesses the client and notes an increase in pulse and decrease in blood pressure from the vital signs 15 minutes prior. What might the nurse consider as a possible cause for the symptoms?

uterine rupture The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration. The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?

"A late preterm newborn may have more clinical problems compared with full-term newborns." The most common complications for late preterm infants are cold stress, respiratory distress, hypoglycemia, sepsis, cognitive delays, hyperbilirubinemia, and feeding difficulties. These are similar to those facing the preterm newborn and require similar management. Late preterm newborns have more clinical problems, longer lengths of stay, higher costs when compared with full-term newborns, and increased mortalities.

A client who gave birth 5 days ago complains to the nurse of profuse sweating during the night. What should the nurse recommend to the client in this regard?

"Be sure to change your pajamas to prevent you from chilling."

The mother of a preterm infant tells her nurse that she would like to visit her newborn who is in the neonatal intensive care unit (NICU). Which response by the nurse would be the most appropriate?

"Certainly. You will need to wash your hands and gown before you can hold him, however." The nurse should be certain the parents of a high-risk newborn are kept informed of what is happening with their child. They should be able to visit the special nursing unit to which the newborn is admitted as soon and as often as they choose, and, after washing and gowning, hold and touch their newborn, both actions which help make the child's birth more real to them.

The mother of a preterm infant tells her nurse that she would like to visit her newborn, who is in the neonatal intensive care unit (NICU). Which of the following would be the most appropriate response by the nurse? a) "I'm sorry. You may not visit your son until he has been released from the NICU." b) "Certainly. You may only observe the child from a distance, however, as his immune system is still not developed adequately." c) "Certainly. You will need to wash your hands and gown before you can hold him, however." d) "I'm sorry. You may not visit the NICU, but we can arrange to have your son brought to your room so that you can hold him."

"Certainly. You will need to wash your hands and gown before you can hold him, however." Correct Explanation: Be certain the parents of a high-risk newborn are kept informed of what is happening with their child. They should be able to visit the special nursing unit to which the newborn is admitted as soon and as often as they choose, and, after washing and gowning, hold and touch their newborn, both actions which help make the child's birth more real to them.

After the nurse provides instructions to a postpartum woman about postpartum blues, which statement would indicate understanding of it? I will a. "Need to take medication daily to treat the anxiety and sadness." b. "Call the OB support line only if I start to hear voices." c. "Contact my doctor if I become dizzy and fell nauseated." d. "Feel like laughing 1 minute and crying the next minute."

"D" because emotional lability is typical of postpartum blues which is usually self-limiting.

At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has has occurred when a participant makes which statement?

"Newborns who are appropriate for gestational age at birth have lower chance of complications than others."

At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has has occurred when a participant makes which statement?

"Newborns who are appropriate for gestational age at birth have lower chance of complications than others." Birth weight variations include appropriate for gestational age (AGA), which describes a newborn with a weight that falls within the 10th to 90th percentile for that particular gestational age. This describes approximately 80% of all newborns. Infants who are appropriate for gestational age have lower morbidity and mortality than other groups.

A client is 32 weeks pregnant and sent home on modified bedrest for preterm labor. She is on tocolytics and wants to know when she can have intercourse again with her husband. What is the most appropriate response by the nurse?

"That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor." The client needs to be on pelvic rest until the health care provider says otherwise. The intercourse can cause excitability in the uterus and encourage cervical softening and should be avoided unless the provider says it is safe.

A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?

"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."

A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?

"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG." The preterm newborn's immune system is very immature, increasing his or her susceptibility to infections. A deficiency of IgG may occur because transplacental transfer does not occur until after 34 weeks' gestation. This protection is lacking if the baby was born before this time. Preterm newborns have an impaired ability to manufacture antibodies to fight infection if they were exposed to pathogens during the birth process. The preterm newborn's thin skin and fragile blood vessels provide a limited protective barrier, adding to the increased risk for infection. Anticipating and preventing infections is the goal with frequent hand washing while caring for them the gold standard. Breastfeeding will eventually establish some protective mechanisms.

The nurse weighs the new infant and calculates his measurements. The new mom asks, "Did my baby grow well? The doctor said he was LGA: What does that mean?" What is the best explanation? a) "That means your baby is over the 90th percentile for weight." b) "That means your baby is in the 5th percentile for weight." c) "That means that your baby is lazy sometimes." d) "That means your baby is average for gestational age."

"That means your baby is over the 90th percentile for weight." Correct Explanation: LGA stands for large for gestational age. These infants are over the 90th percentile for weight. The other choices are not over the 90th percentile for weight or describe a different characteristic.

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?

"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?

"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised." The ability of the placenta to provide adequate oxygen and nutrients to the fetus after 42 weeks' gestation is thought to be compromised, leading to perinatal mortality and morbidity. After 42 weeks the placenta begins aging. Deposits of fibrin and calcium, along with hemorrhagic infarcts, occur and the placental blood vessels begin to degenerate. All of these changes affect diffusion of oxygen to the fetus. As the placenta loses its ability to nourish the fetus, the fetus uses stored nutrients to stay alive, and wasting occurs.

A nurse is examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give to the client?

"The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color." Lochia serosa = leukocytes, decidual tissue, RBCs & serous fluid. Only RBCs & leukocytes = blood leukocytes and decidual tissue = lochia alba

A client who had a vaginal delivery 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate?

"Within 1 -3 weeks, your diaphragm should return to normal and your breathing will feel like it did before your pregnancy."

A premature newborn has repeated blood work drawn by heel prick. The mother asks the nurse, "Does my baby feel the pain from all these procedures?" What is the nurse's best response?

"Your baby is more sensitive to the pain than adults are."

A client who delivered a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid."

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response?

"Your infant cannot sustain respirations yet due to the lack of assistance from surfactant." Preterm infants lacks surfactant to lower the surface tension in the alveoli and stabilize them to prevent their collapse. Even if preterm newborns can initiate respirations, they have a limited ability to retain air due to insufficient surfactant. Preterm newborns develop atelectasis quickly without alveoli stabilization. Fetal circulation patterns persist.

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.

- Dress the newborn in ways to preserve warmth. - Take the newborn's temperature often. - Supply oxygen for the newborn, if necessary. Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.

Women Who Should Not Breast-Feed?

- Drugs such as antithyroid drugs, antineoplastic drugs, alcohol - herpes infection on the breasts - street drugs - HIV positive - newborn with an inborn error of metabolism such as galactosemia or phenylketonuria (PKU) - active tuberculosis, or a mother with - serious mental health disorder that would prevent her from remembering to feed the infant consistently

A newborn is being admitted to the intensive care unit with the diagnosis of postterm infant. Which nursing actions would be the priority? Select all that apply.

- Monitor for hematocrit levels. - Assess for jaundice. - Initiate blood glucose monitoring. Postterm infants will need to be monitored closely for alterations in blood glucose levels. The nurse should also closely assess the postterm infant for polycythemia, which contributes to hyperbilirubinemia, so jaundice would be an indicator. Hct levels will be monitored for the risk of polycythemia. RH factor is not a priority. Temperature monitoring is a standard for all newborn care.

What is a classic sign of neonatal respiratory distress syndrome? Select all that apply.

- expiratory grunting - nasal flaring - retractions - tachypnea The classic signs of respiratory distress are expiratory grunting, nasal flaring, retractions, and tachypnea.

When examining a neonate, which characteristic would indicate to the nurse that the infant is preterm? Select all that apply.

- extended extremities - covered with vernix caseosa - absence of sole creases Characteristics of a preterm infant include extended extremities, presence of vernix caseosa, and the absence of sole creases. A bulging fontanelle is a sign of increased intracranial pressure. An elevated breast bud is consistent with a full-term infant.

Persistent Pulmonary Hypertension of the Newborn

- previously referred to as persistent fetal circulation - is a cardiopulmonary disorder characterized by marked pulmonary hypertension that causes right-to-left extrapulmonary shunting of blood and hypoxemia - It occurs when the newborn's circulatory system does not have normal transition after birth.

An assessment done in the neonatal intensive care unit reveals a small-for-gestational age newborn. Which findings would the nurse connect with this gestational age variation? Select all that apply.

- sunken abdomen - decreased amount of breast tissue - poor muscle tone Nursing assessment of a small for gestational age newborn would include a newborn presenting with decreased amount of breast tissue; scaphoid abdomen (sunken appearance); wide skull sutures; poor muscle tone; and thin umbilical cord. Color would not be ruddy unless polycythemia was present.

nursing management for Periventricular-Intraventricular Hemorrhage

- vitamin K - correct anemia, acidosis and hypotension - administer fluids SLOW - Keep the newborn in a flexed, contained position with the head elevated to prevent or minimize fluctuations in intracranial pressure - measure head circunference daily - reduse stimulation

engrossment behaviors

1. Visual awareness of the newborn 2. Tactile awareness of the newborn 3. Perception of the newborn as perfect 4. Strong attraction to the newborn 5Awareness of distinct features of the newborn 6. Extreme elation 7. Increased sense of self-esteem

What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 10% c) 50% d) 5%

10% Correct Explanation: Most newborns transition to extrauterine life smoothly. About 10% of newborns need some type of assistance at birth.

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity?

100 mm Hg

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity? a) 100 mm Hg b) 180 mm Hg c) 50 mm Hg d) 40 mm Hg

100 mm Hg

With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity? a) 180 mm Hg b) 50 mm Hg c) 100 mm Hg d) 40 mm Hg

100 mm Hg Explanation: Retinal capillaries can be damaged by excessive oxygen levels. Keeping the Pa02 level under 100 mm Hg helps prevent this.

A baby who is declared AGA (appropriate for gestational age) falls in what weight percentile? a) 95 b) 5 c) 9 d) 20

20

A baby who is declared AGA (appropriate for gestational age) falls in what weight percentile? a) 95 b) 20 c) 5 d) 9

20 Explanation: AGA infants are infants that fall between the 10th and 90th percentile for weight.

The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated?

20th

The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this patient?

22 calories per ounce

Assessment of a newborn at 40 weeks' gestation reveals that he is a low birth weight newborn. Which of the following weights would the nurse identify as being low birth weight? a) 2400 g b) 3400 g c) 4400 g d) 1400 g

2400 g

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

40 mg/100 mL whole blood

Hypoglycemia in a mature infant is defined as a blood glucose level below which of the following? a) 100 mg/100 mL whole blood b) 80 mg/100 mL whole blood c) 40 mg/100 mL whole blood d) 30 mg/100 mL whole blood

40 mg/100 mL whole blood

A nurse is assisting with the resuscitation of a preterm newborn. The nurse is giving ventilations to the newborn at which rate?

40 to 60 breaths per minute When performing newborn resuscitation, the nurse would ventilate at a rate of 40 to 60 breaths per minute.

normal newborn length

45-55 cm

Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a) 6 b) 3 c) 4 d) 5

5

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which of the following would the nurse expect to find when assessing the client's fundus? A) Cannot be palpated B) 2 cm below the umbilicus C) 6 cm below the umbilicus D) 10 cm below the umbilicus

A By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

Perinatal Asphyxia

A newborn who fails to establish adequate, sustained respiration after birth is said to have asphyxia.

Peribottle

A plastic squeeze bottle filled with warm tap water that is sprayed over the perineal area after each voiding and before applying a new perineal pad.

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate? a) Monitor the infant's hematocrit levels closely b) Place the infant on a radiant warmer c) Administer PO glucose water immediately d) Administer dextrose intravenously

Administer dextrose intravenously

A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will prescribe?

Administer oxytocin diluted as a "piggyback" infusion. Oxytocin is always infused in a secondary or "piggyback" infusion system so it can be halted quickly if overstimulation of the uterus occurs.

At an amniocentesis just prior to birth, a fetus's lecithin/sphingomyelin ratio was determined to be 1:1. Based on this, she is prone to which type of respiratory problem following birth?

Alveolar collapse on expiration

The results of an amniocentesis conducted just prior to birth showed a fetus's lecithin/sphingomyelin ratio as being 1:1. From this information, for which respiratory problem should the nurse anticipate providing care once the baby is delivered?

Alveolar collapse on expiration

A group of pregnant women are discussing high-risk newborn conditions as part of a prenatal class. When describing the complications that can occur in these newborns to the group, which would the nurse include as being at lowest risk? A) Small-for-gestational-age (SGA) newborns B) Large-for-gestational-age (LGA) newborns C) Appropriate-for-gestational-age (AGA) newborns D) Low-birth-weight newborns

Ans: C Feedback: Appropriate-for-gestational-age (AGA) newborns are at the lowest risk for any problems. AGA characterizes approximately 80% of newborns and describes a newborn with a normal length, weight, head circumference, and body mass index. The other categories all have an increased risk of complications.

A nurse is teaching the mother of a newborn diagnosed with galactosemia about dietary restrictions. The nurse determines that the mother has understood the teaching when she identifies which of the following as needing to be restricted? A) Phenylalanine B) Protein C) Lactose D) Iodine

Ans: C Feedback: Lifelong restriction of lactose is required for galactosemia. Phenylalanine is restricted for those with phenylketonuria. Low protein is needed with maple syrup urine disease. Iodine would not be restricted for any inborn error of metabolism

A newborn with high serum bilirubin is receiving phototherapy. Which of the following is the most appropriate nursing intervention for this client? a) Gentle shaking of the baby b) Delay of feeding until bilirubin levels are normal c) Placing light 6 inches above the newborn's bassinet d) Application of eye dressings to the infant

Application of eye dressings to the infant

A newborn with high serum bilirubin is receiving phototherapy. Which of the following is the most appropriate nursing intervention for this client? a) Gentle shaking of the baby b) Placing light 6 inches above the newborn's bassinet c) Application of eye dressings to the infant d) Delay of feeding until bilirubin levels are normal

Application of eye dressings to the infant Correct Explanation: Continuous exposure to bright lights by phototherapy may be harmful to a newborn's retina, so the infant's eyes must always be covered while under bilirubin lights. Eye dressings or cotton balls can be firmly secured in place by an infant mask. The lights are placed 12 to 30 inches above the newborn's bassinet or incubator. Bilirubin is removed from the body by being incorporated into feces. Therefore, the sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding (either breast milk or formula), therefore, stimulates bowel peristalsis and helps to accomplish this. Gently shaking the infant is a method of stimulating breathing in an infant experiencing apnea.

What assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn? a) Monitor for fall in temperature, indicative of dehydration b) Assess for decrease in urinary output c) Assess for increased muscle tone d) Measure weight once every 2-3 days

Assess for decrease in urinary output

Which assessment by the nurse will best monitor the nutrition and fluid balance in the postterm newborn?

Assess for decrease in urinary output.

Which of the following would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? a) Temperature instability b) Seizures c) Feeble sucking d) Asymmetrical movement

Asymmetrical movement Correct Explanation: A birth injury is typically characterized by asymmetrical movement. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.

_____________ is the development of strong affection between an infant and a significant other (mother, father, sibling, and caretaker).

Attachment

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time?

Avoid any discussion of the situation with the couple. The nurse should encourage discussion of the loss and allow the couple to vent their feelings of grief and guilt. The nurse should allow the parents to spend unlimited time with their stillborn infant so that they can validate the death. Providing the parents and family with mementos of the infant helps validate the reality of the death. Assisting the family with arrangements is helpful to reduce the stress of coping with the situation and making decisions at this difficult time.

A pregnant client is concerned about a blow to the abdomen if she continues to play basketball during her pregnancy. The nurse's response is based upon her knowledge of which of the following facts concerning amniotic fluid? a) The total amount of amniotic fluid during pregnancy is 300 mL. b) Amniotic fluid functions as a cushion to protect against mechanical injury. c) The fetus does not contribute to the production of amniotic fluid. d) Amniotic fluid is slightly acidic.

B During pregnancy, the amniotic fluid protects against injury. After 20 weeks of pregnancy, fluid volume ranges from 700-1000 mL. Some of the amniotic fluid is contributed by the fetus's excreting urine. Amniotic fluid is slightly alkaline.

A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm going to do the best I can for my son." The nurse interprets this as indicating the father is in which stage of adaptation? A) Expectations B) Transition to mastery C) Reality D) Taking-in

B The father's statement reflects transition to mastery because he is making a conscious decision to take control and be at the center of the newborn's life regardless of his preparedness. The expectations stage involves preconceptions about how life will be with a newborn. Reality occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal

A nursing student is preparing a presentation on minimizing heat loss in the newborn. Which of the following would the student include as a measure to prevent heat loss through convection? A) Placing a cap on a newborn's head B) Working inside an isolette as much as possible. C) Placing the newborn skin-to-skin with the mother D) Using a radiant warmer to transport a newborn

B To prevent heat loss by convection, the nurse would keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment, work inside an isolette as much as possible and minimize opening portholes that allow cold air to flow inside, and warm any oxygen or humidified air that comes in contact with the newborn. Placing a cap on the newborn's head would help minimize heat loss through evaporation. Placing the newborn skin-to-skin with the mother helps to prevent heat loss through conduction. Using a radiant warmer to transport a newborn helps minimize heat loss through radiation.

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? A) Evaporation B) Conduction C) Convection D) Radiation

B Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

A nurse is assessing a newborn who is about 41/2 hours old. The nurse would expect this newborn to exhibit which of the following? (Select all that apply.) A) Sleeping B) Interest in environmental stimuli C) Passage of meconium D) Difficulty arousing the newborn E) Spontaneous Moro reflexes

B, C The newborn is in the second period of reactivity, which begins as the newborn awakens and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal newborn (Boxwell, 2010). Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period. In addition, motor activity and muscle tone increase in conjunction with an increase in muscular coordination. Spontaneous Moro reflexes are noted during the first period of reactivity. Sleeping and difficulty arousing the newborn reflect the period of decreased responsiveness.

The nurse is assessing a newborn's eyes. Which of the following would the nurse identify as normal? (Select all that apply.) A) Slow blink response B) Able to track object to midline C) Transient deviation of the eyes D) Involuntary repetitive eye movementE) Absent red reflex

B,C,D

The nurse would expect a postpartum woman to demonstrate lochia in which sequence? A. Rubra, alba, serosa B. Rubra, serosa, alba C. Serosa, alba, rubra D. Alba, rubra, serosa

B. The correct sequence is rubra (red), then serosa (pink/brownish), and then alba (white, creamy).

Which of the following suggestions would be most appropriate to include in the teaching plan for a postpartum woman who needs to lose weight? a. Increase fluid intake and acid-producing foods in her diet. b. Avoid empty-calorie foods, breast-feed, increase exercise. c. Start a high-protein, low carbohydrate diet and restrict fluids. d. Eat no snacks or carbohydrates after dinner.

B. Because weight loss is based on the principle of intake of calories and output of energy, instructing this woman to avoid high-calorie foods that yield no nutritive value and expending more energy through active exercise would result in weight loss for her.

When assessing the term newborn, the following are observed: newborn is alert, heart and respiratory rates have stabilized, and meconium has been passed. The nurse determines that the newborn is exhibiting behaviors indicating: a. Initial period of reactivity b. Second period of reactivity c. Decreased responsiveness period d. Sleep period for newborns

B. The behaviors demonstrated by the newborn, such as alertness, stabilized heart and respiratory rates, and passage of meconium are associated with the second period of reactivity.

A mother asks when a preterm infant receives basic immunizations. Which response by the nurse is most accurate?

Basic immunizations are given according to the chronologic age of an infant.

A mother asks when a preterm infant receives basic immunizations. Which response by the nurse is most accurate?

Basic immunizations are given according to the chronologic age of an infant. The infant will receive basic immunization based on chronologic age and standard criteria for administration.

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn? a) Focus on decreasing blood viscosity by introducing feedings b) Give dextrose intravenously before oral feedings c) Place infant on radiant warmer immediately d) Begin early feedings either by the breast or bottle

Begin early feedings either by the breast or bottle

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?

Begin early feedings either by the breast or bottle.

The newborn nursery nurse has admitted a large-for-gestational age infant, one hour old for observation. The initial blood glucose level is 44 mg/dl (2.44 mmol). What is the nurse's priority action?

Begin supervised feedings for the newborn.

The neonate's respirations are gasping and irregular with a rate of 24 bpm. Which circulatory alteration will the nurse assess for in this infant?

Blood flows from the aorta to the pulmonary artery. Inadequate respiratory effort results in hypoxia. During hypoxia, the ductus arteriosus does not close, resulting in blood flow from the aorta to the pulmonary artery and inadequate pump action of the heart. The pulmonary vein takes blood from the right ventricle to the lungs. The foramen ovale allows blood flow from right atrium to left atrium during fetal life and is not primarily impacted by hypoxia. Oxygenated blood flows from the lungs to the left ventricle to be pumped to the body.

A mother of a 32-week-gestation neonate is encouraged to perform kangaroo care in the neonatal intensive care unit. What would best correlate with this suggestion?

Breastfeeding attempts will be enhanced.

A mother of a 32-week-gestation neonate is encouraged to perform kangaroo care in the neonatal intensive care unit. What would best correlate with this suggestion?

Breastfeeding attempts will be enhanced. To promote nutrition in the preterm newborn the newborn will attempt nuzzling at the breast in conjunction with kangaroo care if the newborn is stable. Kangaroo care offers the most benefits for preterm and low-birth-weight infants with increased weight gain. Preterm infants who experience kangaroo care have improved sleep patterns and breastfeeding attempts. It will not assist in preventing apnea. At 32 weeks' gestation it will not be necessary to have the infant adjust to the environment. Nutrition through breastfeeding is the priority.

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation and intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A) Suggest that the parents stay for just a few minutes to reduce their anxiety. B) Reassure them that their newborn is progressing well. C) Encourage the parents to touch their preterm newborn. D) Discuss the care they will be giving the newborn upon discharge.

C The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated.

A nurse is assessing a postpartum woman's adjustment to her maternal role. Which of the following would the nurse expect to occur first? A) Reestablishing relationships with others B) Demonstrating increasing confidence in care of the newborn C) Assuming a passive role in meeting her own needs D) Becoming preoccupied with the present

C The first task of adjusting to the maternal role is the taking-in phase in which the mother demonstrates dependent behaviors and assumes a passive role in meeting her own basic needs. During the taking-hold phase, the mother becomes preoccupied with the present. During the letting-go phase, the mother reestablishes relationships with others and demonstrates increased responsibility and confidence in caring for the newborn.

A client at 28 weeks gestation is admitted to the labor and birth unit. Which test would most likely be used to assess the client's comprehensive fetal status? a) Ultrasound for physical structure b) Nonstress test (NST) c) Biophysical profile (BPP) d) Amniocentesis

C. Biophysical profile is a comprehensive test that would be used to assess the client's fetal status at 28 weeks gestation. Ultrasound for physical structure is limited to identifying the growth and development of the fetus, and does not assess for other parameters of fetal well-being. Women with a high-risk factor will probably begin having NSTs at 30-32 weeks gestation and at frequent intervals for the remainder of the pregnancy. Amniocentesis late in pregnancy is used to test for lung maturity, not overall fetal status in labor, and when performed earlier it is used to test for specific disorders.

In the taking-in maternal role phase described by Rubin (1984), the nurse would expect the woman's behavior to be characterized as which of the following? a. Gaining self-confidence b. Adjusting to her new relationships c. Being passive and dependent D. Resuming control over her life

C. According to Reva Rubin, the mother is very passive and is dependent on others to care for her for the first 24 to 48 hours after giving birth.

The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?

Closely monitor temperature. Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also is associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority.

Which of the following is an example of developmental care in the NICU? a) Giving a bath b) Cluster care and activities c) Giving medications d) Holding the infant

Cluster care and activities

Which of the following is an example of developmental care in the NICU? a) Giving medications b) Holding the infant c) Giving a bath d) Cluster care and activities

Cluster care and activities Correct Explanation: Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.

The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care?

Clustering care and activities

The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care?

Clustering care and activities Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.

What are the factors that facilitate uterine involution?

Complete expulsion of amniotic membranes and placenta at birth; complication-free labor & birth process; breastfeeding; ambulation

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

Conduction

transfer of heat from one object to another when the two objects are in direct contact with each other

Conduction

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

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

A newborn is receiving bag and mask ventilation and cardiac compression. The resuscitation is paused, and the nurse reassesses the infant. The infant's heart rate is 70 bpm with irregular gasping respirations. What is the appropriate action in this situation?

Continue bag and mask ventilation only.

A nurse is caring for a client in the postpartum period. Which of the following processes should the nurse identify as retrogressive processes involved in involution? (Select all)

Contraction of muscle fibers; catabolism, which reduces individual myometrial cells; regeneration of uterine epithelium.

flow of heat from the body surface to cooler surrounding air or to air circulating over a body surface

Convection

The nurse is teaching a group of students about the differences between a full-term newborn and a preterm newborn. The nurse determines that the teaching is effective when the students state that the preterm newborn has: A) Fewer visible blood vessels through the skin B) More subcutaneous fat in the neck and abdomen C) Well-developed flexor muscles in the extremities D) Greater surface area in proportion to weight

D Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone.

Which of the following would alert the nurse to the possibility of respiratory distress in a newborn? A) Symmetrical chest movements B) Periodic breathing C) Respirations of 40 breaths/minute D) Sternal retractions

D Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life.

The nurse is caring for a client who has just recieved an episiodomy. The nurse observes that the laceration extends through the perneal area and continues through the anterior rectal wall. how does the nurse classify the laceration? A. 1st degree b. 2nd degree c. 3rd degree d. 4th degree

D The nurse should classify the laceration as 4th degree because it continues throught the anterior rectal wall. 1st degree involves only skin and superficial structures above muscles2nd degree extends through perineal muscles3rd degree lacerations extend through the anal sphincter but not through the anterior rectal wall

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first? A) Alert the physician stat and turn the newborn to her right side. B) Administer oxygen via facial mask by positive pressure. C) Lower the newborn's head to stimulate crying. D) Aspirate the oral and nasal pharynx with a bulb syringe.

D The nurse's first action would be to suction the oral and nasal pharynx with a bulb syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the blockage due to secretions. Administering oxygen via positive pressure is not indicated at this time. Lowering the newborn's head would be inappropriate.

A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? A) "Your uterus is still shrinking in size; that's why you're feeling this pain." B) "Let me check your vaginal discharge just to make sure everything is fine." C) "Your body is responding to the events of labor, just like after a tough workout." D) "The baby's sucking releases a hormone that causes the

D The woman is describing afterpains, which are usually stronger during breast-feeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breast-feeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.

After teaching a group of nursing students about thermoregulation and appropriate measures to prevent heat loss by evaporation, which of the following student behaviors would indicate successful teaching? a. Transporting the newborn in an isolette b. Maintaining a warm room temperature c. Placing the newborn on a warmed surface d. Drying the newborn immediately after birth

D. Evaporation is the loss of heat as water is lost from the skin to the environment. Drying the newborn at birth and after bathing, keeping linens dry, and using plastic wrap blankets and heat shields will all prevent heat loss through evaporation.

The nurse is caring for a large-for-gestational-age newborn (also known as macrosomia). What maternal condition is the usual cause of this condition? a) Diabetes b) Celiac disease c) Alcohol use d) Hypertension

Diabetes Correct Explanation: In the condition known as macrosomia, a newborn is born large for gestational age (LGA). These newborns are those with birth weights that exceed the 90th percentile of newborns of the same gestational age. They are born most often to mothers with diabetes.

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply. a) Alcohol use b) Renal infection c) Diabetes mellitus d) Postdates gestation e) Prepregnancy obesity

Diabetes mellitus Postdates gestation Prepregnancy obesity

At birth, a term infant has irregular respirations and a weak cry. What is the sequence of events initiated by the nurse when caring for this infant?

Dry the infant, stimulate the infant, and keep the infant warm.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next?

Educate the client on how to perform Kegel exercises. Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream.

A breast-feeding client informs the nurse that she is unable to maintain her milk supply. What instructions should the nurse give to the client to improve milk supply?

Empty the breasts frequently.

the loss of heat when a liquid is converted to a vapor

Evaporation

drop in maternal blood volume after birth leads to a similar drop in hematocrit. TRUE or FALSE

FALSE hematocrit level remains relatively stable and may even increase, reflecting predominant loss of plasma

Infants of drug-dependent women tend to be large for gestational age. a) True b) False

False

Infants of drug-dependent women tend to be large for gestational age. a) False b) True

False Infants of drug-dependent women tend to be small for gestational age.

What are the postpartum physiologic danger signs?

Fever more than 38 C (100.4 F) after the first 24 hours; foul-smelling lochia or an unexpected change in color or amount; visual changes, such as blurred vision or spots, or headaches; calf pain experienced with dorsiflexion of the foot; swelling, redness, or discharge at the episiotomy site; dysuria, burning, or incomplete emptying of the bladder; shortness of breath or difficulty breathing; depression or extreme mood swings.

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant? a) Check blood glucose within 2 hours of birth by reagent test strip b) Repeat screening every 2 to 3 hours or before feeds c) Focus on decreasing blood viscosity by increasing fluid volume d) Focus on monitoring and maintaining blood glucose levels

Focus on decreasing blood viscosity by increasing fluid volume

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant?

Focus on decreasing blood viscosity by increasing fluid volume.

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant?

Focus on decreasing blood viscosity by increasing fluid volume. The nurse should focus on decreasing blood viscosity by increasing fluid volume in the newborn with polycythemia. Checking blood glucose within 2 hours of birth by a reagent test strip and screening every 2 to 3 hours or before feeds are not interventions that will alleviate the condition of an infant with polycythemia. The nurse should monitor and maintain blood glucose levels when caring for a newborn with hypoglycemia, not polycythemia.

After teaching a group of students about the effects of prematurity on various body systems, the instructor determines that the class was successful when the students identify which of the following as an effect of prematurity? a) Rapid glomerular filtration rate b) Enhanced ability to digest proteins c) Enlarged respiratory passages d) Fragile cerebral blood vessels

Fragile cerebral blood vessels

A newborn that has a surfactant deficiency will have which assessment noted on a physical exam: a) Pink skin b) Regular respirations c) Hypertension d) Grunting

Grunting Correct Explanation: Infants that are deficient in lung surfactant will show signs of respiratory distress: grunting, retracting, tachypnea, cyanosis, poor perfusion, hypotension, and skin mottling.

A client has delivered a small for gestation age (SGA) newborn. Which of the following would the nurse expect to assess? a) Protuberant abdomen b) Brown lanugo body hair c) Round flushed face d) Head larger than body

Head larger than body

A client has delivered a small for gestation age (SGA) newborn. Which of the following would the nurse expect to assess? a) Head larger than body b) Brown lanugo body hair c) Round flushed face d) Protuberant abdomen

Head larger than body Explanation: Head being larger than the rest of the body is the characteristic feature of small for gestational age infants. Small for gestational age infants weigh below the 10th percentile on the intrauterine growth chart for gestational age. The heads of SGA infants appear larger in proportion to their body. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large for gestational age (LGA) infants. Preterm infants, and not SGA infants, are covered with brown lanugo hair all over the body.

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid? a) Respiratory rate of 60-70 bpm b) Total bilirubin level of 15 c) Heart rate of 162 bpm d) Hematocrit of 44%

Heart rate of 162 bpm

A client asks the nurse what surfactant is. Which explanation would the nurse give as the main role of surfactant in the neonate? a) Helps the lungs remain expanded after the initiation of breathing b) Assists with ciliary body maturation in the upper airways c) Helps maintain a rhythmic breathing pattern d) Promotes clearing of mucus from the respiratory tract

Helps the lungs remain expanded after the initiation of breathing

A client asks the nurse what surfactant is. Which explanation would the nurse give as the main role of surfactant in the neonate? a) Helps the lungs remain expanded after the initiation of breathing b) Promotes clearing of mucus from the respiratory tract c) Assists with ciliary body maturation in the upper airways d) Helps maintain a rhythmic breathing pattern

Helps the lungs remain expanded after the initiation of breathing Correct Explanation: Surfactant works by reducing surface tension in the lung, which allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration. Surfactant hasn't been shown to influence ciliary body maturation, clearing of the respiratory tract, or regulation of the neonate's breathing pattern.

Which of the following is a consequence of hypothermia in a newborn? a) Skin pink and warm b) Holds breath 25 seconds c) Heart rate of 126 d) Respirations of 46

Holds breath 25 seconds Explanation: Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

You care for a child born with a tracheoesophageal fistula. Which finding during pregnancy would have caused you to suspect this might be present? a) Oligohydramnios b) A difficult second stage of labor c) Hydramnios d) Bleeding at 32 weeks of pregnancy

Hydramnios

An obese woman with diabetes has just given birth to a term, large for gestational age (LGA) newborn. Which of the following conditions should the nurse most expect to find in this infant? a) Hypotension b) Hypertension c) Hypoglycemia d) Hyperglycemia

Hypoglycemia

An obese woman with diabetes has just given birth to a term, large for gestational age (LGA) newborn. Which of the following conditions should the nurse most expect to find in this infant? a) Hypoglycemia b) Hypertension c) Hypotension d) Hyperglycemia

Hypoglycemia Correct Explanation: LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes which was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.

A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that he's at risk for which complication? a) Anemia b) Hypoglycemia c) Nitrogen loss d) Thrombosis

Hypoglycemia Correct Explanation: Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus through the placenta. The neonate's liver can't initially adjust to the changing glucose levels after birth. This inability may result in an overabundance of insulin in the neonate, causing hypoglycemia. Neonates of mothers with diabetes aren't at increased risk for anemia, nitrogen loss, or thrombosis.

The nurse is caring for a client of Asian descent 1 day after she has given birth. Which foods will the client most likely refuse to eat when her meal tray is delivered? (Select all)

Ice cream; raw carrot & celery; orange slices Many people of Latin American, African, and Asian descent believe that good health involves a balance of heat and cold. The blood loss during childbirth is considered loss of warmth, therefore cold foods are avoided during this time.

In an infant who has hypothermia, what would be an appropriate nursing diagnosis? a) Ineffective parental attachment b) Impaired tissue perfusion c) Alteration in nutrition d) Impaired skin integrity

Impaired tissue perfusion Correct Explanation: Impaired tissue perfusion would be appropriate and may be related to cardiopulmonary, cerebral, gastrointestinal, peripheral, or renal issues.

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings does not confirm that this newborn is 12 days postmature? a) Hypoglycemia. b) Meconium aspiration. c) Absence of lanugo. d) Increased amounts of vernix.

Increased amounts of vernix.

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings does not confirm that this newborn is 12 days postmature? a) Increased amounts of vernix. b) Absence of lanugo. c) Meconium aspiration. d) Hypoglycemia.

Increased amounts of vernix. Correct Explanation: Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. A discrepancy between EDC and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress but does not coincide with gestation. The presence of lanugo is greatest at 28 to 30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation.

The nurse in a newborn nursery is observing for developmentally appropriate care. Which of the following is an example of self-regulation? a) Infant is kicking feet b) Infant has hand in mouth c) Infant is quiet d) Infant is crying

Infant has hand in mouth

The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority?

Initiate early oral feedings. Metabolic needs are increased for catch-up growth in the SGA newborn. Initiate early and frequent oral feedings. Neonatal hypoglycemia is a major cause of brain injury since the brain needs glucose continuously as a primary source of energy. A newborn stressed at birth uses up available glucose stores quickly with resulting hypoglycemia. A plasma glucose concentration at or below 40 mg/dL necessitates and frequent oral feedings. With the loss of the placenta at birth, the newborn now must assume control of glucose homeostasis through oral feedings. The others at this time are not a priority.

An infant that is diagnosed with meconium aspiration displays which symptom? a) Pink skin b) No heart murmur c) Respirations of 45 d) Intercostal and substernal retractions

Intercostal and substernal retractions

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being delivered. Which of the following interventions should the nurse implement as a result of this finding? a) Gently shaking the infant b) Flicking the sole of the infant's foot c) Administration of oxygen via a bag and mask d) Intubation and suctioning of the trachea

Intubation and suctioning of the trachea

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? a) Hyperalert state b) Jitteriness c) Loud and forceful crying d) Serum glucose level of 60 mg/dl

Jitteriness

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? a) Hyperalert state b) Jitteriness c) Loud and forceful crying d) Serum glucose level of 60 mg/dl

Jitteriness

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode? a) Serum glucose level of 60 mg/dl b) Jitteriness c) Hyperalert state d) Loud and forceful crying

Jitteriness Explanation: Hypoglycemia in a neonate is expressed as jitteriness, lethargy, diaphoresis, and a serum glucose level below 40 mg/dl. A hyperalert state in a neonate is more suggestive of neuralgic irritability and has no correlation to blood glucose levels. Weak crying is found in babies with hypoglycemia. A serum glucose level of 60 mg/dl is a normal level.

a client delivers a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home?

Keep the newborn wrapped in a blanked with a cap on its head

A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which of the following should the nurse recommend to the client to improve pelvic floor tone?

Kegel exercises

A newborn is identifies as extremely low birth weight placing the newborn's weight at which level?

Less than 1,000 g.

A newborn is identifies as extremely low birth weight placing the newborn's weight at which level?

Less than 1,000 g. An extremely low-birth-weight newborn weighs less than 1,000 g. A very-low-birthweight newborn weighs less than 1,500 g. A large-for-gestational-age newborn typically weighs more than 4,000 g. A small-for-gestational-age newborn or a low-birth-weight newborn typically weighs about 2,500 g.

A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) Less than 1,000 g b) Less than 1,500 g c) More than 4,000 g d) Approximately 2,500 g

Less than 1,500 g

A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) More than 4,000 g b) Less than 1,500 g c) Less than 1,000 g d) Approximately 2,500 g

Less than 1,500 g

A newborn is designated as very low birthweight. The nurse understands that this newborn's weight is: a) Approximately 2,500 g b) More than 4,000 g c) Less than 1,500 g d) Less than 1,000 g

Less than 1,500 g Correct Explanation: A very-low-birthweight newborn weighs less than 1,500 g. A large-for-gestational-age newborn typically weighs more than 4,000 g. A small-for-gestational-age newborn or a low-birthweight newborn typically weighs about 2,500 g. An extremely-low-birthweight newborn weighs less than 1,500 g.

Which of the following would you expect to assess in an infant with hypoglycemia? a) Prolonged jaundice b) Limpness or jitteriness c) Pain along the sixth cranial nerve d) Excessive hunger

Limpness or jitteriness Correct Explanation: Hypoglycemia (reduced glucose serum level) usually presents with jitteriness.

lochia

Lochia is the vaginal discharge that occurs after birth and continues for approximately four to eight weeks.

At the birth of a high-risk newborn, what is the nurse's priority action to prevent cerebral hypoxia?

Maintain adequate respirations.

A client complains to the nurse of pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints?

Maintain correct posture and positioning.

Which action could the nurse initiate to reduce the discomfort of a woman in labor whose fetus is in an occiput posterior position?

Massage her lower back. Counterpressure against the woman's back by a support person can be helpful in reducing this type of pain.

Upon assessment, a nurse notes the client has a pulse of 90 bpm, moderate lochia, and a boggy uterus. What should the nurse do next?

Massage the client's fundus. Tachycardia and a boggy fundus in the postpartum woman indicate excessive blood loss. The nurse would massage the fundus to promote uterine involution. It is not priority to notify the healthcare provider, assess blood pressure, or change the peri-pad at this time.

The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn?

Maternal Smoking during pregnancy Asthma exacerbations during pregnancy Drug abuse

When reviewing the medical record of a newborn who is large for gestational age (LGA), which of the following factors would the nurse identify as having increased the newborn's risk for being LGA? a) Low weight gain during pregnancy b) Fetal exposure to low estrogen levels c) Low maternal birth weight d) Maternal pregravid obesity

Maternal pregravid obesity

When reviewing the medical record of a newborn who is large for gestational age (LGA), which of the following factors would the nurse identify as having increased the newborn's risk for being LGA? a) Fetal exposure to low estrogen levels b) Low weight gain during pregnancy c) Maternal pregravid obesity d) Low maternal birth weight

Maternal pregravid obesity Correct Explanation: The nurse should identify maternal pregravid obesity as a risk factor for the development of LGA newborns. The other risk factors for the development of LGA newborns include fetal exposure to high estrogen, excess weight gain during pregnancy, gestational diabetes and high maternal birth weight.

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. Which of the following should the nurse expect when assessing the condition of the newborn? a) Tremors, irritability, and high-pitched cry b) Seizures, respiratory distress, cyanosis, and shrill cry c) Meconium aspiration in utero or at birth d) Yellow appearance of the newborn's skin

Meconium aspiration in utero or at birth

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. Which of the following should the nurse expect when assessing the condition of the newborn? a) Meconium aspiration in utero or at birth b) Yellow appearance of the newborn's skin c) Tremors, irritability, and high-pitched cry d) Seizures, respiratory distress, cyanosis, and shrill cry

Meconium aspiration in utero or at birth Correct Explanation: Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.

A nurse is caring for a newborn whose chest x-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. The nurse should prepare for the management of which dangerous conditions when providing care to this newborn? a) Choanal atresia b) Diaphragmatic hernia c) Meconium aspiration syndrome d) Pneumonia

Meconium aspiration syndrome

A preterm infant is receiving indomethacin. What is a priority assessment following administration of indomethacin? Select all that apply.

Monitor urine output. Observe for bleeding.

A perinatal nurse is providing care for a large for gestational age neonate admitted to the observational unit after a complicated vaginal birth resulting in shoulder dystocia. Which assessment would be a priority for the nurse to perform?

Moro assessment

A perinatal nurse is providing care for a large for gestational age neonate admitted to the observational unit after a complicated vaginal birth resulting in shoulder dystocia. Which assessment would be a priority for the nurse to perform?

Moro assessment Thoroughly assess the LGA newborn at birth to identify traumatic birth injuries such as fractured clavicles resulting from the trauma. Shoulder injury may result and can be identified with an absent Moro reflex on injured side. The Ballard Scale is a commonly used technique of gestational age assessment. The Dubowitz assessment is a neurological assessment included in the Ballard assessemnt. Testing the suck reflex would not be a priority.

Respiratory Distress Syndrome signs:

Observe the infant for expiratory grunting, shallow breathing, nasal flaring, chest wall retractions, seesaw respirations, and generalized cyanosis. Auscultate the heart and lungs, noting tachycardia (rates above 150 to 180), fine inspiratory crackles, and tachypnea (rates above 60 breaths per minute).

What is the first action the nurse takes in surfactant administration? a) Call pharmacy for medication. b) Obtain and document baseline vital signs. c) Change the infant's diaper. d) Hold feedings.

Obtain and document baseline vital signs.

What is the first action the nurse takes in surfactant administration?

Obtain and document baseline vital signs. Obtaining a baseline set of vital signs is the first step in surfactant administration. The nurse will need a baseline in case there is any reaction to the medication administration. The other choices are not the first thing done before instilling this medication.

What is the first action the nurse takes in surfactant administration? a) Hold feedings. b) Call pharmacy for medication. c) Obtain and document baseline vital signs. d) Change the infant's diaper.

Obtain and document baseline vital signs. Correct Explanation: Obtaining a baseline set of vital signs is the first step in surfactant administration. The nurse will need a baseline in case there is any reaction to the medication administration. The other choices are not the first thing done before instilling this medication.

AFTERPAINS

Painful contractions of the uterus that occur for several days after delivery

____________ jaundice is manifested within the first 24 hours of life when total bilirubin levels increase by more than 5 mg/dL/day and the total serum bilirubin level is higher than 17 mg/dL in a full-term infant. This condition requires intervention

Pathologic

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

Peeling and wrinkling of the neonate's epidermis

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

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

Which of the following places newborns at risk for ongoing health problems? a) Average weight b) Term birth c) Vaginal delivery d) Perinatal asphyxia

Perinatal asphyxia Correct Explanation: Several disorders can place newborns at risk for ongoing health problems such as prematurity, low birth weight, congenital abnormalities, perinatal asphyxia, and birth trauma. These conditions need further nursing assessment and care for optimal growth and healing. The other choices do not place a risk on the infant.

When preparing to resuscitate a preterm newborn, the nurse would perform which action first?

Place the newborn's head in a neutral position.

When preparing to resuscitate a preterm newborn, which of the following would the nurse do first? a) Administer epinephrine. b) Hyperextend the newborn's neck. c) Place the newborn's head in a neutral position. d) Use positive-pressure ventilation.

Place the newborn's head in a neutral position.

When preparing to resuscitate a preterm newborn, the nurse would perform which action first?

Place the newborn's head in a neutral position. When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation.

When preparing to resuscitate a preterm newborn, which of the following would the nurse do first? a) Use positive-pressure ventilation. b) Administer epinephrine. c) Hyperextend the newborn's neck. d) Place the newborn's head in a neutral position.

Place the newborn's head in a neutral position. Correct Explanation: When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive-pressure ventilation is used if the newborn is apneic or gasping or the pulse rate is less than 100 beats per minute. Epinephrine is given if the heart rate is less than 60 beats per minute after 30 seconds of compression and ventilation.

The nurse caring for a small for gestational age newborn in the specialcare nursery. What characteristics are commonly documented? Select all that apply.

Poor skin turgor Sparse or absent hair Diminished muscle tissue

A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning? a) Administration of chilled oxygen to reduce lung spasm b) Administration of dry oxygen to avoid over-humidification c) Increased inspiratory pressure; decreased expiratory pressure d) Positive end-expiratory pressure to increase oxygenation

Positive end-expiratory pressure to increase oxygenation

A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning? a) Administration of chilled oxygen to reduce lung spasm b) Positive end-expiratory pressure to increase oxygenation c) Increased inspiratory pressure; decreased expiratory pressure d) Administration of dry oxygen to avoid over-humidification

Positive end-expiratory pressure to increase oxygenation Correct Explanation: Positive end-expiratory pressure, like expiratory grunting, prevents alveoli from fully closing on expiration and reduces the respiratory effort needed for inspiration.

The neonatal intensive care nurse admits an infant of a diabetic mother to the unit with symptoms of respiratory distress. The infant is jaundiced with a ruddy skin color. Which action would be a priority?

Prepare for repeat hematocit levels q12h.

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth. The findings are consistent with uterine rupture. An abrupt change in the fetal heart rate pattern is often the most significant finding associated with uterine rupture. Others are reports of pain in the abdomen, shoulder, or back in a laboring woman who had previous good pain relief from epidural anesthesia. Falling blood pressure and rising pulse may be associated with hypovolemia caused by occult bleeding. The treatment is immediate cesarean birth.

A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?

Prepare the client for a cesarean birth. Cephalopelvic disproportion is associated with postterm pregnancy. This client will not be able to vaginally give birth and should be prepared for a cesarean birth. Lithotomy position, artificial rupture of membranes, and oxytocin are interventions for a vaginal birth.

When planning the care for a small for gestational age (SGA) newborn, which action would the nurse determine as a priority?

Preventing hypoglycemia with early feedings

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?

Provide a mobile the child can see no matter how the child is turned. Preterm infants are able to focus at short distances before they can see well at long distances. A mobile offers short-distance stimulation.

An 18-year-old client has given birth to a very-low-birth-weight preterm infant. Which of the following should the nurse consider to prevent the newborn from losing body temperature? a) Hold the newborn close, rocking gently. b) Provide isolette or radiant warmer care to the newborn. c) Give the newborn a warm water bath. d) Administer vitamin K to the newborn.

Provide isolette or radiant warmer care to the newborn. Correct Explanation: The nurse should place the infant in an isolette to simulate the uterine environment as closely as possible and to keep the infant warm. The isolette maintains even levels of temperature, humidity, and oxygen. A hood covers it, and nurses can give care through portholes. Holding and frequent handling of the newborn should be avoided to prevent loss of energy. Minimal handling helps the neonate to conserve energy. Administration of vitamin K to the infant is necessary to prevent bleeding in the infant because the newborn is unable to produce its own vitamin K during the early stages of life. It does not help in providing warmth to the baby. The infant is not given baths until later because this often results in loss of body temperature.

Which action would be most appropriate for the woman who experiences dysfunctional labor in the first stage of labor?

Provide ongoing communication about what is happening. Dysfunctional labor at any point is frustrating to women. Maintaining open lines of communication at least keeps the woman well informed about what is happening.

An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHN). What intervention implemented by the nurse would be appropriate for treating this client?

Provide oxygen by oxygen hood or ventilator.

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?

RDS is caused by a lack of alveolar surfactant.

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?

RDS is caused by a lack of alveolar surfactant. Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest X-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute).

An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which is true for a newborn with RDS? a) Respiratory symptoms of RDS typically improve within a short period of time. b) RDS is caused by a lack of alveolar surfactant. c) Glucocorticosteroid is given to the newborn following birth. d) RDS is characterized by heart rates below 50 beats per minute.

RDS is caused by a lack of alveolar surfactant. Correct Explanation: Respiratory distress syndrome (RDS) is a serious breathing disorder caused by a lack of alveolar surfactant. Betamethasone, a glucocorticosteroid, is often given to the mother 12 to 24 hours before a preterm birth to help reduce the severity of RDS, not to the newborn following birth. Respiratory symptoms in the newborn with RDS typically worsen within a short period of time after birth, not improve. Diagnosis of RDS is made based on a chest x-ray and the clinical symptoms of increasing respiratory distress, crackles, generalized cyanosis, and heart rates exceeding 150 beats per minute (not below 50 beats per minute).

the loss of body heat to cooler, solid surfaces that are in proximity but not in direct contact with the newborn

Radiation

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer? a) Radiation b) Convection c) Evaporation d) Conduction

Radiation Correct Explanation: Radiation heat loss results from the transfer of heat in an environment from warmer to cooler objects that are not in direct contact with each other.

What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? a) Skin as pink b) Respirations as increased and high c) Chest expansion as normal d) Heart rate as normal

Respirations as increased and high

What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? a) Respirations as increased and high b) Skin as pink c) Chest expansion as normal d) Heart rate as normal

Respirations as increased and high Correct Explanation: Infants with meconium aspiration syndrome may show signs of respiratory distress (tachypnea, cyanosis, retractions, chest retractions). The other choices document normal findings.

A newborn is being monitored for retinopathy of prematurity. Which of the following conditions predisposes an infant to this condition? a) Down syndrome b) Esophageal atresia c) Hydrocephalus d) Respiratory distress syndrome

Respiratory distress syndrome

A newborn is being monitored for retinopathy of prematurity. Which of the following conditions predisposes an infant to this condition? a) Esophageal atresia b) Down syndrome c) Respiratory distress syndrome d) Hydrocephalus

Respiratory distress syndrome Correct Explanation: Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.

A client who has given birth is being discharges from the the health care facility. She wants to know how safe it would be for her to have intercourse. Which of the following instructions should the nurse provide to the client regarding intercourse after childbirth?

Resume intercourse if bright-red bleeding stops.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration?

RoP

Amount of lochia

Scant: a 1- to 2-in lochia stain on the perineal pad or approximately a 10-mL loss Light or small: an approximately 4-in stain or a 10- to 25-mL loss Moderate: a 4- to 6-in stain with an estimated loss of 25 to 50 mL Large or heavy: a pad is saturated within 1 hour after changing it

diastasis recti

Separation of the longitudinal muscles of the abdomen (rectus abdominis) during pregnancy.

The nurse would prepare a client for amnioinfusion when which action occurs?

Severe variable decelerations occur and are due to cord compression. Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.

A nurse is caring for a newborn with jaundice undergoing phototherapy. What intervention is appropriate when caring for the newborn? a) Shield the newborn's eyes b) Expose the newborn's skin minimally c) Discourage feeding the newborn d) Discontinue therapy if stools are loose, green, and frequent

Shield the newborn's eyes

When teaching the new mother about breast-feeding, the nurse is correct when providing what instructions?

Show mothers how to initiate breast-feeding within 30 minutes of birth; Encourage breast-feeding of the newborn infant on demand; Place baby in uninterrupted skin-to-skin contact with the mother.

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which of the following additional signs should the nurse consider as indications of respiratory distress syndrome (RDS) in the newborn? a) Inspiratory grunt b) Deep inspiration c) Sternal retraction d) Expiratory lag

Sternal retraction Correct Explanation: The nurse should consider sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration.

Meconium is the first stool passed in a newborn. What would be the correct documentation of the meconium? a) Formed green b) Soft brown c) Seedy yellow d) Sticky forest green

Sticky forest green

Meconium is the first stool passed in a newborn. What would be the correct documentation of the meconium? a) Soft brown b) Sticky forest green c) Seedy yellow d) Formed green

Sticky forest green Correct Explanation: Meconium is usually a sticky, forest-green liquid. It contains bile acids, salts, and mucus. The other choices describe stool at various stages after the passage of meconium.

A nurse is assessing an infant who has experienced asphyxia at birth. Which finding indicates that the resuscitation methods have been successful? a) Heart rate of 80 bpm b) Jitteriness c) Hypotonia d) Strong cry

Strong cry

A concerned client tells the nurse that her husband, who was very excited about the baby before birth, is apparently happy but seems to be afraid of caring for the baby. What suggestions should the nurse give to the client's husband to resolve the issue?

Suggest that her husband begin by holding the baby frequently.

Which of the following would be signs of dehydration in a newborn? a) Eight wet diapers a day b) 10% weight gain c) Sunken fontanels d) Frequent feedings

Sunken fontanels Correct Explanation: Sunken fontanels in a newborn are a sign of dehydration. Other signs are sunken eyeballs, decreased urine output, lethargy, decreased skin turgor, decreased body weight, and irritability.

Which of the following would be signs of dehydration in a newborn? a) Eight wet diapers a day b) 10% weight gain c) Sunken fontanels d) Frequent feedings

Sunken fontanels Sunken fontanels in a newborn are a sign of dehydration. Other signs are sunken eyeballs, decreased urine output, lethargy, decreased skin turgor, decreased body weight, and irritability.

A 39-year-old multigravida with diabetes presents to the clinic at 32 weeks' gestation because she has not felt the fetus moving lately. FHR is absent; sonogram confirms that the fetus has died. The nurse's institution has a policy of taking photographs of such fetuses once they are born. The nurse informs the woman that pictures have been taken and asks her if she wants them; she angrily tells the nurse no, then bursts into tears. How should the nurse respond?

Tell her that the hospital will keep the photos for her in case she changes her mind. Emotional care of the woman is complex. The woman may need time to move through the stages of grief and the responses of grief vary from person to person. The mother may request the items later and they should be stored or kept for a year after the delivery. There is no need to apologize to the client. It would be inappropriate to console her with the fact that she has other children. It negates her feelings and is not supportive of the woman at this time.

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

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

what's the most important thing nurse needs to know about managing newborn with persistent pulmonary hypertension

That Almost any procedure, such as suctioning, weighing, changing diapers, or positioning, can precipitate severe hypoxemia due to the instability of the pulmonary vasculature. Therefore, minimize the newborn's exposure to stimulation as much as possible.

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching?

The client needs to notify the healthcare provider for blurred vision as this can indicate preeclampsia in the postpartum period. The client should also notify the healthcare provider for a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge.

how to administer surfactant replacement therapy?

The earlier the surfactant is administered, the better the effect on gas exchange. Following surfactant administration, the newborn must be closely monitored, and preparation for reduced need for oxygen and ventilation should be anticipated

The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding?

The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.

At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate?

The infant was a preterm, low birth weight and small for gestational age

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The testes in the child may be undescended. b) The newborn may have short nails and hair. c) The infant may have excess of lanugo and vernix caseosa. d) The newborn may look wrinkled and old at birth.

The newborn may look wrinkled and old at birth.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth. Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The newborn may have short nails and hair. b) The newborn may look wrinkled and old at birth. c) The testes in the child may be undescended. d) The infant may have excess of lanugo and vernix caseosa.

The newborn may look wrinkled and old at birth. Correct Explanation: Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. Which of the following might the nurse observe in the newborn during routine assessment? a) The newborn may have short nails and hair. b) The infant may have excess of lanugo and vernix caseosa. c) The testes in the child may be undescended. d) The newborn may look wrinkled and old at birth.

The newborn may look wrinkled and old at birth. Correct Explanation: Postterm babies are those born past 42 weeks of gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants.

The nurse observes a neonate delivered at 28 weeks' gestation. Which finding would the nurse expect to see? a) The pinna of the ear is soft and flat and stays folded. b) The skin is pale, and no vessels show through it. c) The neonate has 7 to 10 mm of breast tissue. d) Creases appear on the interior two-thirds of the sole.

The pinna of the ear is soft and flat and stays folded.

The nurse observes a neonate delivered at 28 weeks' gestation. Which finding would the nurse expect to see? a) The pinna of the ear is soft and flat and stays folded. b) The neonate has 7 to 10 mm of breast tissue. c) The skin is pale, and no vessels show through it. d) Creases appear on the interior two-thirds of the sole.

The pinna of the ear is soft and flat and stays folded. Correct Explanation: The ear has a soft pinna that's flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.

A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?

The supply of brown adipose tissue is not developed.

hemolytic disease of the newborn

This disease occurs in the fetus if the fetus is Rh+ while the mother is Rh-.

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which of the following interventions should the nurse implement at this point? a) Take a blood sample b) Immediately suction the infant's airway c) Place the infant supine in a radiant heat warmer d) Tip the infant into an upright position

Tip the infant into an upright position

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which of the following interventions should the nurse implement at this point? a) Tip the infant into an upright position b) Immediately suction the infant's airway c) Take a blood sample d) Place the infant supine in a radiant heat warmer

Tip the infant into an upright position Explanation: It's important the infant is tipped to an upright position following administration of surfactant and the infant's airway is not suctioned for as long a period as possible after administration of surfactant to help it reach lower lung areas and avoid suctioning the drug away. A blood sample may be taken to rule out a streptococcal infection, which mimics the signs of RDS, but this would have been done before administration of surfactant. The infant should not be placed supine in a radiant heat warmer at this time but should be held in an upright position.

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which intervention should the nurse implement at this point?

Tip the infant into an upright position. It's important the infant is tipped to an upright position following administration of surfactant and the infant's airway is not suctioned for as long a period as possible after administration of surfactant to help it reach lower lung areas and avoid suctioning the drug away. A blood sample may be taken to rule out a streptococcal infection, which mimics the signs of RDS, but this would have been done before administration of surfactant. The infant should not be placed supine in a radiant heat warmer at this time but should be held in an upright position.

A preterm infant is transferred to a distant hospital for care. When her parents visit her, which of the following would be most important for you to urge them to do? a) Stand so the baby can see them. b) Touch and, if possible, hold her. c) Bring a piece of clothing for her. d) Call the baby by her name.

Touch and, if possible, hold her.

In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus.

True

Preterm infant deaths account for 80% to 90% of infant mortality in the first year of life.

True

Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation?

Turn off the pitocin. Hypertonic labor may result from an increased sensitivity of uterine muscle to oxytocin induction or augmentation. Treatment for this iatrogenic cause of hypertonic labor is to decrease or shut off the oxytocin infusion.

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the mid line to the right. What intervention will help the client most?

Urinary catheterization.

A client is undergoing a routine check-up 2 months after the birth of her child. The nurse understands that the client is not practicing Kegel exercises. Which of the following should the nurse tell the client is caused by poor perineal muscular tone?

Urinary incontinence.

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance.

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin, with so little muscle. The nurse responds based on the understanding about which of the following? a) The newborn was exposed to an infection while in utero. b) The newborn aspirated meconium, causing the wasted appearance. c) A postterm newborn has begun to break down red blood cells more quickly. d) With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs. Explanation: After 42 weeks' gestation, the placenta loses its ability to provide adequate oxygen and nutrients to the fetus, causing the fetus to use stored nutrients to stay alive. This leads to wasting. Meconium aspiration can occur with postterm newborns, but this is not the reason for the baby's wasted appearance. Hyperbilirubinemia occurs with the increased breakdown of red blood cells, but this too would not account for the wasted appearance. Exposure to an intrauterine infection is unrelated to the wasted appearance.

he nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breast-fed newborns?

Yellowish gold color Stringy to pasty consistency

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which of the following would the nurse do next? A) Document this as pseudomenstruation B) Notify the practitioner immediately C) Obtain a culture of the discharge D) Inspect for engorgement

a Document this as pseudomenstruation

Respiratory Distress Syndrome

a breathing disorder resulting from lung immaturity and lack of alveolar surfactant, which keeps the air sacs in the lungs from collapsing and allows them to inflate easily. *Without surfactant, the alveoli collapse at the end of expiration. *preterm newborns

imperforate anus

a congenital defect in which the rectal opening is missing or blocked.

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention?

a forceps and vacuum-assisted birth A forceps-and-vacuum-assisted birth is required for the client having a prolonged second stage of labor. The client may require a cesarean birth if the fetus cannot be delivered with assistance. A precipitous birth occurs when the entire labor and birth process occurs very quickly. Artificial rupture of membranes is done during the first stage of labor.

Therapeutic hypothermia

a promising neuroprotective intervention for newborns with moderate to severe perinatal encephalopathy after perinatal asphyxia and has currently been incorporated in many neonatal intensive care units

transient tachypnea of the newborn

a self-limiting condition involving a mild degree of respiratory distress that requires minimal intervention, and resolves over 24 to 72 hours. * It is described as the retention of lung fluid or transient pulmonary edema. * It usually occurs within a few hours of birth and resolves by 72 hours of age.

A client with group AB blood whose husband has group O blood has just given birth. Which complication or test result is a major sign of ABO blood incompatibility that the nurse should look for when assessing this neonate? a) Jaundice within the first 24 hours of life b) Jaundice after the first 24 hours of life c) Negative Coombs' test d) Bleeding from the nose or ear

a) Jaundice within the first 24 hours of life Explanation: The neonate with an ABO blood incompatibility with its mother will have jaundice within the first 24 hours of life. The neonate would have a positive Coombs' test result. Jaundice after the first 24 hours of life is physiologic jaundice. Bleeding from the nose and ear should be investigated for possible causes but probably isn't related to ABO incompatibility

When caring for a week-old infant with jaundice, the nurse observes the infant's urine to be dark in color. The nurse would also expect to assess what as indicative of significant hyperbilirubinemia? Select all that apply. a) Poor feeding and lethargy b) Decreased volume of urination c) Light, tan-colored stool after milk intake d) Jaundice limited to the nose, eyes, and ears e) Late passage of meconium stool

a) Poor feeding and lethargy c) Light, tan-colored stool after milk intake e) Late passage of meconium stool Poor feeding and lethargy, late passage of meconium stool, and light, tan-colored stool after milk intake are features of significant hyperbilirubinemia. Decrease in volume of urination is not seen with hyperbilirubinemia. Jaundice limited to the nose, eyes and ears is a physiologic jaundice, and does not indicate significant hyperbilirubinemia

Which factors could increase the risk of overheating in a newborn? (Select all that apply.) a. Limited ability of diaphoresis b. Underdeveloped lungs c. Isolette that is too warm d. Limited sugar stores e. Lack of brown fat

a. Limited ability of diaphoresis c. Isolette that is too warm

The nurse wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met? a. Promote early breastfeeding for the infants b. Avoid skin-to-skin contact with the mother until the infants are 8 hours old c. Keep the infant transporter temperature between 80℉ and 85℉ d. Avoid bathing the newborn until they are 24 hours old

a. Promote early breastfeeding for the infants

A nursing student is aware that fetal gas exchange takes place in which area?a. placentab. bronchiolesc. uterusd. lungs

a. placenta

A mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that:a. this is a normal finding.b. this is most likely a symptom of impending diarrhea.c. her child may be developing an allergy to breast milk.d. her child will need to be isolated until the stool can be cultured.

a. this is a normal finding.

At what point should the nurse expect a healthy newborn to pass meconium?a. within 24 hours after birthb. before birthc. within 1 to 2 hours of birthd. by 12 to 18 hours of life

a. within 24 hours after birth

What is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight?

ability to tolerate early oral feeding

A nurse is reviewing the maternal history and medical record of an SGA newborn. Which finding would the nurse identify as a placental factor contributing to the newborn's current state?

abnormal cord insertion

When documenting the newborn's weight on a growth chart, the nurse recognizes the newborn is large-for-gestational-size based on which percentile on growth charts?

above 90th percentile

The nurse places a newborn experiencing respiratory difficulty under a radiant warmer to prevent which complication?

acidosis A radiant warmer is use to keep the infant warm. When an infant is cold, brown fat metabolism leads to acidosis, which would further complicate respiratory difficulties.

the immune system's responses may be either natural or

acquired

bonding is affected by

affected by a multitude of factors, including the parent's socioeconomic status, family history, role models, support systems, cultural factors, and birth experiences.

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?

amniotomy Amniotomy is considered a surgical method of cervical ripening. Breast stimulation is considered a nonpharmacologic method for ripening the cervix. Laminaria is a hygroscopic dilator that mechanically causes cervical ripening. Prostaglandins are pharmacologic methods for cervical ripening.

Tracheoesophageal fistula

an abnormal communication between the trachea and esophagus.

Third-degree laceration

anal sphincter also

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?

apnea A premature infant has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress.

During the newborn's assessment, which finding would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma?

asymmetrical movement

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's: A) Finger B) Heel C) Scalp vein D) Umbilical vein

b Heel

Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which of the following would the nurse be least likely to identify as a risk factor for this condition? A) Cesarean birth B) Shortened labor C) Central nervous system depressant during labor D) Maternal asthma

b Shortened labor

A woman with hydramnios has just given birth. The nurse recognizes that the infant must be assessed for which condition? a) ankyloglossia b) esophageal atresia c) torticollis d) talipes

b) esophageal atresia Esophageal atresia must be ruled out in any infant born to a woman with hydramnios (excessive amniotic fluid). Hydramnios occurs because, normally, a fetus swallows amniotic fluid during intrauterine life. A fetus with esophageal atresia cannot effectively swallow, so the amount of amniotic fluid can grow abnormally large. The other conditions listed are not associated with hydramnios.

A newborn is suspected of having fetal alcohol syndrome. Which finding would the nurse expect to assess? a) hydrocephaly b) flattened maxilla c) bradypnea d) hypoactivity

b) flattened maxilla A newborn with fetal alcohol syndrome exhibits characteristic facial features such as microcephaly (not hydrocephaly), small palpebral fissures, and abnormally small eyes, flattened or absent maxilla, epicanthal folds, thin upper lip, and missing vertical groove in the median portion of the upper lip. Bradypnea is not typically associated with fetal alcohol syndrome. Fine and gross motor development is delayed, and the newborn shows poor hand-eye coordination but not hypoactivity

In addition to newborns of diabetic mothers being at risk for hypoglycemia, these newborns are also at risk for which condition? a) hypermagnesemia b) hypocalcemia c) hyperkalemia d) hypobilirubinemia

b) hypocalcemia The newborn of the diabetic mother is at risk for hypocalcemia, hypomagnesemia, polycythemia with hyperviscosity, and hyperbilirubinemia. Potassium concerns are not a risk for these newborns

A nurse is caring for a large-for-gestational-age newborn. Which signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply. a) high-pitched, shrill cry b) lethargy and stupor c) appearance of central cyanosis d) respiratory difficulty e) bulging fontanels

b) lethargy and stupor c) appearance of central cyanosis d) respiratory difficulty The features indicating hypoglycemia in LGA infants include lethargy, stupor, fretfulness, respiratory difficulty, and central cyanosis. The other features include poor feeding in a previously well feeding infant and weak, whimpering cry. High-pitched, shrill cry and bulging fontanels are seen in increased intracranial pressure following head trauma in LGA infants

A nurse is caring for a baby girl born at 34 weeks' gestation. Which feature should the nurse identify as those of a preterm newborn? a) closely approximated labia b) shiny heels and palms c) scant coating of vernix d) paper-thin eyelids

b) shiny heels and palms A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in postterm newborns and is excessive in premature infants.

A nurse is teaching the mother of a newborn experiencing cocaine withdrawal about caring for the neonate at home. The mother stopped using cocaine near the end of her pregnancy. The nurse determines that additional teaching is needed when the mother identifies which action as appropriate for her newborn? a) offering a pacifier b) waking the newborn every hour c) checking the newborn's fontanels d) wrapping the newborn snugly in a blanket

b) waking the newborn every hour Stimuli need to be decreased. Waking the newborn every hour would most likely be too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive sucking. Checking the fontanels provides evidence of hydration

kernicterus

bilirubin staining of the basal nuclei of the brain

During this initial period, the infant is in a quiet, alert state, looking directly at the holder.

bonding is affected by

A client is experiencing shoulder dystocia during birth. The nurse would place priority on performing which assessment postbirth?

brachial plexus assessment The nurse should identify nerve damage as a risk to the fetus in cases of shoulder dystocia. Other fetal risks include asphyxia, clavicle fracture, central nervous system injury or dysfunction, and death. Extensive lacerations is a poor maternal outcome due to the occurrence of shoulder dystocia. Cleft palate and cardiac anomalies are not related to shoulder dystocia.

A nurse is to care for a client during the postpartum period. The client complains of pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts?

breast are hard and tender

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? a) Small pink or red patches on the baby's eyelids, and back of the neck b) Bright red, raised bumpy area noted above the right eye c) Blue or purplish splotches on buttocks d) Fine red rash noted over the chest and back

bright red, raised bumpy area noted above the right eye

What medication does the nurse anticipate administering to the preterm newborn as an inhalant to improve the lungs' ability to mature? a) heparin b) neomycin c) surfactant d) Rho(D) immune globulin

c) surfactant Treatment begins shortly after birth with synthetic or natural surfactant, obtained from animal sources or extracted from human amniotic fluid. The newborn receives surfactant as an inhalant through a catheter inserted into an endotracheal tube. The therapy may be preventive for development of respiratory distress syndrome in the newborn at risk.

A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which of the following would the nurse be most likely to include in the teaching? (Select all that apply.) A) Supplementing with iron if the woman is breast-feeding B) Providing supplemental water intake with feedings C) Feeding the newborn every 2 to 4 hours during the day D) Burping the newborns frequently throughout each feeding E) Usingfeeding time for promoting closeness

c,D,e

A new mother who is breast-feeding her newborn asks the nurse, "How will I know if my baby is drinking enough?"Which response by the nurse would be most appropriate? A) "If he seems content after feeding, that should be a sign." B) "Make sure he drinks at least 5 minutes on each breast." C) "He should wet between 6 to 12 diapers each day." D) "If his lips are moist, then he's okay.

c. "He should wet between 6 to 12 diapers each day."

A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the:

chest rises with each bag compression.

A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the:

chest rises with each bag compression. If air is entering the lungs of a newborn, his or her chest muscles are so elastic that the chest can be seen rising and falling with bag compression.

A premature, 38-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply.

clay-colored stools tea-colored urine increased serum bilirubin levels

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?

conduction A conduction heat loss results from direct contact with an object that is cooler.

Which factors in a maternal birth record are risks for fetal growth restriction?

congenital malformations, infections, or placental insufficiency

Fourth-degree laceration

continues through anterior rectal wall

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction?

contractions most forceful in the middle of uterus rather than the fundus Contractions that are more forceful in the midsection of the uterus rather than in the fundus suggest hypertonic uterine dysfunction. Reports of severe back pain are associated with a persistent occiput posterior position due to the pressure of the fetal head on the woman's sacrum and coccyx. Cervical dilation that has not progressed past 2 cm is associated with dysfunctional labor. A breech position is one in which the fetal presenting part is the buttocks or feet.

A woman is admitted to the labor suite with contractions every five minutes lasting one minute. She is postterm and has oligohydramnios. What does this increase the risk of during birth?

cord compression Oligohydramnios and meconium staining of the amniotic fluid are common complications of postterm pregnancy. Oligohydramnios increases the incidence of cord compression, which can lead to fetal distress during labor.

The nurse teaches the parents of a newborn with hyperbilirubinemia about home phototherapy using bilirubin lights. Which statement indicates that the teaching was successful? a) "We'll place the lights so that they are about 5 inches above our baby at all times." b) "We should see reddened areas on his skin, which means the treatment is working." c) "We will turn him every ½ hour to make sure that his whole body is exposed." d) "We'll take off the patches on his eyes when we're feeding him so he can look at us."

d) "We'll take off the patches on his eyes when we're feeding him so he can look at us." The lights are to be positioned about 12 to 30 inches above the newborn. The newborn is turned every 2 hours while under the bilirubin lights. Eye patches are removed during feedings so that the newborn can interact with the caregiver. Evidence of effectiveness is indicated by loose, green stools indicating that the bilirubin is being broken down.

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?a. Respiratory Rateb. Heart Ratec. Temperatured. Blood Pressure

d. Blood Pressure

Which of the following is an example of developmental care in the NICU? a) Giving medications b) Holding the infant c) Giving a bath d) Cluster care and activities

d. Cluster care and activities Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.

A nurse is transporting a neonate from the nursery to the mother's room. The nurse ensures that the neonate is moved in a warmed isolette to prevent heat loss by which mechanism?a. radiationb. evaporationc. conductiond. convection

d. convection

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?a. increase in the body temperatureb. increased appetitec. hyperglycemiad. lethargy and hypotonia

d. lethargy and hypotonia

A nurse is observing the interaction between a new mother and her neonate. The nurse notes that the neonate moves his head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response?a. habituationb. motor maturityc. self-quieting behaviord. orientation

d. orientation

The nurse recognizes that maternal factors can increase the chance of a large-for-gestational-age newborn. When reviewing maternal history, the nurse would interpret which factors as placing a newborn at risk for being LGA? Select all that apply.

diabetes mellitus multiparity history of postdates gestation

caput succedaneum

diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the a) aorta or aortic valve strictures. b) foramen ovale closes prematurely. c) pulmonary artery closes. d) ductus arteriosus remains open.

ductus arteriosus remains open.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:

ductus arteriosus remains open.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:

ductus arteriosus remains open. Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the a) foramen ovale closes prematurely. b) ductus arteriosus remains open. c) pulmonary artery closes. d) aorta or aortic valve strictures.

ductus arteriosus remains open. Explanation: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

A nurse is assessing a pregnant woman who has come to the clinic. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply.

dull low backache malodorous vaginal discharge dysuria Symptoms of preterm labor are often subtle and may include change or increase in vaginal discharge with mucus, water, or blood in it; pelvic pressure; low, dull backache; nausea, vomiting or diarrhea, and heaviness or aching in the thighs. Constipation is not known to be a sign of preterm labor. Preterm labor is assessed when there are more than six contractions per hour.

The nurse assesses that the fetus of a woman is in an occiput posterior position. Which description identifies the way the nurse would expect the client's labor to differ from others?

experience of additional back pain Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter dilatational stage of labor, it does not indicate the need to have the baby manually rotated, and it does not indicate a necessity for a vacuum extraction birth.

What is a classic sign of neonatal respiratory distress syndrome? Select all that apply.

expiratory grunting nasal flaring retractions tachypnea

A common symptom that would alert you that a preterm infant is developing respiratory distress syndrome is a) inspiratory "crowing." b) inspiratory stridor. c) expiratory grunting. d) expiratory wheezing.

expiratory grunting.

A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is:

expiratory grunting. Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).

A common symptom that would alert you that a preterm infant is developing respiratory distress syndrome is a) inspiratory "crowing." b) expiratory grunting. c) inspiratory stridor. d) expiratory wheezing.

expiratory grunting. Correct Explanation: Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).

A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?

external cephalic version External cephalic version is the turning of a fetus from a breech to a cephalic position before birth. It may be done as early as 34 to 35 weeks, although the usual time is 37 to 38 weeks of pregnancy. A trial birth is performed when a woman has a borderline (just adequate) inlet measurement and the fetal lie and position are good and involves allowing labor to take its normal course as long as descent of the presenting part and dilatation of the cervix continue to occur. Forceps, which are not commonly used anymore, and vacuum extraction are used to facilitate birth when other complications are present, but they would be less likely to be used with a fetus in breech position.

The client is 35 weeks of gestation and is being admitted for vaginal bleeding. She is stable at the time of admission. The priority nursing assessment for the client is for:

fetal heart tones. When a client is admitted for vaginal bleeding and is stable, the next priority assessment is to determine if the fetus is viable. The other options are not a higher priority than fetal heart tones.

The ___________________ is the fetal structure within the heart that allows blood to cross immediately to the left side and bypass the pulmonary circuit. When left side pressure gradients increase at birth, this opening closes, thereby establishing an extrauterine circulation pattern.

foramen ovale

A newborn that has a surfactant deficiency will have which assessment noted on a physical exam?

grunting Infants that are deficient in lung surfactant will show signs of respiratory distress: grunting, retracting, tachypnea, cyanosis, poor perfusion, hypotension, and skin mottling.

A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess?

head larger than body

Pelvic floor exercises

help to strengthen the pelvic floor muscles if done properly and regularly

A small-for-gestational age neonate is admitted to the observational nursery for blood work. Which result would require further assessment?

hematocrit: 80%

source of bilirubin in new born is the ___________ of erythrocyte.

hemolysis

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds Apnea is the cessation of breathing for a specific amount of time, and in newborns it usually occurs when the breath is held for 15 seconds. Apnea, cyanosis, respiratory distress, and increased oxygen demand are all consequences of hypothermia.

At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what does the nurse prepare her?

hospitalization, tocolytic therapy, and IM corticosteroids At 31 weeks gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allow for monitoring and a safe place if the woman continues and gives birth. Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the woman home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal kick counts is typically done with a postterm pregnancy.

The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which occurrence?

hypoglycemia Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.

An obese woman with diabetes has just given birth to a term, large for gestational age (LGA) newborn. Which condition should the nurse most expect to find in this infant?

hypoglycemia LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes which was poorly controlled (the cause of the large size), the infant would have had an increased blood glucose level in utero to match the mother's; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia.

A woman with diabetes has just given birth. While caring for this neonate, the nurse is aware that the child is at risk for which complication?

hypoglycemia Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus through the placenta. The neonate's liver cannot initially adjust to the changing glucose levels after birth. This inability may result in an overabundance of insulin in the neonate, causing hypoglycemia. Neonates of mothers with diabetes are not at increased risk for anemia, nitrogen loss, or thrombosis.

primary body temperature regulators are located in the ___________ and the central nervous system

hypothalamus

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days' postmature. Which physical finding does not confirm that this newborn is 12 days' postmature?

increased amounts of vernix

An infant that is diagnosed with meconium aspiration displays which symptom?

intercostal and substernal retractions Meconium aspiration is when the infant passes the first stool in utero and some of stool particles are ingested into the lungs at birth. This can cause the infant to be in distress displayed by mild cyanosis, tachypnea, retractions, hyperinflated chest, and hypercapnia.

human breast milk provides a passive mechanism to protect the newborn against the dangers of a deficient _______ defense system

intestinal

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?

intubation and suctioning of the trachea

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?

intubation and suctioning of the trachea Although there is some dispute regarding whether all infants with meconium staining need intubation, those with severe staining are usually intubated and meconium is suctioned from their trachea and bronchi. The nurse should not administer oxygen under pressure (bag and mask) until a meconium stained infant has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the infant and flicking the sole of his foot are methods of stimulating breathing in an infant experiencing apnea.

Conduction heat loss

is the loss of heat from the BODY SURFACE to COOLER SURFACES in direct contact

The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?

jitteriness

The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?

jitteriness Jitteriness is evident with a newborn with hypoglycemia as well as poor feeding with feeble sucking. The newborn would have tachypnea. Jaundice is not part of the newborn hypoglycemic syndrome. Positive Moro reflex and palmar creases are normal.

A nurse is reading a journal article about cesarean births and the indications for them. Place the indications for cesarean birth below in the proper sequence from most frequent to least frequent. All options must be used.

labor dystocia abnormal fetal heart rate tracing fetal malpresentation multiple gestation suspected macrosomia The most common indications for primary cesarean births include, in order of frequency, labor dystocia, abnormal fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected macrosomia.

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding?

lack of body posturing

A pregnant client is in labor. The nurse reviews a mother's prenatal history and finds that the client has diabetes mellitus. The nurse anticipates that the newborn is at risk for being

large-for-gestational-age.

A newborn is designated as very low birth weight. When weighing this newborn, the nurse would expect to find which weight?

less than 1,500 g

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?

less than 3 hours Precipitous labor is completed in less than 3 hours.

Which finding would the nurse expect to assess in an infant with hypoglycemia?

limpness or jitteriness Hypoglycemia (reduced glucose serum level) usually presents with jitteriness.

__________ is considered the first stool passed by newborn

meconium

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

meconium aspiration in utero or at birth

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

meconium aspiration in utero or at birth Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.

Which symptom would most accurately indicate that a newborn has experienced meconium aspiration during the birth process?

meconium stained fluids followed by tachypnea Meconium stained cord and skin indicates a potential of meconium aspiration, and the nurse should inform the primary care provider. But if the infant actually experiences respiratory distress following a birth with meconium stained fluids, the likelihood of meconium aspiration is greatly increased. Listlessness or lethargy by themselves does not indicate meconium aspiration. Bluish skin discoloration is normal in infants shortly after birth until the infant's respiratory system clears out all the amniotic fluid.

The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis?

meconium-stained skin and fingernails Postterm newborns typically exhibit the following characteristics: dry, cracked, peeling, wrinkled skin; vernix caseosa and lanugo are absent; long, thin extremities; creases that cover the entire soles of the feet; abundant hair on scalp; thin umbilical cord; long fingernails; limited vernix and lanug; and meconium-stained skin and fingernails.

Pregnant women dependent on opioids are maintained on as the current standard of care, which provides multiple benefits including improved prenatal care, reduced fetal mortality, and improved fetal growth

methadone

Which finding is indicative of hypothermia of the preterm infant?

nasal flaring Nasal flaring is a sign of respiratory distress. Infants with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

After a gavage feeding of a preterm neonate, the nurse aspirates 4 mL of undigested formula. This finding may indicate the development of which complication?

necrotizing enterocolitis

After a gavage feeding of a preterm neonate, the nurse aspirates 4 mL of undigested formula. This finding may indicate the development of which complication?

necrotizing enterocolitis An inability to digest enteral feeding is a sign that necrotizing enterocolitis (NEC), a destructive intestinal disorder that often occurs in preterm babies, may be developing. Dumping syndrome and malabsorption may be consequences of NEC. Neonates rarely develop acute gastroenteritis.

A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?

newly born preterm infant

A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?

newly born preterm infant Newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. The preterm newborn has an inadequate supply of brown fat. The preterm newborn also has decreased muscle tone and thus cannot assume the flexed fetal position, which reduces the amount of skin exposed to a cooler environment. Preterm newborns have large body surface areas compared to their weight. A term infant with RH factor will not be at any greater risk for heat lost and stabilized with age. A 2-day-old infant postmaturity would not be stabilized and would initially be at risk for heat loss. The diabetic infant is stabilized and heat loss is not a great concern.

A nursing student correctly identifies the most desirable position to promote an easy birth as which position?

occiput anterior Any presentation other than occiput anterior or a slight variation of the fetal position or size increases the probability of dystocia.

Losing a newborn is perhaps one of the most difficult situations for a family. Which action by the nurse would be the most appropriate if a newborn dies?

offering mementos to the family of the newborn

A nurse is conducting a class for a group of expectant couples on fetal growth and development. The nurse determines that additional teaching is needed when the class identifies which factor as playing an important role in fetal growth and development?

paternal factors

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

peeling and wrinkling of the neonate's epidermis

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?

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

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant?

placental factors

The small-for-gestational-age neonate is at increased risk for which complication during the transitional period?

polycythemia, probably due to chronic fetal hypoxia The small-for-gestational-age neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores.

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate?

postterm These characteristics are consistent with a postterm infant. An SGA infant has some of these same characteristics but does not exhibit long fingernails. A preterm infant has translucent skin, and an LGA infant has excessive subcutaneous fat.

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

potential lacerations and bleeding. Forcible rotation of the forceps can cause potential lacerations and bleeding. Cervical ripening increases the risk for uterine rupture in a client attempting vaginal birth after undergoing at least one previous cesarean birth. There is an increased risk for cord entanglement in multiple pregnancies. Damage to the maternal tissues happens if the cup slips off the fetal head and the suction is not released.

nurse cares for a newborn with a congenital cardiac anomaly. What component of nursing care is the priority for the new born?

prevent pain as much as possible

vitamin k and fat-soluble vitamin promotes blood clotting by increasing the synthesis of __________ by the liver

prostaglandins

The nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer?

radiation Radiation heat loss results from the transfer of heat in an environment from warmer to cooler objects that are not in direct contact with each other.

Sternal retractions are a sign of ______________ requiring immediate intervention, such as mechanical ventilation and other monitoring devices.

respiratory distress

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

respiratory distress syndrome

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

respiratory distress syndrome Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.

Which assessment finding would best validate a problem in a small-for-gestational age newborn secondary to meconium in the amniotic fluid?

respiratory rate of 60 to 70 bpm

Labor dystocia is an abnormal progression of labor. It is the most common cause of primary cesarean birth. When is it most common for labor dystocia to occur?

second stage of labor Labor dystocia can occur in any stage of labor, although it occurs most commonly once the woman is in active labor or when she reaches the second stage of labor.

A woman the nurse is caring for during labor is having contractions 2 minutes apart but rarely over 50 mm Hg in strength; the resting tone is high, 20 to 25 mm Hg. She asks what she can do to make contractions more effective. The nurse's best response would be that:

she needs to rest because her contractions are hypertonic. These contractions appear to be hypertonic because of the high resting tone. Hypertonic contractions occur because the uterus is being overstimulated or erratically stimulated. Rest is effective in helping contractions become more productive.

A nurse is caring for a baby girl born at 34 weeks' gestation. Which feature should the nurse identify as those of a preterm newborn?

shiny heels and palms A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in postterm newborns and is excessive in premature infants.

newborn normal glucose levels

should remain above 40 mg/dL

First-degree laceration

skin only

Following resuscitation, a 4-pound infant is admitted to the NICU. The nurse would initiate enteral feedings based on which assessment?

stabilized respiratory effort

Which sign would indicate dehydration in a newborn?

sunken fontanels Sunken fontanels in a newborn are a sign of dehydration. Other signs are sunken eyeballs, decreased urine output, lethargy, decreased skin turgor, decreased body weight, and irritability.

Management of TTN is ___________. As the retained lung fluid is absorbed by the infant's lymphatic system, the pulmonary status improves.

supportive

Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?

tea-colored urine Hyperbilirubinemia is associated with jaundice and tea-colored urine. Temperature instability, seizures, and feeble sucking suggest hypoglycemia.

yellowish-green staining of the umbilical cord and nails and skin indicates that

that meconium has been present for some time.

A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?

the 41-year-old client who conceived by in vitro fertilization The nurse should assess infertility treatment as a contributor to increased probability of multiple gestations. Multiple gestations do not occur with an adolescent birth; instead, chances of multiple gestations are known to increase due to the increasing number of women giving birth at older ages.

Convection heat loss

the flow of heat from the body surface to COOLER AIR

Evaporation heat loss

the loss of heat that occurs when a liquid is converted to a vapor

A nurse initiates bag and mask ventilation with an anesthesia bag on a newborn with no spontaneous respiratory effort. What controls the pressure of breaths delivered by an anesthesia bag?

the pressure the nurse uses when the hand squeezes against the bag

a woman has a episiotomy extending from vagina down to through the anal sphincter. What degree of tearing does this describe?

third degree

The "three Cs" of choking, coughing, and cyanosis in conjunction with feeding are considered the classic signs of ________________ and ________.

tracheoesophageal fistula and atresia

A cesarean birth results in an 11-pound (5-kg) infant. The nurse assesses the infant for which complication?

transient lung fluid A large for gestational age (LGA) infant born by cesarean is at risk for transient lung fluid. Broken clavicle and diaphragmatic paralysis are birth injuries associated with a vaginal birth of an LGA infant. All LGA infants are at risk for a serum glucose 45 mg/dL (2.50 mmol/L).

A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?

transverse lie A transverse lie, in which the fetus is more horizontal than vertical, occurs in women with pendulous abdomens, with uterine fibroid tumors that obstruct the lower uterine segment, with contraction of the pelvic brim, with congenital abnormalities of the uterus, or with hydramnios. Anterior fetal position and cephalic presentation are normal conditions. Occipitoposterior position tends to occur in women with android, anthropoid, or contracted pelves.

PHYSIOLOGIC JAUNDICE

unconjugated hyperbilirubinemia that occurs after the first postnatal day and can last up to 1 week. Total serum bilirubin concentrations peak in the first 3 to 5 postnatal days and decline to adult values over the next several weeks.

The nurse is admitting a newborn male for observation with the diagnosis of preterm. What assessment finding corresponds with this gestational age diagnosis?

undescended testes

Urinary retention is a major cause of __________, which allows excessive bleeding.

uterine atony

An infant is born with respiratory depression. The provider begins actions to maintain effective ventilation. When would the nurse initiate chest compressions?

when the heart rate is less than 60 beats per minute In a newborn, cardiac compressions are initiated when the heart rate is less than 60 beats per minute.

A client just delivered a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Dress the baby in a stockinette cap. b) Carry and handle the baby frequently. c) Place the baby under isolette care. d) Dress the baby to keep the body warm. e) Estimate the urinary flow by weighing the diaper.

• Dress the baby in a stockinette cap. • Place the baby under isolette care. • Estimate the urinary flow by weighing the diaper.

A client just delivered a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Estimate the urinary flow by weighing the diaper. b) Dress the baby in a stockinette cap. c) Dress the baby to keep the body warm. d) Place the baby under isolette care. e) Carry and handle the baby frequently.

• Dress the baby in a stockinette cap. • Place the baby under isolette care. • Estimate the urinary flow by weighing the diaper. Explanation: The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature often. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the child. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing.

The nurse in the NICU is caring for preterm newborns. Which of the following are recommended guidelines for care of these newborns? Select all that apply. a) Take the newborn's temperature often. b) Discourage contact with parents to maintain asepsis. c) Dress the newborn in ways to preserve warmth. d) Supply oxygen for the newborn, if necessary. e) Handle the newborn as much as possible. f) Give the newborn a warm bath immediately.

• Dress the newborn in ways to preserve warmth. • Take the newborn's temperature often. • Supply oxygen for the newborn, if necessary. Explanation: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.

A nurse is caring for a large for gestational age newborn. Which of the following signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply. a) Bulging fontanels b) Lethargy and stupor c) Appearance of central cyanosis d) Respiratory difficulty e) High-pitched shrill cry

• Lethargy and stupor • Respiratory difficulty • Appearance of central cyanosis Explanation: The features indicating hypoglycemia in LGA infants include lethargy, stupor and fretfulness, respiratory difficulty and central cyanosis. The other features include poor feeding in a previously well feeding infant and weak whimpering cry. High-pitched shrill cry and bulging fontanels are seen in increased intracranial pressure following head trauma in LGA infants.

The nurse caring for newborns on an obstetrical ward assesses a SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) Tight and moist skin b) Diminished muscle tissue c) Narrow skull sutures d) Poor skin turgor e) Increased fatty tissue f) Sparse or absent hair

• Poor skin turgor • Sparse or absent hair • Diminished muscle tissue

The nurse caring for newborns on an obstetrical ward assesses a SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) Diminished muscle tissue b) Tight and moist skin c) Sparse or absent hair d) Narrow skull sutures e) Poor skin turgor f) Increased fatty tissue

• Poor skin turgor • Sparse or absent hair • Diminished muscle tissue Explanation: Characteristics of the SGA newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts.

Which of the following would the nurse expect to find in a newborn who is considered small for gestational age? Select all that apply. a) Dry or thin umbilical cord b) Sunken abdomen c) Narrow skull sutures d) Poor muscle tone over buttocks e) Increased subcutaneous fat stores

• Sunken abdomen • Poor muscle tone over buttocks • Dry or thin umbilical cord Explanation: A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.

Which of the following would be most effective in reducing pain in the preterm newborn? Select all that apply. a) Increasing the volume on device alarms b) Using cool blankets to soothe the newborn c) Swaddling the newborn closely d) Offering a pacifier prior to a procedure e) Encouraging kangaroo care during procedures f) Removing tape quickly from the skin

• Swaddling the newborn closely • Encouraging kangaroo care during procedures • Offering a pacifier prior to a procedure

The nurse in the NICU is caring for preterm newborns. Which of the following are recommended guidelines for care of these newborns? Select all that apply. a) Give the newborn a warm bath immediately. b) Discourage contact with parents to maintain asepsis. c) Take the newborn's temperature often. d) Dress the newborn in ways to preserve warmth. e) Supply oxygen for the newborn, if necessary. f) Handle the newborn as much as possible.

• Take the newborn's temperature often. • Dress the newborn in ways to preserve warmth. • Supply oxygen for the newborn, if necessary.

Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply. a) Avoid using disposable equipment b) Use sterile gloves for an invasive procedure c) Avoid coming to work when ill d) Cover jewelry while washing hands e) Initiate universal precautions when caring for the infant

• Use sterile gloves for an invasive procedure • Avoid coming to work when ill • Initiate universal precautions when caring for the infant

An infant born 10 minutes prior was brought into the nursery for its exam. The nurse notices the infant's lip and palate are malformed. The father comes up to door and asks if the baby seems okay. What is the appropriate response by the nurse?

"Come on over and I will explain your infant's exam and findings." The nurse should include the parents and notify them of any visible anomalies right away. An in-depth discussion can take place later when the diagnosis is more definitive. Although the family may be in shock or denial, the nurse should give a realistic appraisal of the condition of their baby. Keeping communication lines open will lessen the family's feelings of helplessness and support their parental role.

a nurse in a local health care facility is caring for a new born with periventricular hemorrhage-intraventricular hemorrhage (PVH-IVH), who has recently been discharged from a local NICU. For which likely complications should the nurse assess?

-hydrocephalus -vision or hearing deficit - cerebral palsy

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g and the physician orders 0.1 mL/kg. How much would the nurse administer? a) 0.1 mL b) 0.25 mL c) 0.20 mL d) 0.15 mL

0.15 mL

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g and the physician orders 0.1 mL/kg. How much would the nurse administer? a) 0.25 mL b) 0.20 mL c) 0.15 mL d) 0.1 mL

0.15 mL Correct Explanation: The newborn weighs 1,500 g, which is equivalent to 1.5 kg. Calculating the dose based on 0.1 mL/kg, the nurse would administer 0.15 mL.

phases of maternal adaptation

1. taking-in maternal role phase - the mother is very passive and is dependent on others to care for her for the first 24 to 48 hours after giving birth. 2. taking-hold phase - Gaining self-confidence - mother demonstrates mastery over her own body's functioning and feels more confident in caring for her newborn. 3. letting go phase -when the mother begins to separate from the symbiotic relationship she and her newborn enjoyed during pregnancy and birth. -Resuming control over her life would denote the second phase of taking hold, during which the mother does resume control over her life and gains self-confidence in her newborn care.

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following? A) Normal progression of behavior B) Probable hypoglycemia C) Physiological abnormality D) Inadequate oxygenation

A From 30 to 120 minutes of age, the newborn enters the second stage of transition, that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.

A preterm infant born at 32 weeks gestation is being started on formula. When planning care, the nurse anticipates that which formula type is best?

A 24 cal/oz infant formula.

After teaching a group of nursing students about variations in newborn head size and appearance, the instructor determines that the teaching was successful when the students identify which of the following as a normal variation? (Select all that apply) A) Cephalhematoma B) Molding C) Closed fontanels D) Caput succedaneum E) Posterior fontanel diameter 1.5 cm

A,B,D

Which of the following is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight? a) Decreased muscle mass b) Face is angular and pinched c) Decreased body temperature d) Ability to tolerate early oral feeding

Ability to tolerate early oral feeding Explanation: Unlike preterm babies with low birth weights, a small for gestational age baby can safely tolerate early oral feeding. It usually has a coordinated sucking and swallowing reflex. Decreased muscle mass, decreased body temperature and an angular and pinched face are features common to both an SGA and a preterm baby.

A nurse is assessing a client during the postpartum period. Which of the following indicate normal postpartum adjustment?

Active bowel sounds, passing gas, and non-distended abdomen.

A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated? a) Administer 0.5 ml/kg/hr of breast milk enterally b) Administer dextrose intravenously c) Administer iron supplements d) Administer vitamin D supplements

Administer 0.5 ml/kg/hr of breast milk enterally

The nurse is assessing a preterm newborn who is in the neonatal intensive care unit (NICU) for signs and symptoms of overstimulation. Which of the following would the nurse be least likely to assess? A) Increased respirations B) Flaying hands C) Periods of apnea D) Decreased heart rate

Ans: A Feedback: Conversely, overstimulation may have negative effects by reducing oxygenation and causing stress. A newborn reacts to stress by flaying the hands or bringing an arm up to cover the face. When overstimulated, such as by noise, lights, excessive handling, alarms, and procedures, and stressed, heart and respiratory rates decrease and periods of apnea or bradycardia may occur.

An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting symptoms of hypoglycemia. Which of the following would the nurse do next? A) Administer intravenous glucose immediately. B) Feed the newborn 2 ounces of formula. C) Initiate blow-by oxygen therapy. D) Place the newborn under a radiant warmer.

Ans: A Feedback: If an LGA newborn's blood glucose level is below 40 mg/dL and is symptomatic, continuous infusion of parenteral glucose is needed. Supervised breast-feeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress.

After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A) Presence of lochia serosa B) Frequent scant voiding C) Fundus firm, below umbilicus D) Milk filling in both breasts

Ans: B Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.

After teaching a group of students about risk factors associated with postpartum hemorrhage, the instructor determines that the teaching was successful when the students identify which of the following as a risk factor? (Select all that apply.) A) Prolonged labor B) Placenta previa C) Null parity D) Hydramnios E) Labor augmentation

Ans: B, D, E Risk factors for postpartum hemorrhage include precipitous labor less than 3 hours, placenta previa or abruption, multiparity, uterine overdistention such as with a large infant, twins, or hydramnios, and labor induction or augmentation. Prolonged labor over 24 hours is a risk factor for postpartum infection.

A newborn is suspected of developing persistent pulmonary hypertension. The nurse would expect to prepare the newborn for which of the following to confirm the suspicion? A) Chest x-ray B) Blood cultures C) Echocardiogram D) Stool for occult blood

Ans: C Feedback: An echocardiogram is used to reveal right-to-left shunting of blood to confirm the diagnosis of persistent pulmonary hypertension. Chest x-ray would be most likely used to aid in the diagnosis of RDS or TTN. Blood cultures would be helpful in evaluating for neonatal sepsis. Stool for occult blood may be done to evaluate for NEC.

A nurse is assisting the anxious parents of a preterm newborn to cope with the situation. Which statement by the nurse would be least appropriate? A) "I'll be here to help you all along the way." B) "What has helped you to deal with stressful situations in the past?" C) "Let me tell you about what you will see when you visit your baby." D) "Forget about what's happened in the past and focus on the now."

Ans: D Feedback: Instead of telling the parents to forget about what's happened, the nurse should review with them the events that have occurred since birth to help them understand and clarify any misconceptions they might have. Other helpful interventions would include telling the parents that the nurse will be with them because this provides them with a physical presence and support; asking about previous coping strategies that worked so that they can use them now; and explaining what is happening and all the equipment being used so they can understand the situation.

A newborn has been diagnosed with a Group B streptococcal infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which of the following? A) Improper handwashing B) Contaminated formula C) Nonsterile catheter insertion D) Mother's birth canal

Ans: D Feedback: Most often, a newborn develops a Group B streptococcus infection during the birthing process when the newborn comes into contact with an infected birth canal. Improper handwashing, contaminated formula, and nonsterile catheter insertion would most likely lead to a late-onset infection, which typically occurs in the nursery due to horizontal transmission.

Which of the following would alert the nurse to suspect that a newborn has developed NEC? A) Irritability B) Sunken abdomen C) Clay-colored stools D) Bilious vomiting

Ans: D Feedback: The newborn with NEC may exhibit bilious vomiting with lethargy, abdominal distention and tenderness, and bloody stools.

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Tachycardia b) Apnea c) Sleepiness d) Crying

Apnea

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds. To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the membranes whether this occurs spontaneously or by amniotomy, as the fetal heart rate will be unusually slow or a variable deceleration pattern will become apparent when cord prolapse has occurred. The other answers refer to therapeutic interventions to implement once cord prolapse has been confirmed.

After teaching a class about hepatic system adaptations after birth, the instructor determines that the teaching was successful when the class identifies which of the following as the process of changing bilirubin from a fat-soluble product to a water-soluble product? A) Hemolysis B) Conjugation C) Jaundice D) Hyperbilirubinemia

B The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is called conjugation. Hemolysis involves the breakdown of blood cells. In the newborn, hemolysis of the red blood cells is the principal source of bilirubin. Jaundice is the manifestation of increased bilirubin in the bloodstream. Hyperbilirubinemia refers to the increased level of bilirubin in the blood.

"A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. a. Provide warm water to drink. b. Provide oxygen supplement. c. Massage the newborn's back. d. Ensure the newborn's warmth. e. Observe respiratory status frequently."

B,D,E The nurse should give the new- born oxygen, ensure the newborn's warmth, and observe the newborn's respiratory status frequently. The nurse need not give the newborn warm water to drink or massage the newborn's back."

A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn?

Begin early feedings either by the breast or bottle. The nurse should provide some nutrition to any infant born with hypoglycemia. Dextrose should be given intravenously only if the infant refuses oral feedings, not before offering the infant oral feedings. Placing the infant on a radiant warmer will not help maintain blood glucose levels. The nurse should focus on decreasing blood viscosity in an infant who is at risk for polycythemia, not hypoglycemia.

Before calling the primary care provider to notify him or her of a slow progression or an arrest of labor, several assessments need to be made. What other maternal assessment does the nurse need to make prior to calling the care provider?

Check for a full bladder. A full bladder can interfere with the progress of labor, so the nurse must be sure that the client has emptied her bladder.

The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan?

Closely monitor temperature.

The nurse in the prenatal clinic assesses a 26-year-old client at 13 weeks gestation. Which presumptive (subjective) signs and symptoms of pregnancy should the nurse anticipate? a) Hegar's sign and quickening b) Ballottement and positive pregnancy test c) Chadwick's sign and uterine souffle d) Excessive fatigue and urinary frequency

D Excessive fatigue and urinary frequency both are presumptive (subjective) signs and symptoms of pregnancy. Hegar's sign, ballottement, a positive pregnancy test, Chadwick's sign, and uterine souffle are probable (objective) signs or symptoms of pregnancy.

The nurse is taking an initial history of a prenatal client. Which of the following, if detected by the nurse practitioner, would indicate a positive, or diagnostic sign of pregnancy? a) Positive pregnancy test b) Goodell's sign c) Uterine enlargement and amenorrhea d) Fetal heartbeat with at Doppler at 11 weeks gestation

D The positive signs of pregnancy are completely objective, cannot be confused with a pathologic state, and offer conclusive proof of pregnancy. The fetal heartbeat can be detected with an electronic Doppler device as early as weeks 10-12 of pregnancy. Pregnancy tests detect the presence of hCG in the maternal blood or urine. These are not considered a positive sign of pregnancy because other conditions can cause elevated hCG levels. Physical changes, like Godell's sign and uterine enlargement, can also have other causes and do not confirm pregnancy. The subjective changes of pregnancy, like amenorrhea, are the symptoms the woman experiences and reports. Because they can be caused by other conditions, they cannot be considered proof of pregnancy.

The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: A) Have a smaller body surface compared to body mass B) Lose more body heat when they sweat than adults C) Have an abundant amount of subcutaneous fat all over D) Are unable to shiver effectively to increase heat production

D Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.

"A nurse is caring for a 5-hour-old newborn. The physician has asked the nurse to maintain the newborn's temperature between 97.7° and 99.5° F (between 36.5° and 37.5° C). What nursing intervention should the nurse perform to maintain the temperature within the recommended range? a. Avoid measuring the weight of the infant, as scales may be cold. b. Use the stethoscope over the baby's garment. c. Place the newborn close to the outer wall in the room. d. Place the newborn skin-to-skin with the mother."

D. The nurse should place the newborn skin-to-skin with mother. This would help to maintain baby's temperature as well as promote breastfeeding and bonding between the mother and baby. The nurse can weigh the infant as long as a warmed cover is placed on the scale. The stethoscope should be warmed before it makes contact with the infant's skin, rather than using the stethoscope over the garment because it may obscure the reading. The newborn's crib should not be placed close to the outer walls in the room to prevent heat loss through radiation."

Which of the following would lead the nurse to suspect that a postpartum woman was developing a complication? A. Fatigue and irritability B. Perineal discomfort and pink discharge C. Pulse rate of 60 bpm D. Swollen, tender, hot area on breast

D. A swollen, tender area on the breast would indicate mastitis, which would need medical intervention.

Which of the following newborns could be described as breathing normally? a. Newborn A is breathing deeply, with a regular rhythm, at a rate of 20 bpm. b. Newborn B is breathing diaphragmatically with sternal retractions, at a rate of 70 bpm. c. Newborn C is breathing shallowly, with 40-second periods of apnea and cyanosis. d. Newborn D is breathing shallowly, at a rate of 36 bpm, with short periods of apnea.

D. Normal breathing can be described as shallow, at a rate of 36 bpm, with short periods of apnea.

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. Which of the following is the priority nursing intervention? a) Palpation for a femoral pulse b) Administration of IV epinephrine, as prescribed c) Transfer to a transitional or high-risk nursery for continuous cardiac surveillance d) Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute

If the nurse manages a new infant with low blood sugar, which intervention would be appropriate to prevent hypoglycemia?

Feed the infant. The infant could be fed early either breast milk or formula to prevent low blood sugar. If unable to feed well, the infant can receive intravenous fluids. The other choices do not raise blood sugar.

If the nurse manages a new infant with low blood sugar, which of the following would be an appropriate intervention to prevent hypoglycemia? a) Check the heart rate. b) Hold all feedings. c) Feed the infant. d) Give antibiotics.

Feed the infant. Correct Explanation: The infant could be fed early either breast milk or formula to prevent low blood sugar. If unable to feed well, the infant can receive intravenous fluids. The other choices do not raise blood sugar.

The nurse is caring for a client who had been administered an anesthetic block during labor. Which of the following are risks that the nurse should watch for in the client? (Select all)

Incomplete emptying of the bladder; bladder distention; urinary retention

The nurse in a newborn nursery is observing for developmentally appropriate care. Which of the following is an example of self-regulation? a) Infant has hand in mouth b) Infant is kicking feet c) Infant is crying d) Infant is quiet

Infant has hand in mouth Correct Explanation: Self-regulation is a form of self-soothing for an infant such as sucking on hands or putting hand to mouth type of movements.

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being delivered. Which of the following interventions should the nurse implement as a result of this finding? a) Administration of oxygen via a bag and mask b) Intubation and suctioning of the trachea c) Gently shaking the infant d) Flicking the sole of the infant's foot

Intubation and suctioning of the trachea Correct Explanation: Although there is some dispute regarding whether all infants with meconium staining need intubation, those with severe staining are usually intubated and meconium is suctioned from their trachea and bronchi. Do not administer oxygen under pressure (bag and mask) until a meconium stained infant has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the infant and flicking the sole of his foot are methods of stimulating breathing in an infant experiencing apnea.

An infant is suffering from neonatal abstinence syndrome. The nurse provides appropriate care and support for the infant during the infant's time on the unit. Besides nursing and medical care, what other step would the nurse take to support the infant?

Link the family with community sources for aid. Besides nursing care, the nurse would make sure that interdisciplinary members of team were involved such as the doctor, nutritionist, community worker or resources, and provide a supportive environment for the family and the client. The chaplain may not be support for infant or family may not be present. The bright room is overly stimulating to the withdrawing infant, and feeding is basic care.

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?

McRobert's maneuver The McRobert's maneuver is frequently successful and often tried first. It requires assistance from two people. Two nurses place the client in the lithotomy position, while each holds a leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. What is the first maneuver tried to deliver an infant with shoulder dystocia?

McRoberts maneuver McRoberts maneuver is an intervention that is frequently successful in cases of shoulder dystocia, and it is often tried first. McRoberts requires the assistance of two individuals. Two nurses are ideal; however, a support person or a technician can serve as the second assistant. With the woman in lithotomy position, each nurse holds one leg and sharply flexes the leg toward the woman's shoulders. This opens the pelvis to its widest diameters and allows the anterior shoulder to deliver in almost half of the cases.

Which of the following data is indicative of hypothermia of the preterm infant? a) Regular respirations b) Oxygen saturation of 95% c) Nasal flaring d) Pink skin

Nasal flaring

Which of the following data is indicative of hypothermia of the preterm infant?

Nasal flaring Correct Explanation: Nasal flaring is a sign of respiratory distress. Infants with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

Which of the following data is indicative of hypothermia of the preterm infant? a) Regular respirations b) Oxygen saturation of 95% c) Nasal flaring d) Pink skin

Nasal flaring Correct Explanation: Nasal flaring is a sign of respiratory distress. Infants with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

The small-for-gestation neonate is at increased risk for which complication during the transitional period? a) Polycythemia probably due to chronic fetal hypoxia b) Hyperthermia due to decreased glycogen stores c) Hyperglycemia due to decreased glycogen stores d) Anemia probably due to chronic fetal hypoxia

Polycythemia probably due to chronic fetal hypoxia

The small-for-gestation neonate is at increased risk for which complication during the transitional period? a) Hyperthermia due to decreased glycogen stores b) Polycythemia probably due to chronic fetal hypoxia c) Hyperglycemia due to decreased glycogen stores d) Anemia probably due to chronic fetal hypoxia

Polycythemia probably due to chronic fetal hypoxia Correct Explanation: The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores

The small-for-gestation neonate is at increased risk for which complication during the transitional period? a) Hyperthermia due to decreased glycogen stores b) Polycythemia probably due to chronic fetal hypoxia c) Hyperglycemia due to decreased glycogen stores d) Anemia probably due to chronic fetal hypoxia

Polycythemia probably due to chronic fetal hypoxia The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. This neonate is also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores

how to prevent hypoglycemia in newborn?

Prevent hypoglycemia by providing early oral feedings with breast milk of formula at frequent intervals (every 2 to 3 hours). *Feedings help to control glucose levels, reduce hematocrit, and promote bilirubin excretion. *neutral thermal environment to avoid cold stress, which may stimulate the metabolic rate, thereby increasing the demand for glucose. Provide rest periods to decrease energy demand and expenditure.

The second-year nursing student taking an obstetrics course correctly attributes which descriptions to the term dystocia? Select all that apply.

Progress of labor deviates from normal. Labor is slow. Dystocia is said to exist when the progress of labor deviates from normal and is slow.

What are the factors that inhibit uterine involution?

Prolonged labor & difficult birth; incomplete expulsion of amniotic membranes & placenta; uterine infection; over-distention of uterine muscles due to: multiple gestation, hydramnios, or large fetus, full bladder which displaces uterus & interferes with contractions, anesthesia, which relaxes uterine muscles, close childbirth spacing, leading to frequent & repeated distention and thus decreasing uterine tone & causing muscular relaxation.

A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?

Provide a mobile the child can see no matter how the child is turned.

A woman near term presents to the clinic highly agitated because her membranes have just ruptured and she felt something come out when they did. The nurse is alone with her and notices that the umbilical cord is hanging out of the vagina. What should the nurse do next?

Put her in bed immediately, call for help, and hold the presenting part of the cord. Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, when the presenting part compresses the cord oxygen, and nutrients are cut off to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and the nurse does not leave the woman. A vaginal birth is contraindicated in this situation.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which of the following should the nurse consider as a complication of oxygen administration at a high concentration? a) Bronchopulmonary dysplasia b) Necrotizing enterocolitis c) Retinopathy of prematurity d) Diminished erythropoiesis

Retinopathy of prematurity

A nurse is caring for a baby girl born at 34 weeks' gestation. Which of the following features should the nurse identify as those of a preterm newborn? a) Scant coating of vernix b) Closely approximated labia c) Paper-thin eyelids d) Shiny heels and palms

Shiny heels and palms Correct Explanation: A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in post-term newborns and is excessive in premature infants.

Esophageal Atresia and Tracheoesophageal Fistula what would the nurse notice?

Soon after birth, the newborn may exhibit copious, frothy bubbles of mucus in the mouth and nose, accompanied by drooling. *"the three Cs" (coughing, choking, and cyanosis)

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which of the following additional signs should the nurse consider as indications of respiratory distress syndrome (RDS) in the newborn? a) Sternal retraction b) Deep inspiration c) Expiratory lag d) Inspiratory grunt

Sternal retraction

Which statement describes why hypertonic contractions tend to become very painful?

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells. Hypertonic contractions cause uterine cell anoxia, which is painful.

A client delivers a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of: a) Normal birth weight b) Very low birth weight c) Extremely low birth weight d) Low birth weight

Very low birth weight Correct Explanation: A birth weight of 1.2 kg would be classified as very low birth weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low birth weight. A birth weight between 1,000 g and 1,500 g is termed a very low birth weight. A birth weight less than 1,000 g is termed an extremely low birth weight

The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn? Select all that apply. a) maternal smoking during pregnancy b) asthma exacerbations during pregnancy c) pregnancy weight gain of 25 lb (11 kg) d) drug abuse e) hypotension upon admission

a) maternal smoking during pregnancy b) asthma exacerbations during pregnancy d) drug abuse The nurse should be alert to the possibility of an SGA newborn if the history of the mother reveals smoking, chronic medical conditions (such as asthma), and drug abuse. Additional maternal factors that increase the risk for an SGA newborn include hypertension, genetic disorders, and multiple gestations

The nurse caring for newborns on an obstetrical ward assesses an SGA newborn. What characteristics are typical for this classification of newborn? Select all that apply. a) sparse or absent hair b) increased fatty tissue c) tight and moist skin d) poor skin turgor e) diminished muscle tissue f) narrow skull sutures

a) sparse or absent hair d) poor skin turgor e) diminished muscle tissue Characteristics of the SGA newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts

"A nurse is caring for a newborn with hypo- glycemia. What symptoms of hypoglycemia should the nurse monitor the newborn for? Select all that apply. a. Lethargy b. Low-pitched cry c. Cyanosis d. Skin rashes e. Jitteriness"

a, c,e The nurse should monitor the new- born for lethargy, cyanosis, and jitteriness. Low- pitched crying or rashes on the infant's skin are not signs generally associated with hypoglycemia."

"The mother of a newborn observes a diaper rash on her baby's skin. Which of the fol- lowing should the nurse instruct the parent to prevent diaper rash? a. Expose the newborn's bottom to air several times a day. b. Use plastic pants while bathing the new- born. c. Use products such as powder and items with fragrance. d. Place the newborn's buttocks in warm water often."

a. The nurse should instruct the par- ent to expose the newborn's bottom to air several times per day to prevent diaper rashes. Use of plastic pants and products such as powder and items with fragrance should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night."

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?a. 5% to 10% of their birth weightb. 20% of their birth weightc. 10% to 15% of their birth weightd. 15% to 18% of their birth weight

a. 5% to 10% of their birth weight

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanelle that corresponds with the newborn's heart rate. How would the nurse interpret this?a. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanelle.b. This finding is normal if the pulsation can also be palpated in the posterior fontanelle.c. This is an abnormal finding and needs to be reported immediately.d. If the fontanelle feels full, then this is normal.

a. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanelle.

A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?

administering oxytocin Oxytocin would be appropriate for the woman experiencing hypotonic uterine dysfunction (problem with the powers). Comfort measures minimize the woman's stress and promote relaxation so that she can work more effectively with the forces of labor. An amniotomy may be used with hypertonic uterine dysfunction to augment labor. A hands-and-knees position helps to promote fetal head rotation with a persistent occiput posterior position.

WITHDRAWAL ACRONYM

assess the newborn for signs of neonatal abstinence syndrome using the acronym WITHDRAWAL to focus the assessment: W: Wakefulness: sleep duration less than 3 hours after feeding I: Irritability T: Temperature variation, tachycardia, tremors H: Hyperactivity, high-pitched persistent cry, hyperreflexia, hypertonus D: Diarrhea, diaphoresis, disorganized suck R: Respiratory distress, rub marks, rhinorrhea A: Apneic attacks, autonomic dysfunction W: Weight loss or failure to gain weight A: Alkalosis (respiratory) L: Lacrimation

After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to:

assess the rate of flow of the oxytocin infusion. A toxic effect of oxytocin therapy is water intoxication. Symptoms include dizziness and nausea. Assessing and slowing the infusion rate will relieve symptoms.

Silverman-Anderson Index

assessment scoring system that can be used to evaluate five parameters of work of breathing as it assigns a numerical score for each parameter. *Respiratory Distress Syndrome

A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents state which of the following? A) "We can put a tiny bit of lotion on his skin and then rub it in gently." B) "We should avoid using any kind of baby powder." C) "We need to bathe him at least four to five times a week." D) "We should clean his eyes after washing his face and hair.

b. "We should avoid using any kind of baby powder."

A newborn is suspected of having gastroschisis at birth. How would the nurse differentiate this problem from other congenital defects? a) The umbilical cord comes out of middle of the defect b) The intestines appear reddened and swollen and have no sac around them c) The abdominal contents are contained within a thin, transparent sac d) The skin over the abdomen is wrinkled and looks like a prune

b. The intestines appear reddened and swollen and have no sac around them

A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal?a. 38.0° C (100.4° F)b. 37.0° C (98.6° F)c. 36.0° C (96.8° F)d. 35.0° C (95.0° F)

b. 37.0° C (98.6° F)

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? a. The mother pump her breast milk and measure it before feeding b. Breastfeed the infant every 2 to 3 hours on demand c. Weigh the infant daily to ensure that she is gaining 1 1/2 to 2 oz per day d. Add cereal to the newborn's feedings twice a day

b. Breastfeed the infant every 2 to 3 hours on demand

A primiparous mother delivered a 8lb 12oz (4kg) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine lase evening. Which factor places the newborn at risk for the development of jaundice? a. Formula feeding b. Cephalohematoma c. Female gender d. Hepatitis A vaccinee. Rh-positive blood type

b. Cephalohematoma

A nursing student questions the nursery nurse why they don't bathe the newborn immediately upon admission to the nursery observation area after birth. The nurse states that this would increase the risk of: a. Jaundice b. Infection c. Hypothermia d. Anemia

c. . since newborns can rapidly become stressed by changes in environmental temperatures that bathing would cause through conduction. Postponing the newborn bath until the temperature has stabilized will help prevent newborn hypothermia.

"Which of the following information should the nurse give to a client who is breastfeeding her newborn regarding the nutritional requirements of newborns, as per the recommendations of the American Academy of Pediatrics (AAP)? a. Feed the infant at least 10 mL per kg of water daily."" b. Give iron supplements to the newborn daily. c. Give vitamin D supplements daily for the first 2 months. d. Ensure adequate fluoride supplementation."

c. As per the recommendations of AAP, all newborns should receive a daily supplement of vitamin D during the first 2 months of life to prevent rickets and vitamin D deficiency. There is no need to feed the newborn water, as breast milk contains enough water to meet the newborn's needs. Iron supplements need not be given, as the newborn is being breastfed. Infants over 6 months of age are given fluoride supplementation if they are not receiving fluoridated water."

The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received? a) "I will feed him at least 30 cc of water daily." b) "Since we live in a rural area, I must ensure he receives adequate fluoride supplementation." c) "I need to give him iron supplements daily." d) "I will give him vitamin D supplements daily for the first 2 months of life."

c. "I will give him vitamin D supplements daily for the first 2 months of life."

A young mother is concerned for her baby and asks the nurse if her baby is okay. What is the best response if the nurse notes: RR 66, nostrils flaring, and grunting sounds during respiration? a. "Your baby is fine, just learning how to breath." b. "Let's put a blanket around the baby; the baby is cold." c. "Your baby is having a little trouble breathing. I'll let the RN know." d. "Your baby is too warm. Let's take the blanket off."

c. "Your baby is having a little trouble breathing. I'll let the RN know."

Which factors in a maternal birth record are risks for fetal growth restriction?

congenital malformations, infections, or placental insufficiency Fetal growth restriction can result from aneuploidy, congenital malformations, infections, or uteroplacental insufficiency. Their size falls below the 10th percentile on growth charts. It is the pathological counterpart to a SGA. They are at risk for increased morbidity and mortality. The fetus is thought to have growth potential under normal circumstances. It is analogous to the failure to thrive in the infant. Newborns that experience nutritional deficiencies in utero and born with FGR are at risk of lifelong developmental deficits.

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

continuing to monitor maternal and fetal status Once a breech presentation is confirmed by ultrasound, the nurse should continue to monitor the maternal and fetal status when the team makes decisions about the method of birth. The nurse usually plays an important role in communicating information during this time. Applying suprapubic pressure against the fetal back is the nursing intervention for shoulder dystocia and may not be required for breech presentation. Noting the space or dip at the maternal umbilicus and auscultating the fetal heart rate at the umbilicus level are assessments related to occipitoposterior positioning of the fetus.

A male newborn is born with hypospadias. The nurse doing the newborn physical assessment notes that the penis is also curved downward. What information would the nurse provide the parents for this infant? a) The parents will be taught maneuvers to perform on the penis to help straighten it out prior to repairing the urethral opening. b) The infant's penis will not require surgery but may never be completely straight. c) The circumcision may have to be revised when he is older. d) His ability to void and have an erection in adulthood may be impaired and surgery is needed.

d) His ability to void and have an erection in adulthood may be impaired and surgery is needed. Hypospadias is a relatively common malformation of the male genital organ. It is an abnormal positioning of the urinary meatus on the underside of the penis. It is often accompanied by a downward bowing of the penis (chordee), which can lead to urination and erection problems in adulthood. There are no maneuvers that will improve the penis curvature, surgery is definitely warranted and needed, and infants with hypospadius are never circumcised because the foreskin may be needed for later repairs

A nurse is caring for a 5-hour-old newborn. The physician has asked the nurse to maintain the newborn's temperature between 97.7℉ and 99.5℉ (36.5°C and 37.5°C). Which nursing intervention would be the best approach to maintaining the temperature within the recommended range? a. Delay weighing the infant, as the scales may be cold b. Use the stethoscope over the newborn's garment c. Place the newborn's crib close to the outer wall in the room d. Place the newborn skin-to-skin with the mother

d. Place the newborn skin-to-skin with the mother

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? (Select all that apply.) a. Formed in consistency b. Completely odorless c. Firm in shape d. Yellowish gold color e. Stringy to pasty consistency

d. Yellowish gold colore. Stringy to pasty consistency

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called?

external version External version is the process of manipulating the position of the fetus in order to try to turn the fetus to a cephalic presentation.

A nurse is conducting an in-service presentation for a group of neonatal nurses. After teaching the group about the effects of prematurity on various body systems, the nurse determines that the class was successful when the group identifies which condition as an effect of prematurity?

fragile cerebral blood vessels Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate.

__________ is the newborn's ability to process and respond to visual and auditory stimuli

habituation

An infant has a grade 3 intraventricular hemorrhage (IVH). The nurse monitors the infant for which complication?

hydrocephalus

Recommended exercises for the first few weeks postpartum include:

- abdominal breathing - head lifts - modified sit-ups - double knee roll - and pelvic tilt

A nurse is developing a teaching plan for the parents of a newborn. When describing the neurologic development of a newborn to his parents, the nurse would explain that the development occurs in which fashion? A) Head-to-toe B) Lateral-to-medial C) Outward-to-inward D) Distal-to-caudal

A Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center to outside) pattern.

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as indicating which of the following? A) A good time to initiate breast-feeding B) The period of decreased responsiveness preceding sleep C) The need to be alert for gagging and vomiting D) Evidence that the newborn is becoming chilled

A The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breast-feeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. There is no indication that the newborn may experience gagging or vomiting. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.

A newborn with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which of the following would the nurse anticipate as possibly necessary for this newborn? A) Extracorporeal membrane oxygenation (ECMO) B) Respiratory support with a ventilator C) Insertion of a laryngoscope for deep suctioning D) Replacement of an endotracheal tube via x-ray

Ans: A Feedback: If conventional measures are ineffective, then the nurse would need to prepare the newborn for ECMO. Hyperoxygenation, ventilatory support, and suctioning are typically used initially to promote tissue perfusion. However, if these are ineffective, ECMO would be the next step.

The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which of the following would the nurse correlate with this gestational age variation? A) Strong, brisk motor skills B) Difficulty in arousing to a quiet alert state C) Birth weight of 7 lb 14 oz D) Wasted appearance of extremities

Ans: B Feedback: LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb 13 oz at term.

Which of the following would the nurse expect to assess in a newborn who develops sepsis? A) Increased urinary output B) Interest in feeding C) Hypothermia D) Wakefulness

Ans: C Feedback: Manifestations of sepsis are typically nonspecific and may include hypothermia (temperature instability), oliguria or anuria, lack of interest in feeding, and lethargy.

Which of the following would alert the nurse to suspect that a preterm newborn is in pain? A) Bradycardia B) Oxygen saturation level of 94% C) Decreased muscle tone D) Sudden high-pitched cry

Ans: D Feedback: The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor. In a client with the risk for injury, continuous assessment of contractions using external monitor and palpation to ensure the presence of a low resting tone will assist in collecting information about labor and the need for further intervention. Turning down oxytocin administration by half is required if hyperstimulation occurs not to prevent it. Tocolytic therapy is generally employed when preterm labor has been definitively diagnosed. Administering hydration and sedation frequently and bedrest are employed to halt preterm labor since these stop uterine activity by increasing intravascular volume and uterine blood flow.

Which of the following would lead the nurse to suspect that a large-for-gestational-age newborn has experienced birth trauma? a) Temperature instability b) Asymmetrical movement c) Feeble sucking d) Seizures

Asymmetrical movement

The preterm newborn is experiencing vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea. What is the best explanation for these symptoms? a)Traumatic birth b)Maternal substance abuse c)Sepsis d)Gestational diabetes

B The severity of withdrawal that an infant experiences can be assessed by using a scoring system such as the Finnegan scale. This scale is based on observations and measurement of the responses to neonatal abstinence from substances. It evaluates the infant on potentially life-threatening signs such as vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea.

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings by observing the newborn, which of the following actions would be most appropriate? A) Notify the health care provider immediately. B) Assess the newborn for signs of respiratory distress. C) Reassure the parents that this is an expected pattern. D) Tell the parents not to worry since his color is fine.

B Although periods of apnea of less than 20 seconds can occur, the nurse needs to gather additional information about the newborn's respiratory status to determine if this finding is indicative of a developing problem. Therefore, the nurse would need to assess for signs of respiratory distress. Once this information is obtained, then the nurse can notify the health care provider or explain that this finding is an expected one. However, it would be inappropriate to tell the parents not to worry, because additional information is needed. Also, telling them not to worry ignores their feelings and is not therapeutic.

Which of the following would lead the nurse to suspect that a postpartum woman is experiencing a problem? A) Elevated white blood cell count B) Acute decrease in hematocrit C) Increased levels of clotting factors D) Pulse rate of 60 beats/minute

B Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding. The WBC count remains elevated for the first 4 to 6 days and clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for the first two weeks reflects the decrease in cardiac output.

The nurse observes a 2 in lochia stain on the perineal pad 1 day postpartum. Which of the following should the nurse do next? A. reassess the client in 1 hour. B. Document the lochia as scant c. ask when the peri pas was changed d. massage the fundus

B This is a normal finding postpartum. Scant is 1-2 inch spot on a pad approximately 10 ml loss

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus, expecting it to be at which location? A) Two fingerbreadths above the umbilicus B) At the level of the umbilicus C) Two fingerbreadths below the umbilicus D) Four fingerbreadths below the umbilicus

C During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is about 2 fingerbreadths below the umbilicus.

While observing the interaction between a newborn and his mother, the nurse notes the newborn nestling into the arms of his mother. The nurse identifies this behavior as which of the following? A) Habituation B) Self-quieting ability C) Social behaviors D) Orientation

C Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held. Habituation self-quieting ability refers to newborns' ability to quiet and comfort themselves, such as by hand-to-mouth movements and sucking, alerting to external stimuli and motor activity. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Orientation refers to the response of newborns to stimuli, becoming more alert when sensing a new stimulus in their environment.

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? A) Deep red, fleshy-smelling lochia B) Voiding of 350 cc C) Heart rate of 120 beats/minute D) Profuse sweating

C Tachycardia in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period.

What is the best intervention a nurse can utilize to promote parent-infant attachment? a)Allow for privacy. b)Contact support families that have been through the same diagnosis with their own child and allow time to discuss the situation. c)Provide an extensive handbook with information related to the preterm newborn. d)Encourage rooming in.

D All will help strengthen the attachment bond, but the best answer would be to encourage rooming in. Rooming in can provide a great opportunity for the stable preterm infant and family to get acquainted; it offers both privacy and readily available help.

The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following would the nurse include in the teaching plan to facilitate suppression of lactation? A) Encouraging the woman to manually express milk B) Suggesting that she take frequent warm showers to soothe her breasts C) Telling her to limit the amount of fluids that she drinks D)Instructing her to apply ice packs to both breasts every other hour

D If the woman is not breast-feeding, relief measures for engorgement include wearing a tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, and not stimulating her breasts by squeezing or manually expressing milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was breast-feeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum women, regardless of the feeding method chosen

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: A) Have a smaller body surface compared to body mass B) Lose more body heat when they sweat than adults C) Have an abundant amount of subcutaneous fat all over D) Are unable to shiver effectively to increase heat production

D Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.

At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate?

The infant was a preterm, low birth weight and small for gestational age Born at 36 weeks gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500g) and small for gestational age at the 8th percentile (under the 10th percentile). The other documentation is not accurate.

The nurse is inspecting the external genitalia of a male newborn. Which of the following would alert the nurse to a possible problem? A) Limited rugae B) Large scrotum C) Palpable testes in scrotal sac D) Absence of engorgemen

a. Limited rugae

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition? a) Intermittent tachypnea b) Expiratory grunting c) High-pitched shrill cry d) Bile-stained emesis

b. Expiratory grunting

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?a. Stools should be greenish and formed in consistency.b. Stools should be yellow-gold, loose, and stringy to pasty.c. Stools should be brown and loose.d. Stools should be yellow-green and loose.

b. Stools should be yellow-gold, loose, and stringy to pasty.

All the options are signs of respiratory distress in the newborn except:a. grunting.b. coughing.c. central cyanosis.d. respiratory rate >50 breaths/minute.e. chest retractions.f. nasal flaring.

d. respiratory rate >50 breaths/minute.

The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small-for-gestational-age (SGA) newborn? Select all that apply.

maternal smoking during pregnancy asthma exacerbations during pregnancy drug abuse

The nurse encourages a mother to rock, sing, and talk to her premature newborn. What is the purpose of these activities with the infant?

to develop trust in people

The nurse caring for a small for gestational age newborn in the specialcare nursery. What characteristics are commonly documented? Select all that apply.

- Poor skin turgor - Sparse or absent hair - Diminished muscle tissue Characteristics of the small for gestational age newborn include poor skin turgor, loose and dry skin, sparse or absent hair, wide skull sutures caused by inadequate bone growth, and diminished muscle and fatty tissue. Weight, length, and head circumference are below normal expectations as defined on growth charts.

Which condition may cause intrauterine asphyxia? Select all that apply.

- cord compression - placenta abruption - intrauterine growth restriction Conditions such as cord compression, placenta abruption, and intrauterine growth restriction alter uteroplacental blood flow and may cause intrauterine asphyxia. Gestational diabetes may cause fetal hyperinsulinemia, and group B strep infection may cause intrauterine infection or PROM/preterm labor.

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply.

- diabetes mellitus - postdates gestation - prepregnancy obesity Diabetes mellitus, postdates gestation, and prepregnancy obesity are the maternal factors the nurse should consider that could lead to a newborn being large for gestational age. Renal condition and maternal alcohol use are not factors associated with a newborn's being large for gestational age.

A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply.

- encouraging kangaroo care during procedures - removing tape gently from the skin - using a colorful mobile for distraction Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation. Distraction using colorful mobiles or objects also can be effective.

Omphalocele

-An omphalocele is a defect of the umbilical ring that allows evisceration of the abdominal contents into an external peritoneal sac. - Defects vary in size; they may be limited to bowel loops or may include the entire gastrointestinal tract and liver

postpartum assessment:

-During the first hour: every 15 minutes - During the second hour: every 30 minutes - During the first 24 hours: every 4 hours After 24 hours: every 8 hours

Fetal Alcohol Spectrum Disorders (FASDs)

-Microcephaly -Small palpebral (eyelid) fissures -Missing vertical groove in median portion of upper lip -Thin upper lip -Prenatal or postnatal growth ≤10th percentile -Clinically significant brain abnormalities

phototherapy nursing care

-Nursing responsibilities include ensuring effective irradiance delivery, maximizing skin exposure, providing eye protection and eye care, careful attention to thermoregulation, monitoring the newborn's skin turgor, maintaining adequate hydration, promoting elimination, and supporting parent-infant interaction

Gastroschisis

-herniation of the abdominal contents through an abdominal wall defect, at the umbilicus. -Gastroschisis differs from omphalocele in that there is no peritoneal sac protecting the herniated organs, and thus exposure to amniotic fluid makes them thickened, edematous, and inflamed

Understanding the transition from intrauterine to extrauterine life, what intervention is most appropriate when working with an infant of a diabetic mother? a)Frequent blood glucose checks b)Obtain lab work to look for infection. c)Administer IV fluids. d)Place under radiant warmer bed immediately.

A Lab work, IV fluids, and the radiant warmer bed may all be required for interventions for the infant of a diabetic mother, if the infant is experiencing signs of respiratory distress or sepsis. Frequent blood glucose checks need to be completed to ensure that blood glucose levels are being maintained.

When counseling a mother about the immunologic properties of breast milk, the nurse would emphasize breast milk as a major source of which immunoglobulin? A) IgA B) IgG C) IgM D) IgE

A A major source of IgA is human breast milk. IgG, found in serum and interstitial fluid, crosses the placenta beginning at approximately 20 to 22 weeks' gestation. IgM is found in blood and lymph fluid and levels are generally low at birth unless there is a congenital intrauterine infection. IgE is not found in breast milk and does not play a major role in defense in the newborn.

After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation? A) Dry the newborn thoroughly. B) Put a hat on the newborn's head. C) Check the newborn's temperature. D) Wrap the newborn in a blanket.

A Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.

After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation? A) Dry the newborn thoroughly. B) Put a hat on the newborn's head. C) Check the newborn's temperature. D) Wrap the newborn in a blanket.

A Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.

The nurse interprets which of the following as evidence that a client is in the taking-in phase? A) Client states, "He has my eyes and nose." B) Client shows interest in caring for the newborn. C) Client performs self-care independently. D) Client confidently cares for the newbor

A During the taking-in phase, new mothers when interacting with their newborns spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn such as "he has my nose" or "his fingers are long like his father's." Independence in self-care and interest in caring for the newborn are typical of the taking-hold phase. Confidence in caring for the newborn is demonstrated during the letting-go phase.

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which of the following would the nurse identify as being least significant to this condition? A) Early ambulation B) Prolonged labor C) Large fetus D) Use of anesthetics

A Factors that inhibit involution include prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion of amniotic membranes and placenta at birth, complication-free labor and birth process, breast-feeding, and early ambulation.

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following? A) Normal progression of behavior B) Probable hypoglycemia C) Physiological abnormality D) Inadequate oxygenation

A From 30 to 120 minutes of age, the newborn enters the second stage of transition, the period of decreased responsiveness or that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.

An LGA newborn has a blood glucose level of 23 mg/dL. Which of the following would the nurse do next? A) Administer intravenous glucose immediately. B) Feed the newborn 2 ounces of formula. C) Initiate blow-by oxygen therapy. D) Place the newborn under a radiant warmer.

A If an LGA newborn's blood glucose level is below 25 mg/dL, the nurse should institute immediate treatment with intravenous glucose regardless of the clinical symptoms. Oral feedings would be used to maintain the newborn's glucose level above 40 mg/dL. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress.

When describing the neurologic development of a newborn to his parents, the nurse would explain that it occurs in which fashion? A) Head-to-toe B) Lateral-to-medial C) Outward-to-inward D) Distal-caudal

A Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center to outside) pattern.

A new mother asks the nurse, "Why has my baby lost weight since he was born?" The nurse integrates knowledge of which of the following when responding to the new mother? A) Insufficient calorie intake B) Shift of water from extracellular space to intracellular space C) Increase in stool passage D) Overproduction of bilirubin

A Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth, shifting of intracellular water to extracellular space, and insensible water loss. Stool passage and bilirubin have no effect on weight loss.

While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen level and duration closely based on the understanding that the newborn is at risk for which of the following? A) Retinopathy of prematurity B) Metabolic acidosis C) Infection D) Cold stress

A Oxygen therapy has been implicated in the pathogenesis of retinopathy of prematurity (ROP). Therefore, the nurse monitors the newborn's oxygen therapy closely. Metabolic acidosis may occur due to anaerobic metabolism used for heat production. Infection may occur for numerous reasons, but they are unrelated to oxygen therapy. Cold stress results from problems due to the preterm newborn's inadequate supply of brown fat, decreased muscle tone, and large body surface area.

The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot when evaluating which reflex? A) Babinski B) Tonic neck C) Stepping D) Plantar grasp

A The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The tonic neck reflex is tested by having the newborn lie on his back and then turn his head to one side. The stepping reflex is elicited by holding the newborn upright and inclined forward with the soles of the feet on a flat surface. The plantar grasp reflex is elicited by placing a finger against the area just below the newborn's toes.

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as: A) A good time to initiate breast-feeding B) The period of decreased responsiveness preceding sleep C) The need to be alert for gagging and vomiting D) Evidence that the newborn is becoming chilled

A The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breast-feeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. There is no indication that the newborn may experience gagging or vomiting. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.

Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A) How many hours old is this newborn? B) How long ago did this newborn eat? C) What was the newborn's birthweight? D) Is acrocyanosis present?

A The typical heart rate of a newborn ranges from 120 to 160 beats per minute with wide fluctuation during activity and sleep. Typically heart rate is assessed every 30 minutes until stable for 2 hours after birth. The time of the newborn's last feeding and his birthweight would have no effect on his heart rate. Acrocyanosis is a common normal finding in newborns.

Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess? A) Respiratory rate 45, irregular B) Costal breathing pattern C) Nasal flaring, rate 65 D) Crackles on auscultation

A Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and crackles suggest a problem.

A pregnant client asks why ultrasound is used so frequently during pregnancy. The nurse's response is based on her knowledge that the advantages of ultrasound include which of the following? Select all that apply. a)"It is noninvasive and painless." b)"It can be used to estimate gestational age." c)"Results are immediate." d)"The ultrasound is the only test to determine gender."

A, B, C The ability to establish fetal age accurately by ultrasound is lost in the third trimester because fetal growth is not as uniform as it is in the first two trimesters; however, ultrasound can be used to approximate gestational age within 1-3 weeks' accuracy during the third trimester. A comprehensive ultrasound is used to detect anatomical defects, not gestational age. Ultrasound is not used to determine gender.

The nurse is teaching a prenatal client about chorionic villus sampling (CVS). The nurse correctly teaches the client that risks related to CVS include which of the following? Select all that apply. a)Intrauterine infection b)Rupture of membranes c)Maternal hypertension d)Spontaneous abortion

A, B, D Risks of CVS include failure to obtain tissue, rupture of membranes, leakage of amniotic fluid, bleeding, intrauterine infection, maternal tissue contamination of the specimen, and Rh alloimmunization. CVS testing has a higher rate of spontaneous abortion than amniocentesis. Other complications include fetal limb defects and abnormalities of the fetal face and jaw.

A nurse is teaching a group of first-trimester prenatal clients about the discomforts of pregnancy. A client asks the nurse, "What causes my nausea and vomiting?" The nurse responds indicating which of the following as being contributing factors to first-trimester emesis? Select all that apply. a) Human chorionic gonadotropin b) Estrogen c) Alterations in carbohydrate metabolism d) Prostaglandins

A, C Nausea and vomiting are common during the first trimester because of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. Estrogen stimulates the growth of the uterus and breast tissue. Prostaglandins stimulate uterine contractions.

A nursing instructor is preparing a class on newborn adaptations. When describing the change from fetal to newborn circulation, which of the following would the instructor most likely include? (Select all that apply.) A) Decrease in right atrial pressure leads to closure of the foramen ovale. B) Increase in oxygen levels leads to a decrease in systemic vascular resistance. C) Onset of respirations leads to a decrease in pulmonary vascular resistance. D) Increase in pressure in the left atrium results from increases in pulmonary blood flow. E) Closure of the ductus venosus eventually forces closure of the ductus arteriosus.

A, C, D, E When the umbilical cord is clamped, the first breath is taken and the lungs begin to function. As a result, systemic vascular resistance increases and blood return to the heart via the inferior vena cava decreases. Concurrently with these changes, there is a rapid decrease in pulmonary vascular resistance and an increase in pulmonary blood flow (Boxwell, 2010). The foramen ovale functionally closes with a decrease in pulmonary vascular resistance, which leads to a decrease in right-sided heart pressures. An increase in systemic pressure, after clamping of the cord, leads to an increase in left-sided heart pressures. Ductus arteriosus, ductus venosus, and umbilical vessels that were vital during fetal life are no longer needed.

A newborn is experiencing cold stress. Which of the following would the nurse expect to assess? (Select all that apply.) A) Respiratory distress B) Decreased oxygen needs C) Hypoglycemia D) Metabolic alkalosis E) Jaundice

A, C, E Cold stress in the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production.

Postpartum breast engorgement occurs 48 to 72 hours after giving birth. What physiologic change influences breast engorgement? a. An increase in blood and lymph supply to the breasts b. An increase in estrogen and progesterone levels c. Colostrum production increases dramatically. d. Fluid retention in the breasts due to the intravenous fluids given during labor

A. Engorgement refers to the swelling of the breast tissue as a result of an increase in blood and lymph supply to produce milk for the newborn.

The major purpose of the first postpartum homecare visit is to: A. Identify complications that require interventions B. Obtain a blood specimen for PKU testing C. Complete the official birth certificate D. Support the new parents in their parenting roles

A. Home visits are usually made within the first week of discharge to assess the mother and newborn. This visit is made primarily to provide the nurse with the opportunity to recognize common biomedical and psychosocial problems or complications. Although not the primary reason, this visit also offers an opportunity to provide support and guidance to the parents in making the adjustment to the change in their lives.

After birth, the nurse would expect which fetal structure to close as a result of increases in the pressure gradients on the left side of the heart? a. Foramen ovale b. Ductus arteriosus c. Ductus venosus d. Umbilical vein

A. The foramen ovale is the fetal structure within the heart that allows blood to cross immediately to the left side and bypass the pulmonary circuit. When left side pressure gradients increase at birth, this opening closes, thereby establishing an extrauterine circulation pattern.

Which of the following is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight? a) Ability to tolerate early oral feeding b) Decreased body temperature c) Face is angular and pinched d) Decreased muscle mass

Ability to tolerate early oral feeding

A postpartum woman who is breast-feeding tells the nurse that she is experiencing nipple pain. Which of the following would be least appropriate for the nurse to suggest? A) Use of a mild analgesic about 1 hour before breast-feeding B) Application of expressed breast milk to the nipples C) Application of glycerin-based gel to the nipples D) Reinstruction about proper latching-on technique

Ans: A Nipple pain is difficult to treat, although a wide variety of topical creams, ointments, and gels are available to do so. This group includes beeswax, glycerin-based products, petrolatum, lanolin, and hydrogel products. Many women find these products comforting. Beeswax, glycerin-based products, and petrolatum all need to be removed before breast-feeding. These products should be avoided in order to limit infant exposure because the process of removal may increase nipple irritation. Mild analgesics such as acetaminophen or ibuprofen are considered relatively safe for breast-feeding mothers. Applying expressed breast milk to nipples and allowing it to dry has been suggested to reduce nipple pain. Usually the pain is due to incorrect latch-on and/or removal of the nursing infant from the breast. Early assistance with breast-feeding to ensure correct positioning can help prevent nipple trauma. In addition, applying expressed milk to nipples and allowing it to dry has been suggested to result in less nipple pain for many women.

After reviewing information about postpartum blues, a group of students demonstrate understanding when they state which of the following about this condition? A) "Postpartum blues is a long-term emotional disturbance." B) "Sleep usually helps to resolve the blues." C) "The mother loses contact with reality." D) "Extended psychotherapy is needed for treatment."

Ans: A Postpartum blues are transient emotional disturbances beginning in the first week after childbirth and are characterized by anxiety, irritability, insomnia, crying, loss of appetite, and sadness (Hanley, 2010). These symptoms typically begin 3 to 4 days after childbirth and resolve by day 8 (Mattson & Smith, 2011). These mood swings may be confusing to new mothers but usually are self-limiting. The blues typically resolves with restorative sleep. Postpartum blues are thought to affect up to 75% of all new mothers; this condition is the mildest form of emotional disturbance associated with childbearing (March of Dimes, 2011). The mother maintains contact with reality consistently and symptoms tend to resolve spontaneously without therapy within 1 to 2 weeks.

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take? A) Document the finding, as it is a normal finding at this time. B) Contact the physician, as it indicates early DIC. C) Contact the physician, as it is a first sign of postpartum eclampsia. D) Obtain an order for a CBC, as it suggests postpartum anemia.

Ans: A Pulse rates of 40 to 80 beats per minute (bmp) are normal during the first week after birth. This pulse rate is called puerperal bradycardia. During pregnancy, the heavy gravid uterus causes a decreased flow of venous blood to the heart. After giving birth, there is an increase in intravascular volume. The cardiac output is most likely caused by an increased stroke volume from the venous return now. The elevated stroke volume leads to a decreased heart rate.

The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following would be a priority? A) Placing the call light within her reach B) Teaching her how the sitz bath works C) Telling her to use the sitz bath for 30 minutes D) Cleaning the perineum with the peri-bottle

Ans: A Tremendous hemodynamic changes are taking place within the woman, and safety must be a priority. Therefore, the nurse makes sure that the emergency call light is within her reach should she become dizzy or lightheaded. Teaching her how to use the sitz bath, including using it for 15 to 20 minutes, is appropriate but can be done once the woman's safety is ensured. The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can be done once the woman's safety needs are met.

A nurse is developing a plan of care for a newborn with omphalocele. Which of the following would the nurse include? A) Placing the newborn into a sterile drawstring bowel bag B) Using clean technique for dressing changes C) Preparing the newborn for incision and drainage D) Instituting gavage feedings

Ans: A Feedback: An infant with an omphalocele is placed in a sterile drawstring bowel bag that maintains a sterile environment for the exposed contents, allows visualization, reduces heat and moisture loss, and allows heat from radiant warmers to reach the newborn. The newborn is placed feet-first into the bag and the drawstring is secured around the torso. Strict sterile technique is necessary to prevent contamination of the exposed abdominal contents. An orogastric tube attached to low suction is used to prevent intestinal distention. IV therapy is administered to maintain fluid and electrolyte balance and provide a route for antibiotic therapy. Surgery is done to repair the defect, not incise and drain it.

A nurse is developing a plan of care for a preterm infant experiencing respiratory distress. Which of the following would the nurse be least likely to include in this plan? A) Stimulate the infant with frequent handling. B) Keep the newborn in a warmed isolette. C) Administer oxygen using an oxygen hood. D) Give gavage or continuous tube feedings.

Ans: A Feedback: For the preterm infant experiencing respiratory distress, the nurse would expect to handle the newborn as little as possible to reduce oxygen requirements. Other appropriate interventions include keeping the infant warm, preferably in a warmed isolette to conserve the baby's energy and prevent cold stress; administer oxygen using an oxygen hood; and provide energy through calories via intravenous dextrose or gavage or continuous tube feedings to prevent hypoglycemia.

After determining that a newborn is in need of resuscitation, which of the following would the nurse do first?4A) Dry the newborn thoroughly B) Suction the airway C) Administer ventilations D) Give volume expanders

Ans: A Feedback: If resuscitation is need, the nurse must first stabilize the newborn by drying the newborn thoroughly with a warm towel and provide warmth by placing him or her under a radiant heater to prevent rapid heat loss. Next the newborn's head is placed in a neutral position to open the airway and the airway is cleared with a bulb syringe or suction catheter. Breathing is stimulated. Often handling and rubbing the newborn with a dry towel may be all that is needed to stimulate respirations. Next ventilations and then chest compressions are done. Administration of epinephrine and/or volume expanders is the last step.

While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen therapy duration closely based on the understanding that the newborn is at risk for which of the following? A) Retinopathy of prematurity B) Metabolic acidosis C) Infection D) Cold stress

Ans: A Feedback: Oxygen therapy has been linked the pathogenesis of retinopathy of prematurity and is associated with the duration of oxygen use rather than the concentration of oxygen. Therefore, the nurse monitors the newborn's oxygen therapy closely. Metabolic acidosis may occur due to anaerobic metabolism used for heat production. Infection may occur for numerous reasons, but they are unrelated to oxygen therapy. Cold stress results from problems due to the preterm newborn's inadequate supply of brown fat, decreased muscle tone, and large body surface area.

While reviewing a newborn's medical record, the nurse notes that the chest x-ray shows a ground glass pattern. The nurse interprets this as indicative of: A) Respiratory distress syndrome B) Transient tachypnea of the newborn C) Asphyxia D) Persistent pulmonary hypertension

Ans: A Feedback: The chest x-ray of a newborn with RDS reveals a reticular (ground glass) pattern. For TTN, the chest x-ray shows lung overaeration and prominent perihilar interstitial markings and streakings. A chest x-ray for asphyxia would reveal possible structural abnormalities that might interfere with respiration, but the results are highly variable. An echocardiogram would be done to evaluate persistent pulmonary hypertension.

Which action would be most appropriate for the nurse to take when a newborn has an unexpected anomaly at birth? A) Show the newborn to the parents as soon as possible while explaining the defect. B) Remove the newborn from the birthing area immediately. C) Inform the parents that there is nothing wrong at the moment. D) Tell the parents that the newborn must go to the nursery immediately.

Ans: A Feedback: When an anomaly is identified at or after birth, parents need to be informed promptly and given a realistic appraisal of the severity of the condition, the prognosis, and treatment options so that they can participate in all decisions concerning their child. Removing the newborn from the area or telling them that the newborn needs to go to the nursery immediately is inappropriate and would only add to the parents' anxieties and fears. Telling them that nothing is wrong is inappropriate because it violates their right to know.

When planning the care for an SGA newborn, which action would the nurse determine as a priority? A) Preventing hypoglycemia with early feedings B) Observing for respiratory distress syndrome C) Promoting bonding between the parents and the newborn D) Monitoring vital signs every 2 hours

Ans: A Feedback: With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for respiratory distress, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn.

A nurse suspects that a preterm newborn is having problems with thermal regulation. Which of the following would support the nurse's suspicion? (Select all that apply.) A) Shallow, slow respirations B) Cyanotic hands and feet C) Irritability D) Hypertonicity E) Feeble cry

Ans: A, B, E Feedback: Typically, a preterm newborn that is having problems with thermal regulation is cool to cold to the touch. The hands, feet, and tongue may appear cyanotic. Respirations are shallow or slow, or signs of respiratory distress are present. The newborn is lethargic and hypotonic, feeds poorly, and has a feeble cry. Blood glucose levels are probably low, leading to hypoglycemia, due to the energy expended to keep warm.

A nursing instructor is describing common problems associated with preterm birth. When describing the preterm newborn's risk for perinatal asphyxia, the instructor includes which of the following as contributing to the newborn's risk? (Select all that apply.) A) Surfactant deficiency B) Placental deprivation C) Immaturity of the respiratory control centers D) Decreased amounts of brown fat E) Depleted glycogen stores

Ans: A, C Feedback: Preterm newborns are at risk for perinatal asphyxia due to surfactant deficiency, unstable chest wall, immaturity of the respiratory control centers, small respiratory passages, and inability to clear mucus from the airways. Placental deprivation places the postterm newborn at risk for perinatal asphyxia. Decreased amounts of brown fat and depleted glycogen stores place the SGA newborn at risk for problems with thermoregulation.

A nurse is explaining to the parents of a child with bladder exstrophy about the care their infant requires. Which of the following would the nurse include in the explanation? (Select all that apply.) A) Covering the area with a sterile, clear, nonadherent dressing B) Irrigating the surface with sterile saline twice a day C) Monitoring drainage through the suprapubic catheter D) Administering prescribed antibiotic therapy E) Preparing for surgical intervention in about 2 weeks

Ans: A, C, D Feedback: Care for an infant with bladder exstrophy includes covering the area with a sterile, clear, nonadherent dressing and irrigating the bladder surface with sterile saline after each diaper change to prevent infection, assisting with insertion and monitoring drainage from suprapubic catheter, administering prescribed antibiotic therapy, and preparing the parents and infant for surgery within 48 hours after birth.

A nurse is assessing a newborn who has been classified as small for gestational age. Which of the following would the nurse expect to find? (Select all that apply.) A) Wasted extremity appearance B) Increased amount of breast tissue C) Sunken abdomen D) Adequate muscle tone over buttocks E) Narrow skull sutures

Ans: A, C, E Feedback: Typical characteristics of SGA newborns include a head that is disproportionately large compared to the rest of the body, wasted appearance of the extremities, reduced subcutaneous fat stores, decreased amount of breast tissue, scaphoid abdomen, wide skull sutures, poor muscle tone over buttocks and cheeks, loose and dry skin appearing oversized, and a thin umbilical cord.

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which of the following? (Select all that apply.) A) History of diabetes B) Labor of 12 hours C) Rupture of membranes for 16 hours D) Hemoglobin level 10 mg/dL E) Placenta requiring manual extraction

Ans: A, D, E Risk factors for postpartum infection include history of diabetes, labor over 24 hours, hemoglobin less than 10.5 mg/dL, prolonged rupture of membranes (more than 24 hours), and manual extraction of the placenta.

A nurse is working as part of a committee to establish policies to promote bonding and attachment. Which practice would be least effective in achieving this goal? A) Allowing unlimited visiting hours on maternity units B) Offering round-the-clock nursery care for all infants C) Promoting rooming-in D) Encouraging infant contact immediately after birth

Ans: B Factors that can affect attachment include separation of the infant and parents for long times during the day, such as if the infant was being cared for in the nursery throughout the day. Unlimited visiting hours, rooming-in, and infant contact immediately after birth promote bonding and attachment.

Which statement would alert the nurse to the potential for impaired bonding between mother and newborn? A) "You have your daddy's eyes." B) "He looks like a frog to me." C) "Where did you get all that hair?" D) "He seems to sleep a lot."

Ans: B Negative comments may indicate impaired bonding. Pointing out commonalities such as "daddy's eyes" and expressing pride such as "all that hair" are positive attachment behaviors. The statement about sleeping a lot indicates that the mother is assigning meaning to the newborn's actions, another positive attachment behavior.

The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which of the following? A) Scant B) Light C) Moderate D) Large

Ans: B The amount of lochia is described as light or small for an approximately 4-inch stain. Scant refers to a 1- to 2-inch stain of lochia; moderate refers to a 4- to 6-inch stain; and large or heavy refers to a pad that is saturated within 1 hour after changing.

A nurse is observing a postpartum client interacting with her newborn and notes that the mother is engaging with the newborn in the en face position. Which of the following would the nurse be observing? A) Mother placing the newborn next to bare breast. B) Mother making eye-to-eye contact with the newborn C) Mother gently stroking the newborn's face D) Mother holding the newborn upright at the shoulder

Ans: B The en face position is characterized by the mother interacting with the newborn through eye-to-eye contact while holding the newborn.

The nurse administers RhoGAM to an Rh-negative client after delivery of an Rh-positive newborn based on the understanding that this drug will prevent her from: A) Becoming Rh positive B) Developing Rh sensitivity C) Developing AB antigens in her blood D) Becoming pregnant with an Rh-positive fetus

Ans: B The woman who is Rh-negative and whose infant is Rh-positive should be given Rh immune globulin (RhoGAM) within 72 hours after childbirth to prevent sensitization.

After teaching a postpartum woman about breast-feeding, the nurse determines that the teaching was successful when the woman states which of the following? A) "I should notice a decrease in abdominal cramping during breast-feeding." B) "I should wash my hands before starting to breast-feed." C) "The baby can be awake or sleepy when I start to feed him." D) "The baby's mouth will open up once I put him to my breast."

Ans: B To promote successful breast-feeding, the mother should wash her hands before breast feeding, and make sure that the baby is awake and alert and showing hunger signs. In addition, the mother should lightly tickle the infant's upper lip with her nipple to stimulate the infant to open the mouth wide and then bring the infant rapidly to the breast with a wide-open mouth. The mother also needs to know that her afterpains will increase during breast-feeding.

A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? A) "You are lucky to have given birth to a term newborn." B) "We still need to monitor him closely for problems." C) "How do you feel about delivering your baby at 36 weeks?" D) "Your baby is premature and needs monitoring in the NICU."

Ans: B Feedback: A baby born at 36 weeks' gestation is considered a late preterm newborn. These newborns face similar challenges as those of preterm newborns and require similar care. Telling the mother that close monitoring is necessary can prevent any misconceptions that she might have and prepare her for what might arise. The baby is not considered a term newborn, nor is the baby considered premature. The decision for care in the NICU would depend on the newborn's status. Asking the woman how she feels about the delivery demonstrates caring but does not address the woman's lack of understanding about her newborn.

The nurse is reviewing the medical record of a newborn born 2 hours ago. The nurse notes that the newborn was delivered at 35 weeks' gestation. The nurse would classify this newborn as which of the following? A) Preterm B) Late preterm C) Full term D) Postterm

Ans: B Feedback: A late preterm infant is one born between 34 to 36 6/7 weeks of gestation. A preterm infant is one born before 37 completed weeks' gestation. A full-term infant is one born between 38 to 41 weeks' gestation. A postterm newborn is one born at 42 weeks' gestation or later.

When describing newborns with birth-weight variations to a group of nursing students, the instructor identifies which variation if the newborn weighs 5.2 lb at any gestational age? A) Small for gestational age B) Low birth weight C) Very low birth weight D) Extremely low birth weight

Ans: B Feedback: A low-birth-weight newborn weighs less than 5.5 lb (2,500 g) but more than 3 lb 5 oz. A very-low-birth-weight newborn would weigh less than 3 lb 5 oz but more than 2 lb 3 oz (1,000 g). An extremely-low-birth-weight newborn weighs less than 2 lb 3 oz (1,000g). A small-for-gestational-age newborn typically weighs less than 5 lb 8 oz (2,500 g) at term.

A nurse is assisting in the resuscitation of a newborn. The nurse would expect to stop resuscitation efforts when the newborn has no heartbeat and respiratory effort after which time frame? A) 5 minutes B) 10 minutes C) 15 minutes D) 20 minutes

Ans: B Feedback: According to the American Heart Association and American Academy of Pediatrics Guidelines for Neonatal Resuscitation, resuscitation efforts may be stopped if the newborn exhibits no heartbeat and no respiratory effort after 10 minutes of continuous and adequate resuscitation.

A newborn has an Apgar score of 6 at 5 minutes. Which of the following is the priority? A) Initiating IV fluid therapy B) Beginning resuscitative measures C) Promoting kangaroo care D) Obtaining a blood culture

Ans: B Feedback: An Apgar score below 7 at 1 or 5 minutes indicates the need for resuscitation. Intravenous fluid therapy and blood cultures may be done once resuscitation is started. Kangaroo care would be appropriate once the newborn is stable.

Which of the following would the nurse include in the plan of care for a newborn receiving phototherapy? A) Keeping the newborn in the supine position B) Covering the newborn's eyes while under the bililights C) Ensuring that the newborn is covered or clothed D) Reducing the amount of fluid intake to 8 ounces daily

Ans: B Feedback: During phototherapy, the newborn's eyes are covered to protect them from the lights. The newborn is turned every 2 hours to expose all areas of the body to the lights and is kept undressed, except for the diaper area, to provide maximum body exposure to the lights. Fluid intake is increased to allow for added fluid, protein, and calories.

The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea based on the understanding that this type of feeding is necessary for which reason? A) Lactase enzymatic activity is not adequate. B) Oxygen demands need to be reduced. C) Renal solute lead must be considered. D) Hyperbilirubinemia is likely to develop.

Ans: B Feedback: For the newborn with transient tachypnea, the newborn's respiratory rate is high, increasing his oxygen demand. Thus, measures are initiated to reduce this demand. Gavage feedings are one way to do so. With transient tachypnea, enzyme activity and kidney function are not affected. This condition typically resolves within 72 hours. The risk for hyperbilirubinemia is not increased.

Which of the following would not be considered a risk factor for bronchopulmonary dysplasia (chronic lung disease)? A) Preterm birth (less than 32 weeks) B) Female gender C) White race D) Sepsis

Ans: B Feedback: Male gender is more commonly associated with bronchopulmonary dysplasia. Preterm birth of less than 32 weeks' gestation, sepsis, white race, excessive fluid intake during the first few days of life, severe RDS with mechanical ventilation for more than 1 week, and patent ductus arteriosus are all risk factors associated with chronic lung disease in the newborn.

A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how much should my newborn drink at each feeding?" The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding? A) 1 to 2 ounces B) 2 to 4 ounces C) 4 to 6 ounces D) 6 to 8 ounces

Ans: B Feedback: Newborns need about 108 cal/kg or approximately 650 cal/day (Dudek, 2010). Therefore, explain to parents that a newborn will need to 2 to 4 ounces to feel satisfied at each feeding.

Which of the following would the nurse include when teaching a new mother about the difference between pathologic and physiologic jaundice? A) Physiologic jaundice results in kernicterus. B) Pathologic jaundice appears within 24 hours after birth. C) Both are treated with exchange transfusions of maternal O- blood. D) Physiologic jaundice requires transfer to the NICU.

Ans: B Feedback: Pathologic jaundice appears within 24 hours after birth, whereas physiologic jaundice commonly appears around the third to fourth days of life. Kernicterus is more commonly associated with pathologic jaundice. An exchange transfusion is used only if the total serum bilirubin level remains elevated after intensive phototherapy. With this procedure, the newborn's blood is removed and replaced with nonhemolyzed red blood cells from a donor. Physiologic jaundice often is treated at home.

After teaching the parents of a newborn with periventricular hemorrhage about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A) "We'll make sure to cover both of his eyes to protect them." B) "Our newborn could develop a learning disability later on." C) "Once the bleeding ceases, there won't be any more worries." D) "We need to get family members to donate blood for transfusion."

Ans: B Feedback: Periventricular-intraventricular hemorrhage has long-term sequelae such as seizures, hydrocephalus, periventricular leukomalacia, cerebral palsy, learning disabilities, vision or hearing deficits, and mental retardation. Covering the eyes is more appropriate for the newborn receiving phototherapy. The bleeding in the brain can lead to serious long-term effects. Blood transfusions are not used to treat periventricular hemorrhage.

When planning the care of a newborn addicted to cocaine who is experiencing withdrawal, which of the following would be least appropriate to include? A) Wrapping the newborn snugly in a blanket B) Waking the newborn every hour C) Checking the newborn's fontanels D) Offering a pacifier

Ans: B Feedback: Stimuli need to be decreased. Waking the newborn every hour would most likely be too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive sucking. Checking the fontanels provides evidence of hydration.

A group of nursing students are reviewing the different types of congenital heart disease in infants. The students demonstrate a need for additional review when they identify which of the following as an example of increased pulmonary blood flow (left-to-right shunting)? A) Atrial septal defect B) Tetralogy of Fallot C) Ventricular septal defect D) Patent ductus arteriosus

Ans: B Feedback: Tetralogy of Fallot is a congenital heart condition that results from decreased, not increased, pulmonary blood flow. Atrial septal defect, ventricular septal defect, and patent ductus arteriosus are heart conditions that involve increased blood flow from higher pressure (left side of heart) to lower pressure (right side of heart), resulting in left-to-right shunting.

When developing the plan of care for a newborn with an acquired condition, which of the following would the nurse include to promote participation by the parents? A) Use verbal instructions primarily for explanations B) Assist with decision making process C) Provide personal views about their decisions D) Encourage them to refrain from showing emotions

Ans: B Feedback: To promote parental participation, the nurse should assist them with making decisions about treatment, and support their decisions for the newborn's care. Imposing personal views about their decisions is inappropriate and undermines the nurse-client relationship. In addition, the nurse would assess their ability to cope with the diagnosis, encourage them to verbalize their feelings about the newborn's condition and treatment and educate them about the newborn's condition using written information and pictures to enhance understanding.

Which of the following would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A) Avoid using the terms "death" or "dying." B) Provide opportunities for them to hold the newborn. C) Refrain from initiating conversations with the parents. D) Quickly refocus the parents to a more pleasant topic.

Ans: B Feedback: When dealing with grieving parents, nurses should provide them with opportunities to hold the newborn if they desire. In addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn. These interventions help to validate the parents' sense of loss, relive the experience, and attach significance to the meaning of loss. The nurse should use appropriate terminology, such as "dying," "died," and "death," to help the parents accept the reality of the death. Nurses need to demonstrate empathy and to respect the parents' feelings, responding to them in helpful and supportive ways. Active listening and allowing the parents to vent their frustrations and anger help validate the parents' feelings and facilitate the grieving process.

The nurse is assessing the newborn of a mother who had gestational diabetes. Which of the following would the nurse expect to find? (Select all that apply.) A) Pale skin color B) Buffalo hump C) Distended upper abdomen D) Excessive subcutaneous fat E) Long slender neck

Ans: B, C, D Feedback: Infants of diabetic mothers exhibit full rosy cheeks with a ruddy skin color, short neck, buffalo hump over the nape of the neck, massive shoulders, distended upper abdomen, and excessive subcutaneous fat tissue.

A nurse is developing a teaching plan for a postpartum woman who is breast-feeding about sexuality and contraception. Which of the following would the nurse most likely include? (Select all that apply.) A) Resumption of sexual intercourse about two weeks after delivery B) Possible experience of fluctuations in sexual interest C) Use of a water-based lubricant to ease vaginal discomfort D) Use of combined hormonal contraceptives for the first three weeks E) Possibility of increased breast sensitivity during sexual activity

Ans: B, C, E Typically, sexual intercourse can be resumed once bright-red bleeding has stopped and the perineum is healed from an episiotomy or lacerations. This is usually by the third to the sixth week postpartum. Fluctuations in sexual interest are normal. In addition, breast-feeding women may notice a let-down reflex during orgasm and find that breasts are very sensitive when touched by the partner. Precoital vaginal lubrication may be impaired during the postpartum period, especially in women who are breast-feeding. Use of water-based gel lubricants (KY jelly, Astroglide) can help. The Centers for Disease Control and Prevention recommend that postpartum women not use combined hormonal contraceptives during the first 21 days after childbirth because of the high risk for venous thromboembolism (VTE) during this period.

A newborn is diagnosed with meconium aspiration syndrome. When assessing this newborn, which of the following would the nurse expect to find? (Select all that apply.) A) Pigeon chest B) Prolonged tachypnea C) Intercostal retractions D) High blood pH level E) Coarse crackles on auscultation

Ans: B, C, E Feedback: Assessment findings associated with meconium aspiration syndrome include barrel-shaped chest with an increased anterior-posterior (AP) chest diameter (similar to that found in a client with chronic obstructive pulmonary disease), prolonged tachypnea, progression from mild to severe respiratory distress, intercostal retractions, end-expiratory grunting, and cyanosis. Coarse crackles and rhonchi are noted on lung auscultation.

A nurse is observing a postpartum woman and her partner interact with their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which of the following? (Select all that apply.) A) Frequently ask for the newborn to be taken from the room B) Identify common features between themselves and the newborn C) Refer to the newborn as having a monkey-face D) Make direct eye contact with the newborn E) Refrain from checking out the newborn's features

Ans: B, D Positive behaviors that indicate attachment include identifying common features and making direct eye contact with the newborn. Asking for the newborn to be taken out of the room, referring to the newborn as having a monkey-face and refraining from checking out the newborn's features are negative attachment behaviors.

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be ordered? A) Ferrous sulfate (Feosol) B) Methylergonovine (Methergine) C) Docusate (Colace) D) Bromocriptine (Parlodel)

Ans: C A stool softener such as docusate (Colace) may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.

When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which of the following? A) Superficial structures above the muscle B) Through the perineal muscles C) Through the anal sphincter muscle D) Through the anterior rectal wall

Ans: C A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only the skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

To decrease the pain associated with an episiotomy immediately after birth, which action by the nurse would be most appropriate? A) Offer warm blankets. B) Encourage the woman to void. C) Apply an ice pack to the site. D) Offer a warm sitz bath.

Ans: C An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.

A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction would be most appropriate to aid in relieving her discomfort? A) "Express some milk from your breasts every so often to relieve the distention." B) "Remove your bra to relieve the pressure on your sensitive nipples and breasts." C) "Apply ice packs to your breasts to reduce the amount of milk being produced." D) "Take several warm showers daily to stimulate the milk let-down reflex."

Ans: C For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the woman who was breast-feeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.

A postpartum woman is having difficulty voiding for the first time after giving birth. Which of the following would be least effective in helping to stimulate voiding? A) Pouring warm water over her perineal area B) Having her hear the sound of water running nearby C) Placing her hand in a basin of cool water D) Standing her in the shower with the warm water on

Ans: C Helpful measures to stimulate voiding include placing her hand in a basin of warm water, pouring warm water over her perineal area, hearing the sound of running water nearby, blowing bubbles through a straw, standing in the shower with the warm water turned on, and drinking fluids.

Which of the following factors in a client's history would alert the nurse to an increased risk for postpartum hemorrhage? A) Multiparity, age of mother, operative delivery B) Size of placenta, small baby, operative delivery C) Uterine atony, placenta previa, operative procedures D) Prematurity, infection, length of labor

Ans: C Risk factors for postpartum hemorrhage include a precipitous labor less than 3 hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.

After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify the development of a close emotional attraction to a newborn by parents during the first 30 to 60 minutes after birth as which of the following? A) Reciprocity B) Engrossment C) Bonding D) Attachment

Ans: C The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem? A) Lochia rubra with a fleshy odor B) Respiratory rate of 16 breaths per minute C) Temperature of 101° F D) Pain rating of 2 on a scale from 0 to 10

Ans: C : Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range. Some women experience a slight fever, up to 38º C (100.4º F), during the first 24 hours. A temperature above 38º C (100.4º F) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Foul-smelling lochia or lochia with an unexpected change in color or amount, shortness of breath, or respiratory rate below 16 or above 20 breaths per minute would also be a cause for concern. The goal of pain management is to have the woman's pain scale rating maintained between 0 to 2 points at all times, especially after breast-feeding.

When assessing a postterm newborn, which of the following would the nurse correlate with this gestational age variation? A) Moist, supple, plum skin appearance B) Abundant lanugo and vernix C) Thin umbilical cord D) Absence of sole creases

Ans: C Feedback: A postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet.

The nurse is assessing a newborn who is large for gestational age. The newborn was born breech. The nurse suspects that the newborn may have experienced trauma to the upper brachial plexus based on which assessment findings? A) Absent grasp reflex B) Hand weakness C) Absent Moro reflex D) Facial asymmetry

Ans: C Feedback: An injury to the upper brachial plexus, or Erb's palsy, is manifested by adduction, pronation, and internal rotation of the affected extremity, absent shoulder movement, absent Moro reflex and positive grasp reflex. An absent grasp reflex and hand weakness is noted with a lower brachial plexus injury. Facial asymmetry is associated with a cranial nerve injury.

A group of nursing students are reviewing the literature in preparation for a class presentation on newborn pain prevention and management. Which of the following would the students be most likely to find about this topic? A) Newborn pain is frequently recognized and treated B) Newborns rarely experience pain with procedures C) Pain is frequently mistaken for irritability or agitation D) Newborns may be less sensitive to pain than adult.

Ans: C Feedback: Assessment of pain in the newborn remains a contentious and vexing problem. According to an international consortium, principles of newborn pain prevention and management include the following: newborn pain frequently goes unrecognized and undertreated; newborns experience pain and analgesics should be given; a procedure considered painful for an adults should also be considered painful for a newborn; newborns may be more sensitive to pain than adults; and pain behavior is frequently mistaken for irritability and agitation.

A nursing student is preparing a presentation for the class on clubfoot. The student determines that the presentation was successful when the class states which of the following? A) Clubfoot is a common genetic disorder. B) The condition affects girls more often than boys. C) The exact cause of clubfoot is not known. D) The intrinsic form can be manually reduced.

Ans: C Feedback: Clubfoot is a complex, multifactorial deformity with genetic and intrauterine factors. Heredity and race seem to factor into the incidence, but the means of transmission and the etiology are unknown. Most newborns with clubfoot have no identifiable genetic, syndromal, or extrinsic cause. Clubfoot affects boys twice as often as girls. With the intrinsic type, manual reduction is not possible.

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation and intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A) Suggest that the parents stay for just a few minutes to reduce their anxiety. B) Reassure them that their newborn is progressing well. C) Encourage the parents to touch their preterm newborn. D) Discuss the care they will be giving the newborn upon discharge.

Ans: C Feedback: The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated.

Assessment of newborn reveals a large protruding tongue, slow reflexes, distended abdomen, poor feeding, hoarse cry, goiter and dry skin. Which of the following would the nurse suspect? A) Phenylketonuria B) Galactosemia C) Congenital hypothyroidism D) Maple syrup urine disease

Ans: C Feedback: The manifestations listed correlate with congenital hypothyroidism. With phenylketonuria, the infant appears normal at birth but by 6 months of age, signs of slow mental development are evident. Vomiting, poor feeding, failure to thrive, overactivity and musty-smelling urine are additional signs. With maple syrup urine disease, signs and symptoms include lethargy, poor feeding, vomiting, weight loss, seizures, shrill cry, shallow respirations, loss of reflexes, and a sweet maple syrup odor to the urine. With galactosemia, manifestations include vomiting, hypoglycemia, hyperbilirubinemia, poor weight gain, cataracts, and frequent infections.

When performing newborn resuscitation, which action would the nurse do first? A) Intubate with an appropriate-sized endotracheal tube. B) Give chest compressions at a rate of 80 times per minute. C) Administer epinephrine intravenously. D) Suction the mouth and then the nose.

Ans: D Feedback: After placing the newborn's head in a "sniffing" position, the nurse would suction the mouth and then the nose. This is followed by ventilation, circulation (chest compressions), and administration of epinephrine.

The nurse is teaching a group of students about the differences between a full-term newborn and a preterm newborn. The nurse determines that the teaching is effective when the students state that the preterm newborn has: A) Fewer visible blood vessels through the skin B) More subcutaneous fat in the neck and abdomen C) Well-developed flexor muscles in the extremities D) Greater surface area in proportion to weight

Ans: D Feedback: Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone.

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? a) Sleepiness b) Tachycardia c) Apnea d) Crying

Apnea Explanation: A premature infant has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress.

Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when Ortolani's maneuver is performed. Which of the following would the nurse suspect? A) Slipping of the periosteal joint B) Developmental hip dysplasia C) Normal newborn variation D) Overriding of the pelvic bone

B A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the area. This, along with uneven gluteal creases, suggests developmental hip dysplasia. These findings are not a normal variation and are not associated with slipping of the periosteal joint or overriding of the pelvic bone.

Just after delivery, a newborn's axillary temperature is 94 degrees F. What action would be most appropriate? A) Assess the newborn's gestational age. B) Rewarm the newborn gradually. C) Observe the newborn every hour. D) Notify the physician if the temperature goes lower.

B A newborn's temperature is typically maintained at 36.5 to 37.5 degrees C (97.7 to 99.7 degrees F). Since this newborn's temperature is significantly lower, the nurse should institute measures to rewarm the newborn gradually. Assessment of gestational age is completed regardless of the newborn's temperature. Observation would be inappropriate because lack of action may lead to a further lowering of the temperature. The nurse should notify the physician of the newborn's current temperature since it is outside normal parameters.

A nurse is making a home visit to a postpartum woman who delivered a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as which of the following? A) Involution B) Engorgement C) Mastitis D) Engrossment

B Engorgement is the process of swelling of the breast tissue as a result of an increase in blood and lymph supply as a precursor to lactation (Figure 15.4). Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the next 24 to 36 hours (Chapman, 2011). Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. Involution refers to the process of the uterus returning to its prepregnant state. Mastitis refers to an infection of the breasts. Engrossment refers to the bond that develops between the father and the newborn.

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate? A) "It's difficult to say, but it will probably return in about 2 to 3 weeks." B) "It varies, but you can estimate it returning in about 7 to 9 weeks." C) "You won't have to worry about it returning for at least 3 months." D) "You don't have to worry about that now. It'll be quite a while."

B For the nonlactating woman, menstruation resumes 7 to 9 weeks after giving birth, with the first cycle being anovulatory. For the lactating woman, menses can return anytime from 2 to 18 months after childbirth.

Which of the following would the nurse interpret as being least indicative of paternal engrossment? A) Demonstrating pleasure when touching or holding the newborn B) Identifying imperfections in the newborn's appearance C) Being able to distinguish his newborn from others in the nursery D) Showing feelings of pride with the birth of the newborn

B Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.

The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which of the following would the nurse correlate with this gestational age variation? A) Strong, brisk motor skills B) Difficulty in arousing to a quiet alert state C) Birthweight of 7 lb 14 oz D) Wasted appearance of extremities

B LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb 13 oz at term.

A nurse is visiting a postpartum woman who delivered a healthy newborn 5 days ago. Which of the following would the nurse expect to find? A) Bright red discharge B) Pinkish brown discharge C) Deep red mucus-like discharge D) Creamy white discharge

B Lochia serosa is pinkish brown and is expelled 3 to 10 days postpartum. Lochia rubra is a deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after birth. Lochia alba is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content and occurs from days 10 to 14 but can last 3 to 6 weeks postpartum.

A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate? A) "You probably took iron during your pregnancy." B) "This is meconium stool, normal for a newborn." C) "I'll take a sample and check it for possible bleeding." D) "This is unusual and I need to report this."

B Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: A) Milia B) Mongolian spots C) Stork bites D) Birth trauma

B Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Milia are unopened sebaceous glands frequently found on a newborn's nose. Stork bites are superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling, and possible deformity.

Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: A) Habituation B) Motor maturity C) Orientation D) Social behaviors

B Motor maturity is evidenced by rhythmic, spontaneous movements. Habituation is manifested by the newborn's ability to respond to the environment appropriately. Orientation involves the newborn's response to new stimuli, such as turning the head to a sound. Social behaviors involve cuddling and snuggling into the arms of a parent.

Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: A) Habituation B) Motor maturity C) Orientation D) Social behaviors

B Motor maturity is evidenced by rhythmic, spontaneous movements. Habituation is manifested by the newborn's ability to respond to the environment appropriately. Orientation involves the newborn's response to new stimuli, such as turning the head to a sound. Social behaviors involve cuddling and snuggling into the arms of a parent.

A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern? A) Hemoglobin 19 g/dL B) Platelets 75,000/uL C) White blood cells 20,000/mm3 D) Hematocrit 52%

B Normal newborn platelets range from 150,00 to 350,000/uL. Normal hemoglobin ranges from 17 to 23g/dL, and normal hematocrit ranges from 46% to 68%. Normal white blood cell count ranges from 10,000 to 30,000/mm3.

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate? A) "You must have an infection, so let me get a urine specimen." B) "Your body is undergoing many changes that cause your bladder to fill quickly." C) "Your uterus is not contracting as quickly as it should." D) "The anesthesia that you received is wearing off and your bladder is working again."

B Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines, the buildup and retention of extra fluids during pregnancy, and a decreasing production of aldosterone—the hormone that decreases sodium retention and increases urine production. All these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum. Rapid bladder filling, possible infection, or effects of anesthesia are not involved.

A group of nursing students are reviewing respiratory system adaptations that occur during the postpartum period. The students demonstrate understanding of the information when they identify which of the following as a postpartum adaptation? A) Continued shortness of breath B) Relief of rib aching C) Diaphragmatic elevation D) Decrease in respiratory rate

B Respirations usually remain within the normal adult range of 16 to 24 breaths per minute. As the abdominal organs resume their nonpregnant position, the diaphragm returns to its usual position. Anatomic changes in the thoracic cavity and rib cage caused by increasing uterine growth resolve quickly. As a result, discomforts such as shortness of breath and rib aches are relieved.

A postpartum woman who has experienced diastasis recti asks the nurse about what to expect related to this condition. Which response by the nurse would be most appropriate? A) "You'll notice that this will fade to silvery lines." B) "Exercise will help to improve the muscles." C) "Expect the color to lighten somewhat." D) "You'll notice that your shoe size will increase."

B Separation of the rectus abdominis muscles, called diastasis recti, is more common in women who have poor abdominal muscle tone before pregnancy. After birth, muscle tone is diminished and the abdominal muscles are soft and flabby. Specific exercises are necessary to help the woman regain muscle tone. Fortunately, diastasis responds well to exercise, and abdominal muscle tone can be improved. Stretch marks (striae gravidarum) fade to silvery lines. The darkened pigmentation of the abdomen (linea nigra), face (melasma), and nipples gradually fades. Parous women will note a permanent increase in shoe size.

A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate? A) "You probably took iron during your pregnancy." B) "This is meconium stool, normal for a newborn." C) "I'll take a sample and check it for possible bleeding." D) "This is unusual and I need to report this."

B The mother is describing meconium. Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.

The nurse is teaching a group of students about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed? A) The newborn's skin and that of an adult are similar in thickness. B) The newborn's sweat glands function fully, just like those of an adult. C) Skin development in the newborn is not complete at birth. D) The newborn has fewer fibrils connecting the dermis and epidermis

B The newborn has sweat glands, like an adult, but full adult functioning is not present until the second or third year of life. The newborn and adult epidermis is similar in thickness and lipid composition, but skin development is not complete at birth. Fewer fibrils connect the dermis and epidermis in the newborn when compared with the adult.

When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because of which of the following? A) The newborn should not be sleeping on his back. B) Stuffed animals should not be in areas where infants sleep. C) The bulb syringe should not be kept in the bassinet. D) This newborn should be sleeping in a crib.

B The nurse should instruct the mother to remove all fluffy bedding, quilts, stuffed animals, and pillows from the crib to prevent suffocation. Newborns and infants should be placed on their backs to sleep. Having the bulb syringe nearby in the bassinet is appropriate. Although a crib is the safest sleeping location, a bassinet is appropriate initially.

The partner of a woman who has given birth to a healthy newborn says to the nurse, "I want to be involved, but I'm not sure that I'm able to care for such a little baby." The nurse interprets this as indicating which of the following stages? A) Expectations B) Reality C) Transition to mastery D) Taking-hold

B The partner's statement reflects stage 2 (reality), which occurs when fathers or partners realize that their expectations in stage 1 are not realistic. Their feelings change from elation to sadness, ambivalence, jealousy, and frustration. Many wish to be more involved in the newborn's care and yet do not feel prepared to do so. New fathers or partners pass through stage 1 (expectations) with preconceptions about what home life will be like with a newborn. Many men may be unaware of the dramatic changes that can occur when this newborn comes home to live with them. In stage 3 (transition to mastery), the father or partner makes a conscious decision to take control and be at the center of his newborn's life regardless of his preparedness. Taking-hold is a stage of maternal adaptation.

The nurse places a warmed blanket on the scale when weighing a newborn. The nurse does so to minimize heat loss via which mechanism? A) Evaporation B) Conduction C) Convection D) Radiation

B Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

Which of the following would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A) Avoid using the terms "death" or "dying." B) Provide opportunities for them to hold the newborn. C) Refrain from initiating conversations with the parents. D) Quickly refocus the parents to a more pleasant topic.

B When dealing with grieving parents, nurses should provide them with opportunities to hold the newborn if they desire. In addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn. These interventions help to validate the parents' sense of loss, relive the experience, and attach significance to the meaning of loss. The nurse should use appropriate terminology, such as "dying," "died," and "death," to help the parents accept the reality of the death. Nurses need to demonstrate empathy and to respect the parents' feelings, responding to them in helpful and supportive ways. Active listening and allowing the parents to vent their frustrations and anger help validate the parents' feelings and facilitate the grieving process.

A nurse is teaching postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching? A) "We can put him in the tub to bathe him once the cord falls off and is healed." B) "The cord stump should change from brown to yellow." C) "Exposing the stump to the air helps it to dry." D) "We need to call the doctor if we notice a funny odor."

B) "The cord stump should change from brown to yellow."

A nursing instructor is describing the advantages and disadvantages associated with newborn circumcision to a group of nursing students. Which statement by the students indicates effective teaching? A) "Sexually transmitted infections are more common in circumcised males." B) "The rate of penile cancer is less for circumcised males." C) "Urinary tract infections are more easily treated in circumcised males." D) "Circumcision is a risk factor for acquiring HIV infection."

B) "The rate of penile cancer is less for circumcised males."

A prenatal client at 30 weeks gestation is scheduled for a nonstress test (NST) and asks the nurse, "What is this test for?" The nurse correctly responds that the test is used to determine which of the following? Select all that apply. a)Fetal lung maturity b)Adequate fetal oxygenation c)Accelerations of fetal heart rate d)Fetal well-being

B, C, D An NST documents fetal well-being by measuring fetal oxygenation and fetal heart rate accelerations, but not fetal lung maturity.

A nursing student is preparing a class presentation about changes in the various body systems during the postpartum period and their effects. Which of the following would the student include as influencing a postpartum woman's ability to void? (Select all that apply.) A) Use of an opioid anesthetic during labor B) Generalized swelling of the perineum C) Decreased bladder tone from regional anesthesia D) Use of oxytocin to augment labor E) Need for an episiotomy

B, C, D Many women have difficulty feeling the sensation to void after giving birth if they received an anesthetic block during labor (which inhibits neural functioning of the bladder) or if they received oxytocin to induce or augment their labor (antidiuretic effect). These women will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention. In addition, urination may be impeded by perineal lacerations; generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus; hematomas; decreased bladder tone as a result of regional anesthesia; and diminished sensation of bladder pressure as a result of swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor.

A nurse has been assigned to care for a client who has just given birth. How frequently should the nurse perform assessments during the first hour of birth? A. every 30 minutes b. every 15 minutes c. every 30 minutes d. every 45 minutes

B. postpartum assessment is typically performed every 15 minutes fro the first hour. After the second hour assessment is performed every 30 minutes. the client has to be monitored closely during the first hour after birth .

A 28-week-gestation newborn experienced birth asphyxia at the time of delivery. What is a long-term complication of birth asphyxia? a)Necrotizing enterocolitis b)Retinopathy of prematurity c)Intraventricular hemorrhage d)Anemia of prematurity

C Birth asphyxia will cause an insult to the brain, and more often than not will cause a bleed or intraventricular hemorrhage. Birth asphyxia is not directly correlated with NEC, retinopathy of prematurity, or anemia of prematurity. These are common for the premature infant, but not necessarily birth asphyxia.

The physician orders an ultrasound for a prenatal client prior to an amniocentesis. The nurse explains to the client that the purpose of the ultrasound is to: a)Determine the gestational sac volume. b)Measure the fetus's crown-rump length. c)Locate the placenta. d)Measure the fetus's biparietal diameter.

C During an amniocentesis, the physician scans the uterus using ultrasound to identify the fetal and placental positions and to identify adequate pockets of amniotic fluid. Determination of the gestational sac volume, measuring the crown-rump length, and measuring the biparietal diameter are aspects of assessing fetal well-being (biophysical profile, or BPP), and may or may not be done prior to the amniocentesis, depending on gestational age.

A prenatal client at 35 weeks gestation is scheduled for an amniocentesis to determine fetal lung maturity. The nurse expects the lecithin/sphingomyelin (L/S) ratio to be: a)0.5:1 b)1:1 c)2:1 d)3:1

C Early in pregnancy, the sphingomyelin concentration in amniotic fluid is greater than the concentration of lecithin, and so the L/S ratio is low (lecithin levels are low and sphingomyelin levels are high). At about 32 weeks gestation, sphingomyelin levels begin to fall and the amount of lecithin begins to increase. By 35 weeks gestation, an L/S ratio of 2:1 (also reported as 2.0) is usually achieved in the normal fetus.

A client states that she had a spontaneous abortion 12 months ago. The client asks if her hormones may have contributed to the loss of the pregnancy. The nurse's response is based upon her knowledge of which of the following facts? a) Implantation occurs when progesterone levels are low. b) hCG reaches a maximum level at 4 weeks gestation. c) Progesterone decreases the contractility of the uterus. d) Progesterone is only produced by the corpus luteum during pregnancy.

C Progesterone decreases the contractility of the uterus, thus preventing uterine contractions that might cause spontaneous abortion. Progesterone must be present in high levels for implantation to occur. After 10 weeks, the placenta takes over the production of progesterone. hCG reaches its maximum level at 50-70 days gestation.

The nurse is preparing an educational workshop on fetal development. Which statement by the student would require the nurse to explain further? a) "True knots are usually associated with a cord that is too long." b) "The average cord length at term is 22 inches." c) "The umbilical cord normally contains two veins and one artery." d) "The high blood volume and Wharton's jelly content of the umbilical cord prevents compression of the cord."

C Umbilical cords appear twisted or spiraled. This is most likely caused by fetal movement. A true knot in the umbilical cord rarely occurs; if it does, the cord is usually long. More common are so-called false knots, caused by the folding of cord vessels. A nuchal cord is said to exist when the umbilical cord encircles the fetal neck. A normal umbilical cord contains one large vein and two smaller arteries. A specialized connective tissue known as Wharton's jelly surrounds the blood vessels in the umbilical cord. This tissue, plus the high blood volume pulsating through the vessels, prevents compression of the umbilical cord in utero.

When assessing a postterm newborn, which of the following would the nurse correlate with this gestational age variation? A) Moist, supple, plum skin appearance B) Abundant lanugo and vernix C) Thin umbilical cord D) Absence of sole creases

C A postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet.

The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which of the following? A) Inability to clear fluids B) Immature respiratory control center C) Deficiency of surfactant D) Smaller respiratory passages

C A preterm newborn is at increased risk for respiratory distress syndrome (RDS) because of a surfactant deficiency. Surfactant helps to keep the alveoli open and maintain lung expansion. With a deficiency, the alveoli collapse, predisposing the newborn to RDS. An inability to clear fluids can lead to transient tachypnea. Immature respiratory control centers lead to an increased risk for apnea. Smaller respiratory passages led to an increased risk for obstruction.

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes? A) Gastrointestinal and hepatic B) Urinary and hematologic C) Respiratory and cardiovascular D) Neurological and integumentary

C Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes? A) Gastrointestinal and hepatic B) Urinary and hematologic C) Respiratory and cardiovascular D) Neurological and integumentary

C Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

When describing the complications that can occur in newborns to a group of pregnant women, which would the nurse include as being at lowest risk? A) Small-for-gestational-age newborns B) Large-for-gestational-age newborns C) Appropriate-for-gestational-age newborns D) Low-birthweight newborns

C Appropriate-for-gestational-age newborns are at the lowest risk for any problems. The other categories all have an increased risk of complications.

A group of nursing students are reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as which of the following? A) Puerperium B) Lactation C) Attachment D) Engrossment

C Attachment is a formation of a relationship between a parent and her/his newborn through a process of physical and emotional interactions. Puerperium refers to the postpartum period. Lactation refers to the process of milk secretion by the breasts. Engrossment refers to the bond that develops between the father and the newborn.

A group of nursing students are reviewing the changes in the newborn's lungs that must occur to maintain respiratory function. The students demonstrate understanding of this information when they identify which of the following as the first event? A) Expansion of the lungs B) Increased pulmonary blood flow C) Initiation of respiratory movement D) Redistribution of cardiac output

C Before the newborn's lungs can maintain respiratory function, the following events must occur: respiratory movement must be initiated; lungs must expand, functional residual capacity must be established, pulmonary blood flow must increase, and cardiac output must be redistributed.

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? A) To aid in maturing the newborn's sucking reflex B) To encourage the development of maternal antibodies C) To facilitate maternal-infant bonding D) To enhance the clearing of the newborn's respiratory passages

C Breast-feeding can be initiated immediately after birth. This immediate mother-newborn contact takes advantage of the newborn's natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn's temperature, blood glucose level, and respiratory rate. It is not associated with maturing the sucking reflex, encouraging the development of maternal antibodies, or aiding in clearing of the newborn's respiratory passages.

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: A) Molding B) Microcephaly C) Caput succedaneum D) Cephalhematoma

C Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of the skull.

The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform Kegel exercises. The nurse includes this information for which reason? A) Reduce lochia B) Promote uterine involution C) Improve pelvic floor tone D) Alleviate perineal pain

C Kegel exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.

The nurse assesses a 1-day-old newborn. Which finding indicates that the newborn's oxygen needs aren't being met? A) Respiratory rate of 54 breaths/minute B) Abdominal breathing C) Nasal flaring D) Acrocyanosis

C Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.

The nurse is teaching a group of students about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed? A) The newborn's skin and that of an adult are similar in thickness. B) The lipid composition of the skin of a newborn and adult is about the same. C) Skin development in the newborn is complete at birth. D) The newborn has more fibrils connecting the dermis and epidermis

C The newborn and adult epidermis is similar in thickness and lipid composition, but skin development is not complete at birth. Fewer fibrils connect the dermis and epidermis in the newborn when compared with the adult.

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: A) Greater than after a vaginal delivery B) About the same as after a vaginal delivery C) Less than after a vaginal delivery D) Saturated with clots and mucus

C Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.

A nurse is applyng ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? A. apply ice packs directly to the peri area b. apply ice packs for 40 minutes continuously c. ensure ice pack is changed frequently d. use ice packs for a week after birth

C it should be changed frequently to promote normal hygiene

The nurse performs a physical examination on a newborn 2 hours after birth. Which of the following findings indicate a need for a pediatric consultation? (Select all that apply) a. Respiratory rate of 50 breaths per minute b. Intermittent episodes of apnea, lasting <10 seconds each c. Absent Moro reflex when startled d. Preauricular skin tag noted on left ear e. White raised bumps noted on nose and face f. Yellow blanching of the skin when pressure applied to the nos

C, F. - Absence of the Moro reflex might indicate a neurologic problem - yellow blanching of the skin over a bony prominence might indicate pathologic jaundice since it is before 24 hours old. Physiologic jaundice typically occurs after 24 hours old, but a pathologic jaundice occurs before 24 hours old.

After teaching a group of breast-feeding women about nutritional needs, the nurse determines that the teaching was successful when the women state that they need to increase their intake of which nutrients? a. Carbohydrates and fiber b. Fats and vitamins c. Calories and protein D. Iron-rich foods and minerals

C. Lactating mothers need an extra 500 calories to sustain breast-feeding. An additional 20 g of protein is also needed to help build and regenerate body cells for the lactating woman. *Additional intake of carbohydrates or fiber is not suggested for lactation.

The nurse is assessing Ms. Smith, who gave birth to her first child 5 days ago. What findings by the nurse would be expected? A. Cream-colored lochia; uterus above the umbilicus B. Bright-red lochia with clots; uterus 2 fingerbreadths below umbilicus C. Light pink or brown lochia; uterus 4 to 5 fingerbreadths below umbilicus D. Yellow, mucousy lochia; uterus at the level of the umbilicus

C. The nurse would expect light pink or brown lochia, and the uterus should be four to five fingerbreadths below the umbilicus.

When assessing a term newborn (6 hours old), the nurse auscultates bowel sounds and documents recent passing of meconium. These findings would indicate: a. Abnormal gastrointestinal newborn transition and needs to be reported b. An intestinal anomaly that needs immediate surgery c. A patent anus with no bowel obstruction and normal peristalsis d. A malabsorption syndrome resulting in fatty stools

C. The findings indicate a patent anus with no bowel obstruction and normal peristalsis.

A nurse is working with a client who has just begun labor and who has given birth vaginally five previous times. Which of the following interventions will the nurse most likely need to implement to meet the needs of this particular client?

Convert the birthing room to birth readiness before full dilatation is obtained Both grand multiparas (women who have given birth five or more times) and women with histories of precipitate labor should have the birthing room converted to birth readiness before full dilatation is obtained. Then, even if a sudden birth should occur, it can be accomplished in a controlled surrounding. As the client is likely to give birth relatively quickly, there is no need for oxytocin or to darken the room lights. There is also no indication that cesarean birth will be necessary, particularly because all of the client's previous births were vaginal.

The nurse is preparing a prenatal client for a transvaginal ultrasound. What nursing action should the nurse include in the preparations? Select all that apply. a)Advise the client to empty her bladder. b)Encourage the client to drink 1.5 quarts of fluid. c)Apply transmission gel over the client's abdomen. d)Place client in lithotomy position.

D After having the client void, assist her to a lithotomy position for a transvaginal ultrasound. Preparation for a transabdominal ultrasound includes encouraging the client to drink 1.5 quarts of fluid, maintaining a full bladder, and applying transmission gel over the client's abdomen.

A nurse, while examining a newborn, observes salmon patches on the nape and on the eyelids. Which of the following is the most likely cause of the salmon patches?"" a. Concentration of pigmented cells b. Eosinophils reacting to environment c. Immature autoregulation of blood flow d. Concentration of immature blood vessels"

D A concentration of immature blood vessels causes salmon patches. Mongolian spots are caused by a concentration of pigmented cells and usually disappear within the first 4 years of life. Erythema toxicum is caused by the newborn's eosinophils reacting to the environment as the immune system matures, and Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low-birth-weight newborns."

The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest? A) 38 breaths per minute B) 46 breaths per minute C) 54 breaths per minute D) 68 breaths per minute

D After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). Thus a newborn with a respiratory rate below 30 or above 60 breaths per minute would require further evaluation.

A nurse teaches a postpartum woman about her risk for thromboembolism. Which of the following would the nurse be least likely to include as a factor increasing her risk? A) Increased clotting factors B) Vessel damage C) Immobility D) Increased red blood cell production

D Clotting factors that increased during pregnancy tend to remain elevated during the early postpartum period. Giving birth stimulates this hypercoagulability state further. As a result, these coagulation factors remain elevated for 2 to 3 weeks postpartum (Silver & Major, 2010). This hypercoagulable state, combined with vessel damage during birth and immobility, places the woman at risk for thromboembolism (blood clots) in the lower extremities and the lungs. Red blood cell production ceases early in the puerperium, which causes mean hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly over the next 2 weeks

The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal? A) Prevent cold stress B) Increase surfactant levels in the lungs C) Promote respiratory stability D) Decrease the serum bilirubin level

D Jaundice reflects elevated serum bilirubin levels; phototherapy helps to break down the bilirubin for excretion. Phototherapy has no effect on body temperature, surfactant levels, or respiratory stability.

A nurse is assessing a newborn and observes the newborn moving his head and eyes toward a loud sound. The nurse interprets this as which of the following? A) Habituation B) Motor maturity C) Social behavior D) Orientation

D Orientation refers to the response of newborns to stimuli. It reflects newborns' response to auditory and visual stimuli, demonstrated by their movement of head and eyes to focus on that stimulus. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held.

A group of students are reviewing the process of breast milk production. The students demonstrate understanding when they identify which hormone as responsible for milk let-down? A) Prolactin B) Estrogen C) Progesterone D) Oxytocin

D Oxytocin is released from the posterior pituitary to promote milk let-down. Prolactin levels increase at term with a decrease in estrogen and progesterone; estrogen and progesterone levels decrease after the placenta is delivered. Prolactin is released from the anterior pituitary gland and initiates milk production.

A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds based on the understanding that this most likely is due to which of the following? A) Placing the newborn prone after feeding B) Limited ability of digestive enzymes C) Underdeveloped pyloric sphincter D) Relaxed cardiac sphincter

D The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in their ability to digest complex carbohydrates and fats; this results in fatty stools, not regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric contents.

After teaching new parents about the sensory capabilities of their newborn, the nurse determines that the teaching was successful when they identify which sense as being the least mature? A) Hearing B) Touch C) Taste D) Vision

D Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature? A) Hearing B) Touch C) Taste D) Vision

D Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales? A) Stop Rh sensitization B) Increase erythopoiesis C) Enhance bilirubin breakdown D) Promote blood clotting

D Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the liver. RhoGAM prevents Rh sensitization. Erythropoietin stimulates erythropoiesis. Phototherapy enhances bilirubin breakdown.

A prenatal client in her second trimester is admitted to the maternity unit with painless, bright red vaginal bleeding. What test might the physician order? a)Alpha-fetoprotein (AFP) b)Contraction stress test (CST) c)Amniocentesis d)Ultrasound

D. An ultrasound for placenta location to rule out placenta previa would be ordered for a client who presents with painless, bright red vaginal bleeding. The ability to see the lower portion of the uterus and cervix with ultrasound is particularly important when vaginal bleeding is noted and placenta previa is the suspected cause. Alpha-fetoprotein (AFP) is a test used to screen for neural tube defects. A contraction stress test is ordered in the third trimester to evaluate the respiratory function of the placenta. Amniocentesis is a procedure used for genetic diagnosis or, in later pregnancy, for lung maturity studies.

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. What is the priority nursing intervention?

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats per minute, closed-chest massage should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both your thumbs, on the lower third of the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 times per minute. If the pressure and the rate of massage are adequate, it should be possible, in addition, to palpate a femoral pulse. If heart sounds are not resumed above 60 beats per minute after 30 seconds of combined positive-pressure ventilation and cardiac compressions, intravenous epinephrine may be prescribed. Following cardio-resuscitation, newborns need to be transferred to a transitional or high-risk nursery for continuous cardiac surveillance to be certain cardiac function is maintained.

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. Which of the following is the priority nursing intervention? a) Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute b) Transfer to a transitional or high-risk nursery for continuous cardiac surveillance c) Administration of IV epinephrine, as prescribed d) Palpation for a femoral pulse

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute Explanation: If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats per minute, closed-chest massage should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both your thumbs, on the lower third of the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 times per minute. If the pressure and the rate of massage are adequate, it should be possible, in addition, to palpate a femoral pulse. If heart sounds are not resumed above 60 beats per minute after 30 seconds of combined positive-pressure ventilation and cardiac compressions, intravenous epinephrine may be prescribed. Following cardio-resuscitation, newborns need to be transferred to a transitional or high-risk nursery for continuous cardiac surveillance to be certain cardiac function is maintained.

The nurse in a newborn nursery is observing for developmentally appropriate care. Which is an example of self-regulation?

Infant has hand in mouth Self-regulation is a form of self-soothing for an infant such as sucking on hands or putting hand to mouth type of movements.

A client with diabetes delivers a full-term neonate who weights 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse palpates the clavicles for which reason? a) Clavicles are commonly absent in neonates of mothers with diabetes. b) Neonates of mothers with diabetes have brittle bones. c) LGA neonates have glucose deposits on their clavicles. d) One of the neonate's clavicles may have been broken during delivery.

One of the neonate's clavicles may have been broken during delivery. Correct Explanation: Because of the neonate's large size, clavicular fractures are common during delivery. The nurse should assess all LGA neonates for this occurrence. None of the other options are true.

____________ jaundice typically starts after 72 hours of breast-feeding. There is an enzyme in breast milk that inhibits the breakdown of bilirubin, and it is reflected on the newborn skin as jaundice.

Physiologic

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration?

Retinopathy of prematurity Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which of the following should the nurse consider as a complication of oxygen administration at a high concentration? a) Retinopathy of prematurity b) Diminished erythropoiesis c) Bronchopulmonary dysplasia d) Necrotizing enterocolitis

Retinopathy of prematurity Correct Explanation: Retinopathy of prematurity can occur as a complication associated with the use of high concentrations of oxygen. High concentrations of oxygen can damage the fragile retinal blood vessels of the preterm infants and cause retinopathy. Bronchopulmonary dysplasia, diminished erythropoiesis, and necrotizing enterocolitis are not complications associated with a high concentration of oxygen. Bronchopulmonary dysplasia is a chronic lung disease that results from the effect of long-term mechanical ventilation. Diminished erythropoiesis in the preterm newborn is due to immaturity of the hemopoietic system. Necrotizing enterocolitis is associated with ischemia of the bowel, leading to necrosis and perforation.

A woman gives birth to a newborn at 38 weeks' gestation. The nurse classifies this newborn as which of the following? a) Late preterm b) Term c) Preterm d) Postterm

Term Correct Explanation: A term newborn is one born from the first day of the 38th week of gestation through 42 weeks. A postterm newborn is one born after completion of 42 weeks' gestation. A preterm newborn is one born before completion of 37 weeks' gestation. A late preterm newborn is one who is bone between 34 and 36-6/7 weeks' gestation

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

Term, small for gestational age, and low-birth-weight infant

Prioritize the postpartum mother's needs 4 hours after giving birth by placing a number 1, 2, 3, or 4 in the blank before each need. 1. _________ Learn how to hold and cuddle the infant. 2. _________Watch a baby bath demonstration given by the nurse. 3. _________ Sleep and rest without being disturbed for a few hours. 4. _________ Interaction time (first 30 minutes) with the infant to facilitate bonding

The correct answer would be: 1. Interaction time (first 30 minutes) with the infant to facilitate bonding 2. Sleep and rest without being disturbed for a few hours 3. Learn how to hold and cuddle the infant 4. Watch a baby bath demonstration given by the nurse

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred? a) The infant's mother must have had a long labor. b) The infant's mother probably used alcohol. c) The infant's mother probably had diabetes. d) The infant may have experienced birth trauma.

The infant's mother probably had diabetes.

A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant?

The neonate is small for its gestational age.

A 20-year-old client gave birth to a baby boy during the 43rd week of gestation. What might the nurse observe in the newborn during routine assessment?

The newborn may look wrinkled and old at birth.

A preterm infant is transferred to a distant hospital for care. When her parents visit her, which of the following would be most important for you to urge them to do? a) Call the baby by her name. b) Touch and, if possible, hold her. c) Stand so the baby can see them. d) Bring a piece of clothing for her.

Touch and, if possible, hold her. Correct Explanation: Preterm infants may be hospitalized for an extended time, so parents need to be encouraged to touch and interact with the infant to begin bonding.

The nurse is assisting with the birth of the second child of a healthy young woman. Her pregnancy has been uneventful, and labor has been progressing well. The fetal head begins to emerge, but instead of continuing to emerge, it retracts into the vagina. What should the nurse try first?

Use McRobert's maneuver. This intervention is used with a large baby who may have shoulder dystocia and require assistance. The legs are sharply flexed, by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli's maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is out of the province of the LVN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

A nurse is assessing a full-term client in labor and determines the fetus is occiput posterior. The client states that all her discomfort is in her lower back. What intervention can the nurse provide that will help alleviate this discomfort?

Use a fist to apply counter pressure to the lower back. Counter pressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" characteristic of the occiput posterior position.

A client who has given birth a week ago complains to the nurse of discomfort when defecating and ambulating. The birth involved an episiotomy. Which of the following should the nurse suggest to the client to provide local comfort? (Select all)

Use of warm sitz baths; use of anesthetic sprays; use of witch hazel pads

A client delivers a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of: a) Low birth weight b) Very low birth weight c) Normal birth weight d) Extremely low birth weight

Very low birth weight

A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?

With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.

A nurse is caring for a newborn with transient tachypnea. Which is the priority nursing intervention? a) Administer IV fluids; gavage feedings. b) Monitor for signs of hypotonia. c) Perform gentle suctioning. d) Maintain adequate hydration.

a) Administer IV fluids; gavage feedings. The nurse should administer IV fluids and gavage feedings until the respiratory rate decreases enough to allow oral feedings when caring for a newborn with transient tachypnea. Maintaining adequate hydration and performing gentle suctioning are relevant nursing interventions when caring for a newborn with respiratory distress syndrome. The nurse need not monitor the newborn for signs and symptoms of hypotonia because hypotonia is not known to occur as a result of transient tachypnea. Hypotonia is observed in newborns with inborn errors of metabolism or in cases of periventricular hemorrhage/intravenricular hemorrhage

Which finding would alert the nurse to suspect that a newborn has developed NEC? a) bilious vomiting b) clay-colored stools c) sunken abdomen d) irritability

a) bilious vomiting Explanation: The newborn with NEC may exhibit bilious vomiting with lethargy, abdominal distention and tenderness, and bloody stools.

The nurse is providing care to a newborn who was born at 36 weeks' gestation. Based on the nurse's understanding of gestational age, the nurse identifies this newborn as: a) late preterm. b) preterm. c) postterm. d) term.

a) late preterm. Gestational age is typically measured in weeks: a newborn born before completion of 37 weeks is classified as a preterm newborn, and one born after completion of 42 weeks is classified as a postterm newborn. An infant born from the first day of the 38th week through 42 weeks is classified as a term newborn. The late preterm newborn (near term) is one who is born between 34 weeks and 36 weeks, 6 days of gestation

Which findings would the nurse expect in a newborn who is considered small for gestational age? Select all that apply. a) sunken abdomen b) increased subcutaneous fat stores c) poor muscle tone over buttocks d) narrow skull sutures e) dry or thin umbilical cord

a) sunken abdomen c) poor muscle tone over buttocks e) dry or thin umbilical cord A small-for-gestational-age newborn typically has a sunken abdomen, wide skull sutures, decreased subcutaneous fat stores, poor muscle tone over buttocks and cheeks, and a thin umbilical cord.

"A mother who is 4 days postpartum, and is breastfeeding, expresses to the nurse that her breast seems to be tender and engorged. What education should the nurse give to the mother to relieve breast engorgement? Select all that apply. a. Take warm-to-hot showers to encourage milk release. b. Feed the newborn in the sitting position only. c. Express some milk manually before breastfeeding. d. Massage the breasts from the nipple toward the axillary area.e. Apply warm compresses to the

a, c, e To relieve breast engorgement in the client, the nurse should educate the cli- ent to take warm-to-hot showers to encourage milk release, express some milk manually before breastfeeding, and apply warm compresses to the breasts before nursing. The mother should be asked to feed the newborn in a variety of positions—sitting up and then lying down. The breasts should be massaged from under the axil- lary area, down toward the nipple."

"A nurse is performing a detailed newborn assessment of a female baby. Which of the following observations indicate a normal finding? Select all that apply. a. Mongolian spots b. Enlarged fontanelles c. Swollen genitals d. Low-set ears e. Short, creased neck"

a, c, e Mongolian spots, swollen genitals in the female baby, and a short, creased neck are normal findings in a newborn. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Female babies may have swollen genitals as a result of maternal estrogen. The newborn's neck will appear almost nonexistent because it is so short. Creases are usually noted. Enlarged fontanelles are associated with malnutrition; hydrocephaly; congenital hypothyroidism; triso- mies 13, 18, and 21; and various bone disorders such as osteogenesis imperfecta. Low-set ears are characteristic of many syndromes and genetic abnormalities such as trisomies 13 and 18 and internal organ abnormalities involving the renal system."

"As a part of the newborn assessment, the nurse determines the skin turgor. Which of the following nursing interventions is relevant when observing the turgor of the newborn's skin? a. Pinch skin and note return to original position. b. Examine for stork bites or salmon patches. c. Check for unopened sebaceous glands. d. Inspect for blue or purple splotches on buttocks."

a. Skin turgor is checked by pinching the skin over chest or abdomen and noting the return to original position; if the skin remains "tented" after pinching, it denotes dehydration. Stork bites or salmon patches, unopened sebaceous glands, and blue or purple splotches on buttocks are common skin variations not related to skin turgor."

A first-time mother informs the nurse that she is unable to breastfeed her baby through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her baby. What instruction should the nurse offer the woman to ensure the safety of stored expressed breast milk? a. Use sealed and chilled milk within 24 hours b. Use frozen milk within 6 months of obtaining it c. Use microwave ovens to warm chilled milk d. Refreeze any unused milk for later use"

a. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it."

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition? a. Caput succedaneum b. Harlequin sign c. Increased intracranial pressure d. Molding

a. Caput succedaneum

A woman whose fetus in in the occiput-posterior position is experiencing increased back pain. Which is the best way for the nurse to help alleviate this back pain?

applying counter pressure to the back Counter pressure applied to the lower back with a fisted hand sometimes helps the woman cope with "back labor" associated with occiput-posterior positioning. The others are not recommended or used techniques for a woman in labor with back pain.

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? a. "Your newborn should finish a bottle in less than 15 minutes." b. "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." c. "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." d. "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding.""

b. A sign of adequate formula intake is when the newborn seems satisfied and is gaining weight regularly. The formula fed newborn should take 30 minutes or less to finish a bottle, not less than 15 minutes. The newborn does normally produce several stools per day, but should wet 6 to 10 diapers rather than 3 to 4 per day. The newborn should consume approximately 2 oz of formula per pound of body weight per day, not per feeding."

"The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? a. Immediately after birth, in the birthing area b. Within the first 2 to 4 hours, when the newborn is in the nursery c. Before the newborn is discharged d. The day after the newborn's birth"

b. The nurse should complete the sec- ond assessment for the newborn within the first 2 to 4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged."

The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location? A) Just superior to the nipple, at the midsternum B) Lateral to the midclavicular line at the fourth intercostal space C) At the fifth intercostal space to the left of the sternum D) Directly adjacent to the sternum at the second intercostals space

b. The point of maximal impulse in a newborn is lateral to the midclavicular line at the fourth intercostal space. A displaced PMI may indicate a tension pneumothorax or cardiomegaly.

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?a. Conductionb. Convectionc. Radiationd. Evaporation

b. Convection

A client delivers a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home? a. Ensure cool air is circulating over the newborn to prevent overheating b. Keep the newborn wrapped in a blanket, with a cap on its head c. Encourage the mother to keep the infant in her bed to ensure that the infant stays warm d. Keep the infant's room temperature at least 80 degrees

b. Keep the newborn wrapped in a blanket, with a cap on its head

A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula fed. What instruction should the nurse give this client? a. Switch to feeding breast milk b. No action is needed; this is normal c. Increase the newborn's fluid intake d. Change to a soy-based formula

b. No action is needed; this is normal

a nurse is caring for a newborn with asphyxia. What nursing management is involved when treating a newborn with asphyxia? a) Administer surfactant as ordere b) Ensure effective resuscitation measures c) Ensure adequate tissue perfusion d) Administer IV fluids

b. ensure effective resuscitation measures

A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client?a. hypotensionb. fluid overloadc. decreased level of consciousnessd. tachycardia

b. fluid overload

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?a. enhanced shivering abilityb. limited voluntary muscle activityc. thick skin with deep lying blood vesselsd. expanded stores of glucose and glycogen

b. limited voluntary muscle activity

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?a. nonshivering thermogenesisb. radiation, convection, and conductionc. sweating and peripheral vasoconstrictiond. lack of brown adipose tissue

b. radiation, convection, and conduction

During the first few days after birth, the uterus typically descends from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day. By 3 days, the fundus lies 2 to 3 fingerbreadths below the umbilicus (or slightly higher in multiparous women). By the end of 10 days, the fundus usually cannot be palpated. Why?

because it has descended into the true pelvis.

puerperium period

begins after the delivery of the placenta and lasts approximately 6 weeks. *During this period the woman's body begins to return to its prepregnant state, and these changes generally resolve by the sixth week after giving birth.

A nursing student correctly identifies the problem of fetal buttocks instead of the head presenting first as which type of presentation?

breech presentation Breech presentation is when the fetal buttocks present first rather than the head. Face and brow presentation has complete extension of the fetal head. Brow presentation is when the fetal head is between full extension and full flexion so that the largest fetal skull diameter presents to the pelvis. Persistent occiput posterior position is the engagement of fetal head in the left or right occiputo-transverse position with the occiput rotating posteriorly rather than into the more favorable occiput anterior position. Normal presentation is head first or occiput anterior.

"A nurse observes that a newborn has a 1-minute Apgar score of 5 points. What should the nurse conclude from the observed Apgar score? a. Severe distress in adjusting to extrauter- ine life b. Better condition of the newborn c. Moderate difficulty in adjusting to extra-uterine life d. Abnormal central nervous system status"

c The nurse should conclude that the newborn is facing moderate difficulty in adjusting to extrauterine life. The nurse need not conclude severe distress in adjusting to extra- uterine life, better condition of the newborn, or abnormal central nervous system status. If the Apgar score is 8 points or higher, it indicates that the condition of the newborn is better. An Apgar score of 0 to 3 points represents severe distress in adjusting to extrauterine life."

A client breastfeeding a newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the clients condition? A. recommend a moisturizing soap to clean nipples. b. encourage use of breast pads with plastic liners c. offer suggestions based on observation to correct positioning or latching d. fasten the nursing bra flaps immediately after feeding

c offer suggestions based on observation to correct positioning or latching

A client just gave birth to a preterm baby in the 30th week of gestation. The nurse knows that which nursing measures will be performed for this infant? Select all that apply. a) Carry and handle the baby frequently. b) Dress the baby to keep the body warm. c) Estimate the urinary flow by weighing the diaper. d) Place the baby under isolette care. e) Dress the baby in a stockinette cap.

c) Estimate the urinary flow by weighing the diaper. d) Place the baby under isolette care. e) Dress the baby in a stockinette cap. The nurse should dress the baby in a stockinette cap, place the baby under isolette care, and estimate the urinary flow by weighing the diaper. Controlling the temperature in high-risk newborns is often difficult; therefore, special care should be taken to keep these babies warm by dressing then in a stockinette cap and recording their temperature often. Isolette care simulates the uterine environment as closely as possible, thus maintaining even levels of temperature, humidity, and oxygen for the child. The isolette is transparent, so the newborn is visible at all times. The kidneys of preterm infants are not fully developed; hence, they may have difficulty eliminating wastes. The nurse should determine accurate output by weighing the diaper before and after the infant urinates. The diaper's weight difference in grams is approximately equal to the number of milliliters voided. Frequently carrying and handling the baby should be avoided so that the infant can conserve energy. Generally, preterm newborns in the high-risk category are not dressed, so the attending nurse can observe their breathing

A nurse is conducting an in-service presentation for a group of neonatal nurses. After teaching the group about the effects of prematurity on various body systems, the nurse determines that the class was successful when the group identifies which condition as an effect of prematurity? a) enhanced ability to digest proteins b) rapid glomerular filtration rate c) fragile cerebral blood vessels d) enlarged respiratory passages

c) fragile cerebral blood vessels Preterm newborns have fragile blood vessels in the brain, and fluctuations in blood pressure can predispose these vessels to rupture, causing intracranial hemorrhage. The preterm newborn typically has smaller respiratory passages, leading to an increased risk for obstruction. Preterm newborns have a limited ability to digest proteins. The preterm newborn's renal system is immature, which reduces his or her ability to concentrate urine and slow the glomerular filtration rate

"A nurse is required to obtain the temperature of a healthy newborn who is placed in an open crib. Which of the following is the most appropriate method for measuring a newborn's temperature? a. Tape electronic thermistor probe to the abdominal skin. b. Obtain temperature orally. c. Place electronic temperature probe in themidaxillary area. d. Obtain temperature rectally."

c. The nurse should obtain a new- born's temperature by placing an electronic tem- perature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns

A mother is concerned because her 2-day-old newborn's birth weight was 8 lb (3584 g) and his current weight is 7 lb 8 oz (3360 g). What would be the nurse's response to the mother's concern?a. "The weight loss may be indicative of some underlying health problem. I need to notify the doctor."b. "The newborn needs to be fed more frequently to stop this weight loss pattern."c. "The weight loss is a normal finding, since newborns lose 5% to 10% of their birth weight in the first few days after birth."d. "Although newborns lose some weight after birth due to poor nutrition, this amount is concerning."

c. "The weight loss is a normal finding, since newborns lose 5% to 10% of their birth weight in the first few days after birth."

The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth?a. Longitudinal but no horizontal creasesb. Heel but no anterior creasesc. Creases on two-thirds of the footd. Creases covering one fourth of the foot

c. Creases on two-thirds of the foot

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex?a. Turn the head to one side without moving the rest of the body.b. Startle the newborn by letting the head drop back slightly.c. Gently stroke the newborn's cheek.d. Place a gloved finger in the newborn's mouth.

c. Gently stroke the newborn's cheek.

The nurse enters the room and notes the infant is in it's bed sleeping, close to the outside window. Which action should the nurse prioritize?a. Place another blanket on the infant.b. Observe infant's status.c. Move the infant away from the window.d. Check the infant's vital signs.

c. Move the infant away from the window.

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? a. After the newborn has received the initial feeding b. 24 hours after admission to the nursery c. On admission to the nursery d. 4 hours after admission to the nursery

c. On admission to the nursery

What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia?a. Feed the newborn some formula immediately.b. Start an IV to provide intravenous glucose.c. Perform a heel stick to obtain a blood sample for testing for glucose level.d. Check the client's blood sugar by a venous blood draw.

c. Perform a heel stick to obtain a blood sample for testing for glucose level.

A nurse is assessing the temperature of a newborn using a skin temperature probe. Which point should the nurse keep in mind while taking the newborn's temperature? a. Ensure that the newborn is lying on it's abdomen b. Tape the temperature probe to the forehead c. Place the temperature probe over the liver d. Use the skin temperature probe only in open bassinets

c. Place the temperature probe over the liver

The nurse cares for a newborn with a congenital cardiac anomaly. What component of nursing care is the priority for the newborn? a. Maintain oxygen saturation at 95% or above b. Accompany the newborn to all radiologic examinations c. Prevent pain as much as possible d. Teach the parents to take pulse and blood pressure measurements

c. Prevent pain as much as possible

What should the nurse expect for a full-term newborn's weight during the first few days of life?a. There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies.b. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only.c. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.d. A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%.

c. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick hematocrit of 66. What is the best response to this finding? a) A capillary hematocrit needs to be rechecked in 8 hours to see if it increases or decreases. b) This is a normal lab value, and no intervention is needed. c) The infant is suffering from polycythemia and needs a partial exchange transfusion to prevent complications. d) The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.

d) The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is. A hematocrit above 65% is considered elevated and polycythemia is diagnosed. However, to get an accurate venous reading, a central venous hematocrit needs to be drawn to verify the value. Drawing the blood in 8 hours does not address the problem at present, and the infant does not need a partial exchange transfusion immediately. Health care providers will decide if this is needed after monitoring the infant for symptoms and following the central hematocrit levels.

Parents tell the nurse that they have been told to keep their newborn away from windows and be sure to cover the baby with a light blanket. They do not understand why this is necessary. What rationale would the nurse provide for this care?a. Newborns have very thin skin, which allows radiant heat loss.b. Newborns weighing below 8 pounds lack enough brown fat to produce heat.c. Windows can be drafty and placing the newborn by one can result in evaporative heat loss.d. Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.

d. Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.

A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function?a. voluntary movementsb. crying responsec. orientation to surroundingsd. reflex

d. reflex

The nurse providing care for a woman with preterm labor on magnesium sulfate would include which assessment for safe administration of the drug?

deep tendon reflexes (DTR)s Assessing deep tendon reflexes hourly in a client receiving magnesium sulfate is appropriate as depressed DTRs are a sign of magnesium toxicity. Elevated blood glucose is a fetal side effect but not noted to assess with the mother. Assessing for depressed respiration and hypotension not tachypnea or tachycardia would be appropriate assessments needed for the safe administration of magnesium sulfate.

Lochia rubra

deep-red mixture of mucus first 3 to 4 days

Periventricular-Intraventricular Hemorrhage

defined as bleeding that usually originates in the subependymal germinal matrix region of the brain, often extending into the ventricular system *IVH occurs in up to 50% of infants with birthweight less than 1,500 g and/or born at less than 35 weeks' gestation. It is uncommon in term neonates but may occur with birth trauma or asphyxia

Infants of diabetic mothers can be large for gestational age (LGA) or small for gestational age (SGA). Why?

depending on the vascular impact of this chronic systemic disease on the mother prior to and during the pregnancy.

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?

diabetes Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in postdate pregnancies. A pendulous abdomen is associated with the transverse lie fetal position not with shoulder dystocia.

A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?

identical The incidence of twins is about 1 in 30 conceptions, with about 2/3 being from the fertilization of two ova (fraternal) and about 1/3 from the splitting of one fertilized ovum (identical).

A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm. dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?

occiput posterior position A labor complicated by occiput posterior position is usually prolonged and characterized by maternal perception of increased intensity of back discomfort. The lay term for this type of labor is "back labor."

A nurse is caring for a newborn with tecrotizing enterocolitis (NEC) who is schedule to undergo surgery for a bowel resection. The infant's parents wish to know the implications of the surgery. What information should the nurse provide?

surgery requires placement of a proximal enterostomy

A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification?

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

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of:

very low birth weight. A birth weight of 1.2 kg would be classified as very low birth weight. A normal birth weight at term ranges between 2,500 g and 4,000 g. Typically it is between 3,000 g and 4,000 g. A birth weight below 2,500 g is termed a low birth weight. A birth weight between 1,000 g and 1,500 g is termed a very low birth weight. A birth weight less than 1,000 g is termed an extremely low birth weight.

Which of the following would be most effective in reducing pain in the preterm newborn? Select all that apply. a) Removing tape quickly from the skin b) Swaddling the newborn closely c) Offering a pacifier prior to a procedure d) Encouraging kangaroo care during procedures e) Increasing the volume on device alarms f) Using cool blankets to soothe the newborn

• Swaddling the newborn closely • Encouraging kangaroo care during procedures • Offering a pacifier prior to a procedure Explanation: Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation.

During a neonate resuscitation attempt, the neonatologist has ordered 0.1 mL/kg IV epinephrine (adrenaline) in a 1:10,000 concentration to be given stat. The neonate weighs 3000 grams and is 38 centimeters long. How many millimeters (mL) should the nurse administer? Record your answer using one decimal place.

0.3

A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. The nurse integrates understanding of this measure, administering the feedings at which rate?

0.5 to 1 mL/kg/h

The experienced labor and birth nurse knows to evaluate progress in active labor by using which simple rule?

1 cm/hour for cervical dilation In evaluating the progress in active labor, the nurse uses the simple rule of 1 cm/hour for cervical dilation.

How to assess the uterus?

1. have the woman empty her bladder before assessing the fundus and auscultate her bowel sounds prior to uterine palpation. 2. Using a two-handed approach with the woman in the supine position with her knees flexed slightly and the bed in a flat position or as low as possible 3. palpate the abdomen gently, feeling for the top of the uterus while the other hand is placed on the lower segment of the uterus to stabilize it 4. Once the fundus is located, place your index finger on the fundus and count the number of fingerbreadths between the fundus and the umbilicus (1 fingerbreadth is approximately equal to 1 cm)

What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 10% c) 5% d) 50%

10%

What percentage of neonates requires some type of assistance to transition to extrauterine life? a) 25% b) 5% c) 10% d) 50%

10%

Women who are unable to return to a healthy weight by ____ months postpartum increase their risk factors for the development of chronic diseases including metabolic syndrome, obesity, and cardiovascular disease

6

laceration degrees

1st degree - skin only 2nd degree - muscle also 3rd degree - anal sphincter also 4th degree - rectal mucosa also

When caring for a preterm infant, what intervention will best address the sensorimotor needs of the infant?

rocking and massaging

Assessment of a newborn at 40 weeks' gestation reveals that he is a low birth weight newborn. Which of the following weights would the nurse identify as being low birth weight? a) 4400 g b) 1400 g c) 2400 g d) 3400 g

2400 g Correct Explanation: A birth weight of less than 2500 g is categorized as a low birth weight in infants. The normal birth weight of term infants ranges from 3000-4000 g. Hence infants with a birth weight of 3500 g or 4500 g will not be categorized as low birth weight infants. Infants having birth weights lower than 1500g are termed as very low birth weight infants, and not merely low birth weight.

Lochia serosa

second stage pinkish brown 3 to 10 days postpartum

Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chest circumference would be:

32

Normal chest circumference

32-38 cm

normal head circumference

33-37 cm

Neonatal Abstinence Syndrome. frequently, the first inkling of drug use appears in the newborn when symptoms of withdrawal begin within ____ hours after birth.

72

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?

40 mg/100 mL whole blood Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 mL whole blood is considered hypoglycemia.

A nurse is assisting with the resuscitation of a preterm newborn. The nurse is giving ventilations to the newborn at which rate?

40 to 60 breaths per minute

The nurse is caring for a client after experiencing a placental abruption. Which finding is the priority to report to the health care provider?

45 ml urine output in 2 hours The nurse knows a placental abruption places the client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss. The hematocrit, hemoglobin, and platelet counts are all within expected levels.

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:

5. A Bishop score less than 6 usually indicates that a cervical ripening method should be used before labor induction.

Esophageal Atresia

a congenitally interrupted esophagus where the proximal and distal ends do not communicate; the upper esophageal segment ends in a blind pouch and the lower segment ends a variable distance above the diaphragm

Which statement by the parents is evidence of meeting the desired outcome for a nursing diagnosis of impaired parenting?

"I'm so happy to hold you; I think you like it too."

Lochia alba

- final stage - creamy white or light brown and consists of leukocytes

The neonate's respirations are gasping and irregular with a rate of 24 bpm. Which circulatory alteration will the nurse assess for in this infant?

Blood flows from the aorta to the pulmonary artery.

risk factors for Transient tachypnea of the newborn (TTN)

Lower gestational age, cesarean birth, and male sex

Seesaw respirations is seen in

Respiratory Distress Syndrome

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The pinna of the ear is soft and flat and stays folded.

recommeded fluid intake for breastfeeding mother?

at least 2,500 mL (approximately 84 oz).