OB Exam 2 - PRACTICE TEST

What characteristic shows the greatest gestational maturity?

Some peeling and cracking of the skin A. Few rugae on the scrotum show a younger age in the newborn. B. Extended arms and legs is a sign of preterm infants. C. Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. D. "The arm can be positioned with the elbow beyond the midline of the chest" - This result of the scarf sign shows a younger newborn.

A woman has tested human immunodeficiency virus (HIV)-positive and has now discovered that she is pregnant. Which statement indicates that she understands the risks of this diagnosis?

"Even though my test is positive, my baby might not be affected." A. The fetus is likely to test positive for HIV in the first 6 months until the inherited immunity from the mother wears off. Many of these babies will convert to HIV-negative status. B. With the newer drugs, the risk for infection of the fetus has decreased. C. The pregnancy will increase the chance of converting. D. With the newer drugs, the risk for infection of the fetus has decreased. Also, the life span of an infected newborn has increased.

Toxoplasmosis is a protozoal infection transmitted through organisms in raw and undercooked meat or through contact with contaminated cat feces. While providing education to the pregnant woman, the nurse evaluates the learning and understands that the patient requires further instruction when she states

"I will be certain to empty the litter boxes regularly." A. The patient should avoid contact with materials that are possibly contaminated with cat feces while pregnant. This includes cat litter boxes, sand boxes, and garden soil. She should wash her hands thoroughly after working with soil or handling animals. B. The patient should avoid undercooked eggs and unpasteurized milk. C. All fruits and vegetables should be washed thoroughly before eating. D. Meat should be cooked thoroughly to an internal temperature of at least 160° F or as high as 180° F for poultry. All surfaces should be washed after they come into contact with uncooked meat. The patient should be instructed not to use the same utensils or cutting board for meat and produce.

Which woman is most likely to have severe afterbirth pains and request a narcotic analgesic?

A - Gravida 5, para 5 A. The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. B. Afterpains are particularly severe during breastfeeding, not bottle-feeding. C. The uterus of a primipara tends to remain contracted. D. The nonnursing mother may have engorgement problems. She should empty her breasts regularly to stimulate milk production so she will have the milk when the baby is strong enough to nurse.

A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse? A. Blood pressure increase to 138/86 mm Hg B. Weight gain of 0.5 kg during the past 2 weeks C. A dipstick value of 3+ for protein in her urine D. Pitting pedal edema at the end of the day

A dipstick value of 3+ for protein in her urine A. Generally, hypertension is defined as a BP of 140/90 or an increase in systolic pressure of 30 mm Hg or 15 mm Hg diastolic pressure.B. Preeclampsia may be manifested as a rapid weight gain of more than 2 kg in 1 week.C. Proteinuria is defined as a concentration of 1+ or greater via dipstick measurement. A dipstick value of 3+ should alert the nurse that additional testing or assessment should be made.D. Edema occurs in many normal pregnancies as well as in women with preeclampsia. Therefore, the presence of edema is no longer considered diagnostic of preeclampsia.

An important independent nursing action to promote normal progress in labor is

ANS: B Encouraging urination about every 1 to 2 hours A. Assessment of the fetus is an important task, but will not promote normal progression of labor. B. The bladder can reduce room in the woman's pelvis that is needed for fetal descent and can increase her discomfort. C. The woman needs her support system during labor, and contact should not be limited. D. Maintaining hydration is an important task, but it will not promote normal progression of labor.

The patient who is being treated for endometritis is placed in Fowler's position because it

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

Which assessment finding could indicate hemorrhage in the postpartum patient?

AND: D Elevated pulse rate A. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. B. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits. C. If the blood volume were diminishing, the blood pressure would decrease. D. An increasing pulse rate is an early sign of excessive blood loss.

The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to

ANS: A Assess fetal heart rate (FHR) and maternal vital signs. A. Assessment of the FHR and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the mother and fetus. B. The most important assessment is to check mother/fetal well-being. The blood levels can be obtained later. C. It is important to assess future bleeding, but the top priority is mother/fetal well-being. D. Monitoring uterine contractions is important, but not the top priority.

Birth for the nulliparous woman with a fetus in a breech presentation is usually by

ANS: A Cesarean delivery A. Delivery for the nulliparous woman with a fetus in breech presentation is almost always cesarean section. The greatest fetal risk in the vaginal delivery of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The delivery of the rest of the baby must be quick so that the infant can breathe. B. The greatest fetal risk in the vaginal delivery of breech presentation is that the head (largest part of the fetus) is the last to be delivered. The delivery of the rest of the baby must be quick so the infant can breathe. C. The physician may assist rotation of the head with forceps. A cesarean birth may be required. D. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult.

Which data should alert the nurse that the neonate is postmature?

ANS: A Cracked, peeling skin A. Loss of vernix caseosa, which protects the fetal skin in utero, may leave the skin macerated. B. Postmature infants usually have long, thin arms and legs. C. Vernix caseosa decreases in the postmature infant. D. Absence of lanugo is common in postmature infants.

What is the priority nursing assessments for a woman receiving tocolytic therapy with terbutaline? A. Fetal heart rate, maternal pulse, and blood pressure B. Maternal temperature and odor of amniotic fluid C. Intake and output D. Maternal blood glucose

ANS: A Fetal heart rate, maternal pulse, and blood pressure A. All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. B. These are important if the membranes have ruptured, but they are not relevant to the medication. C. This is not an important assessment to monitor for side effects of terbutaline. D. This is not an important assessment to monitor for side effects of terbutaline.

Which factor is most likely to result in fetal hypoxia during a dysfunctional labor?

ANS: A Incomplete uterine relaxation A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually does not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow.

Which measure may prevent mastitis in the breastfeeding mother?

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

Which nursing action is designed to avoid unnecessary heat loss in the newborn?

ANS: A Place a blanket over the scale before weighing the infant A. Padding the scale prevents heat loss from the infant to a cold surface by conduction. B. Room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. C. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature due to convection. D. Hourly assessments are not necessary for a normal newborn with a stable temperature.

A woman in preterm labor at 30 weeks of gestation receives two 12 mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to

ANS: A Stimulate fetal surfactant production. A. Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. B. Inderal would be given to reduce the effects of ritodrine administration. C. Betamethasone has no effect on uterine contractions. D. Calcium gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by A. Subinvolution of the uterus B. Defective vascularity of the decidua C. Cervical lacerations D. Coagulation disorders

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

The nurse should alert the physician when

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

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data?

ANS: A The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth. A. This is a common condition for infants delivered by cesarean section. B. Surfactant is produced by the lungs, so aspiration is not a concern. C. It is common to have some fluid left in the lungs; this will be absorbed within a few hours. D. The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems.

Late preterm infants need closer monitoring during her hospital stay than term infants. In order to prevent unrecognized cold-stress the nurse should perform all except

ANS: A Wean the infant to an open crib. A. The infant can be placed in an open bassinet after the nurse is assured that the baby is not experiencing cold stress and can maintain his or her body temperature. B. LPI infants should have their temperature checked every 3 to 4 hours, depending on need and agency policy. C. Kangaroo care (a method of providing skin to skin contact between infants and their parents) should be encouraged. D. If the infant cannot maintain normal temperature they should be placed on a radiant warmer or in an incubator.

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? A, Babinski B. Tonic neck C. Stepping D. Plantar grasp

ANS: A Babinski A. The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. B. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. C. The stepping reflex occurs when infants are held upright with their heel touching a solid surface and the infant appears to be walking. D. Plantar grasp reflex is similar to the palmar grasp reflex: when the area below the toes are touched, the infant's toes curl over the nurse's finger.

Which assessment finding should convince the nurse to "hold" the next dose of magnesium sulfate? A. Absence of deep tendon reflexes B. Urinary output of 100 mL total for the previous 2 hours C. Respiratory rate of 14 breaths/min D. Decrease in blood pressure from 160/100 to 140/85

ANS: Absence of deep tendon reflexes A. Because absence of deep tendon reflexes is a sign of magnesium toxicity, the next scheduled dose should not be administered. Calcium gluconate is the antidote that should be administered. B. An hourly output of less than 30 mL could indicate toxicity. C. A respiratory rate of less than 12 breaths/min could indicate toxicity. D. Decrease in blood pressure is an expected side effect of magnesium sulfate

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

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

If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the patient has

ANS: B A distended bladder A. Position of the patient should not alter uterine position. B. The presence of a full bladder will displace the uterus. C. The problem is a full bladder displacing the uterus. D. This is not an expected finding.

What is most helpful in preventing premature birth?

ANS: B Adequate prenatal care A. People with higher socioeconomic status are more likely to seek adequate prenatal care. The care is the most helpful in prevention. B. Prenatal care is vital in identifying possible problems. C. Lower socioeconomic groups do not seek out health care, and that puts them at risk for preterm labor. D. This aids in the nutritional status of the pregnant woman, but the most helpful aid in prevention of premature births is adequate prenatal care.

A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action?

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

While providing care in an obstetric setting, the nurse should understand that postpartum care of the woman with cardiac disease

ANS: B Includes rest, stool softeners, and monitoring of the effect of activity. A. Care of the woman with cardiac disease in the postpartum period is tailored to the woman's functional capacity. B. Bed rest may be ordered, with or without bathroom privileges. Bowel movements without stress or strain for the woman are promoted with stool softeners, diet, and fluid. C. The woman will be on bed rest to conserve energy and reduce the strain on the heart. D. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated.

If a woman's fundus is soft 30 minutes after birth, the nurse's first response should be to

ANS: B Massage the fundus. A. The blood pressure is an important assessment to determine the extent of blood loss, but it is not the top priority. B. The nurse's first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. C. Notification should occur after all nursing measures have been attempted with no favorable results. D. Trendelenburg position is contraindicated for this woman at this point. This position does not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.

A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000 g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. The nurse should

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

A woman has a history of drug use and is screened for hepatitis B during the first trimester. What is an appropriate action?

ANS: B Offer the vaccine. A. Care is supportive and includes bed rest and a high protein, low fat diet. B. A person who has a history of high-risk behaviors should be offered the hepatitis B vaccine. C. The first trimester is too early to discuss feeding methods with a woman in the high-risk category. D. Hepatitis B is transmitted through blood.

The nurse's initial action when caring for an infant with a slightly decreased temperature is to

ANS: B Place a cap on the infant's head and have the mother perform kangaroo care. A. Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary. B. A cap will prevent further heat loss from the head, and having the mother place the infant skin-to-skin should increase the infant's temperature. C. A slightly decreased temperature can be treated in the mother's room. This would be an excellent time for parent teaching on prevention of cold stress. D. Mild temperature instability is an expected deviation from normal during the first days as the infant adapts to external life

A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to

ANS: B Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. A. Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial infection. B. This is an accurate explanation. C. Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. It is instilled to prevent gonorrheal or chlamydial infection. D. Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems.

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

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

A patient with pregnancy-induced hypertension is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate A. Anxiety due to hospitalization B. Worsening disease and impending convulsion C. Effects of magnesium sulfate D. Gastrointestinal upset

ANS: B Worsening disease and impending convulsion A. These are danger signs and should be treated. B. Headache and visual disturbances are due to increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent. C. She has not been started on magnesium sulfate as a treatment yet. Also, these are not expected effects of the medication. D. These are danger signs showing increased cerebral edema and impending convulsion.

The nurse knows that a measure for preventing late postpartum hemorrhage is to

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

A woman taking magnesium sulfate has respiratory rate of 10 breaths/min. In addition to discontinuing the medication, the nurse should

ANS: C Administer calcium gluconate. A. Stimulation will not increase the respirations. B. This will not be successful in reversing the effects of the magnesium sulfate. C. Calcium gluconate reverses the effects of magnesium sulfate. D. Increasing her IV fluids will not reverse the effects of the medication.

A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. The nurse should recommend that the infant be given:

ANS: C Commercial iron-fortified formula. A. Cow's milk should not be used in children younger than 12 months. B. Cow's milk should not be used in children younger than 12 months. C. For children younger than 1 year, the American Academy of Pediatrics recommends the use of breast milk. If breastfeeding has been discontinued, then iron-fortified commercial formula should be used. D. Maternal iron stores are almost depleted by this age; the iron-fortified formula will help prevent the development of iron-deficiency anemia.

The nurse should suspect uterine rupture if

ANS: C Contractions abruptly stop during labor. A. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. B. This is not an early sign of a rupture. C. A large rupture of the uterus will disrupt its ability to contract. D. Contractions will stop with a rupture.

What finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole? A. Complaint of frequent mild nausea B. Blood pressure of 120/80 mm Hg C. Fundal height measurement of 18 cm D. History of bright red spotting for 1 day, weeks ago

ANS: C Fundal height measurement of 18 cm A. Nausea increases in a molar pregnancy because of the increased production of hCG. B. A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension. C. The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. D. The history of bleeding is normally described as being brownish.

What documentation on a woman's chart on postpartum day 14 indicates a normal involution process?

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

Of all the signs seen in infants with respiratory distress syndrome, which sign is especially indicative of the syndrome? A. Pulse more than 160 beats/min B. Circumoral cyanosis C. Grunting D. Substernal retractions

ANS: C Grunting A. Grunting is more indicative of respiratory distress syndrome. B. Grunting is more indicative of respiratory distress syndrome. C. Grunting increases the pressure inside the alveoli to keep them open when surfactant is insufficient. D. Grunting is more indicative of this syndrome.

The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the Pitocin infusion, the nurse reviews the woman's latest laboratory test findings, which reveal a low platelet count, an elevated aspartate transaminase (AST) level, and a falling hematocrit. The nurse notifies the physician, because the lab results are indicative of

ANS: C HELLP syndrome A. Eclampsia is determined by the presence of seizures. B. DIC (Disseminated intravascular coagulation) is a potential complication associated with HELLP syndrome. C. HELLP syndrome is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). D. These are not clinical indications of Rh incompatibility.

What is the only known cure for preeclampsia?

ANS: C The only cure for preeclampsia is delivery A. Magnesium sulfate is one of the medications used to treat but not to cure preeclampsia. B. Antihypertensive medications are used to lower the dangerously elevated blood pressures in preeclampsia and eclampsia. C. If the fetus is viable and near term, delivery is the only known "cure" for preeclampsia. D. Low doses of ASA (60 to 80 mg) have been administered to women at high risk for developing preeclampsia.

To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD)

ANS: C Is distinguished by pervasive sadness that lasts at least 2 weeks A. PPD is more serious and persistent than postpartum baby blues. B. PPD is more common among younger mothers and African-American mothers. C. PPD is characterized by a persistent depressed state. The woman is unable to feel pleasure or love although she is able to care for her infant. She often experiences generalized fatigue, irritability, little interest in food and sleep disorders. D. Most women need professional help to get through PPD, including pharmacologic intervention.

Postpartal overdistention of the bladder and urinary retention can lead to which complication?

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

In which infant behavioral state is bonding most likely to occur?

ANS: C Quiet alert A. In the drowsy state the eyes may remain closed. If open they are unfocused. The infant is not interested in the environment at this time. B. In the active alert state infants are often fussy, restless, and not focused. C. In the quiet alert state, the infant is interested in his or her surroundings and will often gaze at the mother or father or both. D. During the crying state the infant does not respond to stimulation and cannot focus on parents.

The nurse thoroughly dries the infant immediately after birth primarily to

ANS: C Reduce heat loss from evaporation. A. Rubbing the infant does stimulate crying, but it is not the main reason for drying the infant. B. Drying the infant after birth does not remove all of the maternal blood. C. Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. D. The main purpose of drying the infant is to prevent heat loss.

Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem?

ANS: C Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers. A. This may understimulate the infant during those long periods and overtire the infant during the procedures. B. This may cause overstimulation. C. Parents should be taught these signs of overstimulation so they will learn to adapt their care to the needs of their infant. D. Placing objects on top of the incubator or using it as a writing surface increases the noise inside.

What will the nurse note when assessing an SGA infant with asymmetric intrauterine growth restriction?

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

A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital, 5 days after her son was circumcised. She is very concerned. On which rationale should the nurse base her reply?

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

Which statement is true about large for gestational age (LGA) infants?

ANS: C They are prone to hypoglycemia, polycythemia, and birth injuries. A. LGA infants are determined by their weight compared to their age. B. They are above the 90th percentile on the gestational growth charts. C. All three of these complications are common in LGA infants. D. Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

After a birth complicated by a shoulder dystocia, the infant's Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should

ANS: C palpate the infant's clavicles. A. The Apgar indicates that no respiratory interventions are needed. B. The infant needs to be assessed for clavicle fractures before excessive movement. C. Because of the shoulder dystocia, the infant's clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. D. A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant.

The mother-baby nurse must be able to recognize what sign of thrombophlebitis?

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

A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that

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

The infant with the lowest risk of developing high levels of bilirubin is the one who

ANS: D Breastfeed within the first hour of life. The infant who is fed early will be less likely to retain meconium and reabsorb bilirubin from the intestines back into the circulation. A. Bruising will release more bilirubin into the system. B. Cephalhematomas will release bilirubin into the system as the red blood cells die off. C. Brown fat is normally used to produce heat in the newborn. D. The infant who is fed early will be less likely to retain meconium and reabsorb bilirubin from the intestines back into the circulation.

Which combination of expressing pain could be demonstrated in a neonate?

ANS: D Cry face, eye squeeze, increase in blood pressure A. Cry and an increased heart rate are manifestations of neonatal pain. Typically, infants will close their eyes tightly when in pain, not open them wide. B. Infants may cry in response to pain. Additionally, they may display a rigid posture with the mouth open. C. A high-pitched, shrill cry is associated with genetic/neurologic anomalies. The infant may cry, withdraw limbs, and become tachycardic with pain. D. These manifestations are indicative of pain in the neonate.

What nursing action is especially important for the SGA newborn? Observe for respiratory distress syndrome. Observe for and prevent dehydration. Promote bonding. Prevent hypoglycemia by early and frequent feedings.

ANS: D Prevent hypoglycemia by early and frequent feedings. A. Respiratory distress syndrome is seen in preterm infants. B. Dehydration is a concern for all infants and is not specific for SGA infants. C. Promoting bonding is a concern for all infants and is not specific for SGA infants. D. The SGA infant has poor glycogen stores and is subject to hypoglycemia.

Which maternal event is abnormal in the early postpartum period?

ANS: D Lochial color changes from rubra to alba A. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. B. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. C. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor. D. For the first 3 days after childbirth, lochia is termed

Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth?

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

Which nursing action must be initiated first when evidence of prolapsed cord is found?

ANS: D Reposition the mother with her hips higher than her head. The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority. A. Trying to relieve pressure on the cord should be the first priority. B. Trying to relieve pressure on the cord should take priority over increasing fetal monitoring techniques. C. Emergency cesarean delivery may be necessary if relief of the cord is not accomplished. D. The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed

Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant?

ANS: D Risk for infection A. Growth and development may be affected, but only indirectly. B. Thermoregulation may be affected, but only indirectly. C. Feeding may be affected, but only indirectly. D. The nurse needs to know that decreased immune functioning increases the risk for infection.

A woman with preeclampsia has a seizure. The nurse's primary duty during the seizure is to

ANS: D Stay with the patient and call for help. A. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the patient's head to the side to prevent aspiration. B. Once the seizure has ended, it may be necessary to suction the patient's mouth. C. Oxygen would be administered after the convulsion has ended. D. If a patient becomes eclamptic, the nurse should stay with her and call for help. Nursing actions during a convulsion are directed towards ensuring a patent airway and patient safety.

Which is true about newborns classified as small for gestational age (SGA)?

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

In caring for a pregnant woman with sickle cell anemia the nurse is aware that signs and symptoms of sickle cell crisis include

ANS: Fever and pain. Women with sickle cell anemia have recurrent attacks (crisis) of fever and pain, most often in the abdomen, joints, and extremities. These attacks are attributed to vascular occlusion when RBCs assume the characteristic sickled shape. Crises are usually triggered by dehydration, hypoxia, or acidosis. Women with sickle cell anemia are not iron deficient. Therefore, routine iron supplementation, even that found in prenatal vitamins, should be avoided in order to prevent iron overload. Women with sickle cell trait usually are at greater risk for postpartum endometritis (uterine wall infection); however, this is not likely to occur in pregnancy and is not a sign of crisis. These women are at an increased risk for UTIs; however, this is not an indication of sickle cell crisis.

Which clinical sign is not included in the classic symptoms of preeclampsia? Hypertension Edema Proteinuria Glycosuria

ANS: Glycosuria Glucose into the urine is not one of the three classic symptoms of preeclampsia. The first sign noted by the pregnant client is rapid weight gain and edema of the hands and face. Proteinuria usually develops later than the edema and hypertension. The first indication of preeclampsia is usually an increase in the maternal blood pressure. A. The first indication of preeclampsia is usually an increase in the maternal blood pressure. B. The first sign noted by the pregnant woman is a rapid weight gain and edema of the hands and face. C. Proteinuria usually develops later than the edema and hypertension. D. Spilling glucose into the urine is not one of the three classic symptoms of preeclampsia.

What condition indicates concealed hemorrhage in an abruptio placentae?

ANS: Hard boardlike abdomen Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. The client will have shock symptoms that include tachycardia. The fundal height will increase as bleeding occurs. Abdominal pain may increase. A. Abdominal pain may increase. B. The patient will have shock symptoms that include tachycardia. C. Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. D. The fundal height will increase as bleeding occurs.

Which technique is least effective for the woman with persistent occiput posterior position? A. Lie supine and relax B. Sit or kneel, leaning forward with support. C. Rock the pelvis back and forth while on hands and knees. D. Squat

ANS: Lie supine and relax. A. Lying supine increases the discomfort of "back labor." B. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. C. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior. D. Squatting aids both rotation and fetal descent.

Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? A. Hypoglycemia B. Hypercalcemia C. Hypobilirubinemia D. Hypoinsulinemia

ANS:A Hypoglycemia A. The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal glucose supply stops and the neonatal insulin exceeds the available glucose, leading to hypoglycemia. B. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. C. Excess erythrocytes are broken down after birth, releasing large amounts of bilirubin into the neonate's circulation, which results in hyperbilirubinemia. D. Because fetal insulin production is accelerated during pregnancy, the neonate shows hyperinsulinemia.

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

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

What is a result of hypothermia in the newborn?

ANSWER: C Increased glucose demands A. Shivering is not an effective method of heat production for newborns. B. Oxygen demands increase with hypothermia. C. In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. D. The metabolic rate increases with hypothermia.

A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called

Acrocyanosis

Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus?

Assist the patient in emptying her bladder. A. Nursing actions need to be implemented before notifying the physician. B. This is an important assessment if the bleeding continues. However, the focus should be on controlling the bleeding. C. The focus needs to be on controlling the bleeding. D. Urinary retention can cause overdistention of the urinary bladder, which lifts and displaces the uterus

Heat loss by convection occurs when a newborn is A. Placed on a cold circumcision board B. Given a bath C. Placed in a drafty area of the room D. Wrapped in cool blankets

C. Placed in a drafty area of the room A. This is conduction. B. This is evaporation. C. Convection occurs when infants are exposed to cold air currents. D. This is conduction.

To provide competent newborn care, the nurse understands that respirations are initiated at birth as a result of

Chemical, sensory, thermal and mechanical factors. **No explanation provided**

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

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

Why is adequate hydration important when uterine activity occurs before pregnancy is at term?

Dehydration may contribute to uterine irritability for some women. Feedback A Fluid and electrolyte imbalances are not associated with preterm labor. B Intravenous fluids are ordered according to their expected benefit. Adequate hydration promotes urination and decreased risk for infection. C The woman has an increase blood volume during pregnancy. D Fluid needs do not increase due to contractions.

With regard to the association of maternal diabetes and other risk situations affecting mother and fetus, nurses should be aware that A. Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy. B. Hydramnios occurs approximately twice as often in diabetic pregnancies. C. Infections occur about as often and are considered about as serious in diabetic and nondiabetic pregnancies. D. Even mild to moderate hypoglycemic episodes can have significant effects on fetal well-being.

Diabetic ketoacidosis can lead to fetal death at any time during pregnancy. A. Prompt treatment of DKA is necessary to save the fetus and the mother. B. Hydramnios (excess amniotic fluid) occurs 10 times more often in diabetic pregnancies. C. Infections are more common and more serious in pregnant women with diabetes. D. Mild to moderate hypoglycemic episodes do not appear to have significant effects on fetal well-being.

For which of the infectious diseases can a woman be immunized?

Rubella *** but NOT during pregnancy b/c MMR is LIVE A. There is no vaccine available for toxoplasmosis. B. Rubella is the only infectious disease for which a vaccine is available. C. There is no vaccine available for cytomegalovirus. D. There is no vaccine available for herpesvirus type 2

The nurse has been caring for a primiparous patient who is suspected of carrying a macrosomic infant. Pushing appears to have been effective so far; however, as soon as the head is born, it retracts against the perineum much like a turtle's head drawing into its shell. In evaluating the labor progress so far, the nurse is aware that this is normal with large infants and extra pushing efforts by the mother may be necessary. Is this statement true or false?

FALSE This is often referred to as the "turtle sign" and is an indication of shoulder dystocia. Delayed or difficult birth of the shoulders may occur if they become impacted above the maternal symphysis pubis. This complication of birth requires immediate intervention because the umbilical cord is compressed and the chest cannot expand within the vagina. Any of several methods may be employed to relieve the impacted shoulders. Shoulder dystocia is unpredictable and although more common in large infants, can occur with a baby of any weight.

An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called

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

If the nurse suspects a uterine infection in the postpartum patient, she should assess the

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

The primary symptom present in abruptio placentae that distinguishes it from placenta previa is A. Vaginal bleeding B. Rupture of membranes C. Presence of abdominal pain D. Changes in maternal vital signs

Presence of abdominal pain A. Both may have vaginal bleeding. B. Rupture of membranes may occur with both conditions. C. Pain in abruptio placentae occurs in response to increased pressure behind the placenta and within the uterus. Placenta previa manifests with painless vaginal bleeding. D. Maternal vital signs may change with both if bleeding is pronounced.

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is

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

Decreased surfactant production in the preterm lung is a problem because surfactant

keeps the alveoli open during expiration. A. Surfactant prevents the alveoli from collapsing. B. By keeping the alveoli open, it permits better oxygen exchange, but that is not its main purpose. C. Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. D. It does not affect the bronchioles.