OB Exam 4

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will: A. monitor arterial oxygen levels with a pulse oximeter. B. position the head slightly lower than the body. C. administer low concentrations of oxygen. D. keep the infant's eyes covered at all times.

ANS: A Rationale: Use of a pulse oximeter to carefully monitor arterial blood gases in high-risk infants continues to be a priority in the neonatal intensive care unit (NICU).

The nurse performs a newborn assessment and evaluates the infant's reflexes. How does the nurse perform the Moro reflex? A. Slightly raise the infant's head and trunk and allow the infant to drop back 30 degrees. B. Place a finger in the infant's palm and assess whether the infant's hand closes in a fist. C. Stroke the lateral side of the sole of the infants foot from the heel to the ball of the foot. D. Hold the infant upright with his feet touching a solid surface.

ANS: A Rationale: This would elicit the infant's arms and legs to extend and abduct, with fingers fanning open. B- This is the palmar grasp reflex. C- This is done to elicit the Babinski reflex. D- This would elicit the stepping reflex.

While caring for a post-term infant, the nurse recognizes that the elevated hematocrit level most likely results from: a. hypoxia in utero. b. underproduction of red blood cells. c. increased breakdown of red blood cells. d. the normal expected shift from fetal hemoglobin to normal hemoglobin.

ANS: A Rationale: While in utero, the infant who is hypoxic will compensate by producing more red blood cells. An elevated hematocrit results from an overproduction of red blood cells. It would be seen with a decreased breakdown of red blood cells and is not a normal shift from fetal hemoglobin to normal hemoglobin.

A nurse is caring for a 10-day-old neonate who was born at 33 weeks' gestation. Which of the following actions assist the nurse in assessing for signs of feeding tolerance (Select all that apply.) a. Check for presence of bowel sounds b. Assess temperature c. Check gastric residual by aspirating stomach contents d. Assess stools

ANS: A, C, D Rationale: a. Feedings should be held and physician notified if bowel sounds are absent. b. The neonate's temperature has no direct effect on feeding tolerance. c. Aspirated stomach contents are assessed for amount, color, and consistency. This assists in the evaluation of the degree of digestion and absorption. d. Stools are assessed for consistency, amount, and frequency. This assists in the evaluation of the degree of digestion and absorption.

Which adverse reactions are associated with the administration of clomiphene citrate (Clomid)? (Select all that apply.) a. Abdominal bloating b. Diarrhea c. Oliguria d. Nausea and vomiting e. Abnormal uterine bleeding

ANS: A, D, E Rationale: Some adverse reactions associated with Clomid are abdominal distension, frequent urination, nausea and vomiting, and abnormal uterine bleeding. Diarrhea is not a common presentation.

The nurse explains that the age of a neonate that is based on the actual time in utero is the ________age. A. maturational B. gestational C. neurological D. chronological

ANS: B Rationale: The gestational age is the age based on the actual time in the uterus.

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

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

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

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

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

ANS: C Rationale: Delayed absorption of fetal lung fluid is thought to be the reason for TTN. A- Lack of surfactant causes respiratory distress syndrome. B- TTN is caused by delayed absorption of fetal lung fluid. D- A slow vaginal delivery will help prevent TTN.

Infants of mothers with diabetes are at higher risk for developing: A. Anemia. B. Hyponatremia. C. Respiratory distress syndrome. D. Sepsis.

ANS: C Rationale: Infants of diabetic mothers (IDMs) are not at risk for anemia. They are at risk for polycythemia. IDMs are not at risk for hyponatremia. They are at risk for hypocalcemia and hypomagnesemia. IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. IDMs are not at risk for sepsis.

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

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

A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is: a. Soft and supple skin. b. A hematocrit level of 55%. c. Lack of subcutaneous fat. d. An abundance of vernix caseosa.

ANS: C Rationale: This post-term infant actually lost weight in utero, which is seen as loss of subcutaneous fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the expected range of all newborns. There is no vernix caseosa in a post-term infant.

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

ANS: C Rationale: This would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. This type of warming would not be appropriate because it is not a thermoregulated environment. Additionally, abdominal warming is not indicated with feedings of any kind. Feedings by gravity are done slowly over 20- to 30-minute periods to prevent adverse reactions. Small feedings at room temperature are recommended to prevent adverse reactions.

The nurse carefully assesses the preterm infant for respiratory distress syndrome because of a deficiency of: A. protein. B. estrogen. C. hyaline. D. surfactant.

ANS: D Rationale: The production of surfactant, necessary for the absorption of oxygen by the lungs, is deficient in the preterm infant.

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

ANS: D Rationale: Because glucose is necessary to produce heat, the infant who is also hypoglycemic will not be able to produce enough body heat. A hematocrit level of 58% is within the expected range for newborns. WBC count may be as high as 30,000 cells/mm3. RBC count ranges from 3.9 to 5.5 million/L.

Which of the following lab values indicates that an infant may have polycythemia? a. Hb 18 g/dL, Hct 50% b. Hb 25/dL, Hct 55% c. Hb 20/dL, Hct 65% d. Hb 30 g/dL, Hct 70%

ANS: D Rationale: The presence of polycythemia in an infant is characterized by a hemoglobin level greater than 22 g/dL and a hematocrit value greater than 65%.

The nurse assessing a preterm infant understands that the infant's level of maturation refers to: A. actual time the fetus remained in the uterus. B. age on the Dubowitz scoring system. C. infant's weight as compared to the gestational age. D. ability of the organs to function outside of the uterus.

ANS: D Rationlae: Level of maturation refers to how well developed the infant is at birth and the ability of the organs to function outside of the uterus.

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

ANS: pain Rationale: These are all nonverbal cues to newborn pain. Other signs include moaning, whimpering, tense rigid muscles, increased or decreased heart rate, apnea, increased blood pressure, sleep-wake pattern changes, or display of a "cry face." The nurse should discuss the infant's response to pain with his provider to ensure that appropriate medications are available. Ordered medications should always be given before any painful procedure.

A 48-year-old woman tells the nurse, "I missed my period last month. Am I in menopause" The nurse would respond that a woman is considered to be menopausal when: A. her periods have stopped for 1 year. B. her periods have been irregular and light for 12 months. C. she has symptoms of vasomotor instability. D. she experiences symptoms of decreased estrogen, such as dyspareunia.

ANS: A

A benign breast condition that includes dilation and inflammation of the collecting ducts is called A. Ductal ectasia B. Intraductal papilloma C. Chronic cystic disease D. Fibroadenoma

ANS: A Rationale: A- Generally occurring in women approaching menopause, ductal ectasia results in a firm irregular mass in the breast, enlarged axillary nodes, and nipple discharge. B- Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the mass grows, it causes trauma or erosion within the ducts. C- Chronic cystic disease causes pain and tenderness. The cysts that form are multiple, smooth, and well delineated. D- Fibroadenoma is fibrous and glandular tissues. They are felt as firm, rubbery, and freely mobile nodules.

To assist the woman in regaining control of the urinary sphincter, the nurse should teach her to A. Practice Kegel exercises. B. Void every hour while awake. C. Allow the bladder to become distended before voiding. D. Drink 8 to 10 glasses of water each day.

ANS: A Rationale: A- Kegel exercises, tightening and relaxing the pubococcygeal muscle, will improve control of the urinary sphincter. B- A prescribed schedule may help, but every hour is too frequent. C- Overdistention of the bladder will cause incontinence. D- Restricting fluids will cause bladder irritation that increases the problem. Drinking adequate fluids will not help the problem.

A postmenopausal woman who is 54 years old has been diagnosed with two leiomyomas. What assessment finding is most commonly associated with the presence of leiomyomas? A. Abnormal uterine bleeding B. Diarrhea C. Weight loss D. Acute abdominal pain

ANS: A Rationale: A- Most women are asymptomatic. Abnormal uterine bleeding is the most common symptom of leiomyomas, or fibroids. B- Diarrhea is not commonly associated with leiomyomas (fibroids). C- Weight loss does not usually occur in the woman with leiomyomas (fibroids). D- The patient with leiomyomas (fibroids) is unlikely to experience abdominal pain.

A woman is 6 weeks pregnant and has elected to terminate her pregnancy. The nurse knows that the most common technique used for medical termination of a pregnancy in the first trimester is A. Administration of prostaglandins B. Dilation and evacuation C. Intravenous administration of Pitocin D. Vacuum aspiration

ANS: A Rationale: A- The most common technique for medical termination of a pregnancy within the first 7 weeks of pregnancy is administration of prostaglandins. B- This is the most common method of surgical abortion used if medical abortion fails. C- Intravenous administration of Pitocin is used to induce labor in a woman with a third trimester fetal demise. D- Vacuum aspiration is used for abortions in the first trimester.

A 70-year-old woman should be taught to report what condition to her health care provider? A. Vaginal bleeding B. Pain with intercourse C. Breasts become smaller D. Skin becomes thinner

ANS: A Rationale: A- Vaginal bleeding after menopause should always be investigated. It is highly suggestive of endometrial cancer. B- Pain with intercourse is an expected change that occurs due to the aging process. C- Breast shrinkage is an expected change that occurs due to the aging process. D- Skin thinning is an expected change that occurs due to the aging process.

When discussing estrogen replacement therapy (ERT) with a perimenopausal woman, the nurse should include the risks of A. Breast cancer B. Vaginal and urinary tract atrophy C. Osteoporosis D. Arteriosclerosis

ANS: A Rationale: A- Women with a high risk of breast cancer should be counseled against using ERT. B- Estrogen prevents atrophy of vaginal and urinary tract tissue. C- Estrogen protects against the development of osteoporosis. D- Estrogen has a favorable effect on circulating lipids, reducing low density lipoprotein (LDL) and total cholesterol and increasing high density lipoprotein (HDL). It also has a direct antiatherosclerotic effect on the arteries.

The nurse reminds a group of high school students that the most effective choice of birth control for preventing pregnancy and sexually transmitted diseases is to: A. abstain from sex. B. use the male condom. C. use the female condom. D. use the barrier method.

ANS: A Rationale: Abstinence is 100% effective in preventing pregnancy and sexually transmitted diseases.

When a preterm infant who is being gavage fed has a bloody stool, the nurse should: A. assess for abdominal distention. B. decrease the amount of the next feeding. C. institute enteric precautions. D. get a culture of the next stool.

ANS: A Rationale: Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis. Specific nursing responsibilities include measuring the abdomen and listening to bowel sounds.

The nurse explains that the drug clomiphene (Clomid) is used in infertility treatment because it: A. induces ovulation. B. reduces endometriosis. C. promotes implantation of a fertilized ovum. D. inhibits excess prolactin secretion.

ANS: A Rationale: Clomiphene (Clomid) induces ovulation. It may also increase sperm production, although this is an unlabeled use.

The mother of a postterm infant asks the nurse why the infant is being watched so closely. The nurse answers that postterm infants are at risk because: A. the placenta does not function adequately as it ages. B. infants born postmaturely are generally large. C. delivery of the postterm infant is more difficult. D. there is less amniotic fluid.

ANS: A Rationale: Fetal distress may occur in the postterm infant because placental functioning becomes inadequate with maturity.

When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and expiratory grunting. These findings are indicative of: A. respiratory distress syndrome. B. postmaturity syndrome. C. apneic episode. D. cold stress.

ANS: A Rationale: Insufficient amounts of surfactant predispose the preterm infant to respiratory distress. The signs manifested by the infant are indicative of respiratory distress.

The nurse is caring for an infant born at 43 weeks. A physical assessment would reveal: A. dry, peeling skin. B. minimal hair on the head. C. short, rough nails. D. abundant lanugo on the body.

ANS: A Rationale: Loss of vernix caseosa leaves the skin dry, causing peeling.

The nurse caring for a preterm infant will record the intake and output. The nurse is aware that an optimum output would be _mL/kg/hr. A. 1-3 B. 4-6 C. 7-9 D. 10-14

ANS: A Rationale: The optimum output for a preterm infant should be 1-3 mL/kg/hr.

A 21-year-old college student has come to see the nurse practitioner for treatment of a vaginal infection. Physical assessment reveals inflammation of the vagina and vulva, and vaginal discharge has a cottage cheese appearance. These findings are consistent with: A. candidiasis. B. trichomoniasis. C. bacterial vaginosis. D. Chlamydia.

ANS: A Rationale: The signs and symptoms of candidiasis include inflammation of the vagina and vulva and a cottage cheese appearance to the vaginal discharge.

The nurse explains that a 4-day-old infant born at 33 weeks of gestation may need to be fed by gavage during the first few days of life because the infant: A. often has a very weak or absent sucking or swallowing reflex. B. is unable to digest food properly. C. refuses to take formula by mouth. D. needs a larger quantity of formula at each feeding.

ANS: A Rationale: When the preterm infant's sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition.

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

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

A 42-week gestation neonate is admitted to the NICU (neonatal intensive care unit). This neonate is at risk for which complication a. Meconium aspiration syndrome b. Failure to thrive c. Necrotizing enterocolitis d. Intraventricular hemorrhage

ANS: A Rationale: a. Although there is nothing in the scenario that states that the amniotic fluid is green tinged, post-term babies are high risk for meconium aspiration syndrome. b. Post-term babies often gain weight very quickly. c. Preterm, not post-term, babies are high risk for necrotizing enterocolitis. d. Preterm, not post-term, babies are high risk for intraventricular hemorrhages.

The laboratory reported that the L/S ratio (lecithin/sphingomyelin) results from an amniocentesis of a gravid client with preeclampsia are 2:1. The nurse interprets the result as which of the following a. The baby's lung fields are mature. b. The mother is high risk for hemorrhage. c. The baby's kidneys are functioning poorly. d. The mother is high risk for eclampsia.

ANS: A Rationale: a. An L/S ratio of 2:1 usually indicates that the fetal lungs are mature. b. L/S ratios are unrelated to maternal blood loss. c. L/S ratios are unrelated to fetal renal function. d. L/S ratios are unrelated to maternal risk for becoming eclamptic.

A baby boy was just born to a mother who had positive vaginal cultures for group B streptococci. The mother was admitted to the labor room 30 minutes before the birth. For which of the following should the nursery nurse closely observe this baby a. Grunting b. Acrocyanosis c. Pseudostrabismus d. Hydrocele

ANS: A Rationale: a. This infant is high risk for respiratory distress. The nurse should observe this baby carefully for grunting. b. Acrocyanosis is a normal finding. c. Pseudostrabismus is a normal finding. d. Hydrocele should be reported to the neonatologist. It is not, however, an emergent problem, and it is not related to group B streptococci colonization in the mother.

A major nursing intervention for an infant born with myelomeningocele is to: A. Protect the sac from injury. B. Prepare the parents for the child's paralysis from the waist down. C. Prepare the parents for closure of the sac at around 2 years of age. D. Assess for cyanosis.

ANS: A Rationale: A major preoperative nursing intervention for a neonate with a myelomeningocele is protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system infection. The long-term prognosis in an affected infant can be determined to a large extent at birth with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. A myelomeningocele should be surgically closed within 24 hours. Although the nurse would assess for multiple potential problems in this infant, the major nursing intervention would be to protect the sac from injury.

Another woman in the class said she had heart that there is a genetic test that would diagnose breast cancer. What is the best response by the nurse? A. "A positive test for the BRCA1 mutation identifies an increased risk for breast cancer, but is not a certainty." B. "If the BRCA1 mutation test is positive it indicates an increased risk for emphysema." C. "If the BRCA1 mutation test is positive, a bilateral mastectomy is the required." D. "A positive BRCA2 mutation gene indicates breast cancer metastasis."

ANS: A Rationale: A positive BRCA1 gene mutation test indicates an increased risk for breast cancer. Screenings procedures should be emphasized.

In vitro fertilization-embryo transfer (IVF-ET) is a common approach for women with blocked fallopian tubes or with unexplained infertility and for men with very low sperm counts. A husband and wife have arrived for their pre-procedural interview. The husband asks the nurse to explain what the procedure entails. The nurse's most appropriate response is A. "IVF is a type of assisted reproductive therapy that involves collecting eggs from your wife's ovaries, fertilizing them in the lab with your sperm, and transferring the embryo to her uterus." B. "A donor embryo will be transferred into your wife's uterus." C. "Donor sperm will be used to inseminate your wife." D. "Don't worry about the technical stuff; that's what we are here for."

ANS: A Rationale: A woman's eggs are collected from her ovaries, fertilized in the laboratory with sperm, and transferred to her uterus after normal embryonic development has occurred. B- This statement describes therapeutic donor insemination. C- This statement describes the procedure for a donor embryo. D- This statement discredits the patient's need for teaching and is not the most appropriate response.

In vitro fertilization-embryo transfer (IVF-ET) is a common approach for women with blocked fallopian tubes or with unexplained infertility and for men with very low sperm counts. A husband and wife have arrived for their preprocedural interview. Which explanation regarding the procedure is most accurate A. "The procedure begins with collecting eggs from your wife's ovaries." B. "A donor embryo will be transferred into your wife's uterus." C. "Donor sperm will be used to inseminate your wife." D. "Don't worry about the technical stuff; that's what we are here for."

ANS: A Rationale: A woman's eggs are collected from her ovaries, fertilized in the laboratory with the partner's sperm, and transferred to her uterus after normal embryonic development has occurred. Transferring a donor embryo to the woman's uterus describes the procedure for a donor embryo. Inseminating the woman with donor sperm describes therapeutic donor insemination. Telling the client not to worry discredits the client's need for teaching and is not the most appropriate response.

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

ANS: A Rationale: A- Neonates with a birth weight of less than 2500 grams but greater than 1500 grams are classified as low birth weight. B- Neonates with birth weight less than 1500 grams but greater than 1000 grams are classified as very low birth weight. C- Neonates with birth weight less than 1000 grams are classified as extremely low birth weight. D- Neonates born less than 32 weeks' gestation are classified as very premature.

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 A. Wean the infant to an open crib. B. Check temperature every 3 to 4 hours. C. Encourage kangaroo care. D. Place infant on a radiant warmer.

ANS: A Rationale: 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.

The priority assessment for the Rh-positive infant whose mother's indirect Coombs test was positive at 36 weeks is: a. skin color. b. temperature. c. respiratory rate. d. blood glucose level.

ANS: A Rationale: An Rh-negative infant whose mother was sensitized during the current pregnancy will have decreased red blood cells (RBCs) and exhibit skin pallor because of erythroblastosis fetalis. The temperature, respiratory rate, and blood glucose level are not assessments associated with erythroblastosis fetalis.

The nurse is discussing cervical mucus changes with a woman who wishes to use natural family planning methods. The nurse determines the woman understands the information presented when she says the changes in cervical mucus at ovulation: A. enhance the motility of the sperm. B. indicate endometrial readiness for implantation. C. facilitate movement of the ovum through the fallopian tube. D. provide vaginal lubrication during intercourse.

ANS: A Rationale: Around the time of ovulation, the slippery, clear cervical mucus enhances the motility of the sperm.

The nurse observes that the infant is jaundiced on his face, head, and chest. What action should the nurse take next? A. Obtain blood for laboratory analysis. B. Monitor for the infant for increasing jaundice. C. Give the infant water to promote bowel movements. D. Anticipate changing from milk to soy-based formula.

ANS: A Rationale: Blood drawn for serum bilirubin provides additional data and the basis for treatment of hyperbilirubinemia, which may be physiologic or nonphysiologic. B- Although the nurse should monitor the infant, another action should be done first. C- Typically, feedings are increased for formula-fed and breastfed infants. Although water may be given later, another action should be done first. D- Jaundice is not related to milk or soy-based formula but is usually related to a decreased ability of the liver to conjugate bilirubin .

Which TORCH infection could be contracted by the infant because the mother owned a cat? A. Toxoplasmosis B. Varicella-zoster C. Parvovirus B19 D. Rubella

ANS: A Rationale: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litterbox. The infection is passed through the placenta. The varicella-zoster virus is responsible for chickenpox and shingles. Approximately 90% of childbearing women are immune. This virus cannot be contracted from a cat. During pregnancy infection with parvovirus can result in abortion, fetal anemia, hydrops, intrauterine growth restriction (IUGR), and stillbirth. This virus is spread by vertical transmission, not by felines. Since vaccination for rubella was begun in 1969, cases of congenital rubella infection have been reduced significantly. Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in periodic outbreaks of rubella (German measles).

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

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

Which action should the nursery nurse take first in caring for the infant? A. Dry the infant quickly with warm blankets B. Use a scale to immediately weigh the infant. C. Apply a servomechanism temperature probe. D. Cover the infant's head using a soft cap.

ANS: A Rationale: Drying the infant is a priority to prevent heat loss. B- Weighing the infant can be delayed and another intervention done first. C- Applying a temperature probe is a common procedure when a radiant warmer is used; however, another action should come first. D- Another action should be taken first.

Postcoital contraception with Ovral A- Requires that the first dose be taken within 72 hours of unprotected intercourse B- Requires that the woman take second and third doses at 24 and 36 hours after the first dose C- Must be taken in conjunction with an IUD insertion D- Is commonly associated with the side effect of menorrhagia

ANS: A Rationale: Emergency contraception is most effective when used within 72 hours of intercourse but may be used with lessened effectiveness up to 120 hours later. B- The first dose of an emergency contraception should be taken within 72 hours after coitus. C- Insertion of the copper IUD within 5 days of intercourse may also be used and is up to 99% effective. D- The common side effect of postcoital contraception is nausea.

Which intervention should make phototherapy most effective in reducing the indirect bilirubin in an affected newborn? a. Turn the infant every 2 hours. b. Place eye patches on the newborn. c. Wrap the infant in triple blankets to prevent cold stress. d. Increase the oral intake of water between and before feedings.

ANS: A Rationale: Exposure of all parts of the skin increases the effectiveness of phototherapy. Placing eye patches is important to protect the eyes; however, this is not what affects the bilirubin levels. Wrapping the infant in blankets will prevent the phototherapy from getting to the skin and being effective. The infant should be uncovered and unclothed. It is important to increase oral feedings, but water should not necessarily be given, which would not reduce the bilirubin.

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

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

The conscious decision on when to conceive or avoid pregnancy throughout the reproductive years is called A. Family planning B. Birth control C. Contraception D. Assisted reproductive therapy

ANS: A Rationale: Family planning is the process of deciding when and if to have children. B- Birth control is the device and/or practice used to reduce the risk of conceiving or bearing children. C- Contraception is the intentional prevention of pregnancy during sexual intercourse. D- Assisted reproductive therapy is one of several possible treatments for infertility.

In helping bereaved parents cope and move on, nurses should keep in mind that: A perinatal or parental grief support group is more likely to be helpful if the needs of the parents are matched with the focus of the group. When pictures of the infant are taken for keepsakes, no close-ups should be taken of any congenital anomalies. No significant differences exist in grieving individuals from various cultures, ethnic groups, and religions. In emergency situations, nurses who are so disposed must resist the temptation to baptize the infant in the absence of a priest or minister.

ANS: A Rationale: For example, a religious-based group may not work for nonreligious parents. Close-up pictures of the baby must be taken as the infant was, congenital anomalies and all. Although death and grieving are events shared by all people, mourning rituals, traditions, and taboos vary by culture, ethnicity, and religion. Differences must be respected. Baptism for some religious groups can be performed by a layperson such as a nurse in an emergency situation when a priest is not available. Right

In conjunction with phototherapy, which intervention is most effective in reducing the indirect bilirubin in an affected newborn? A. Increase the frequency of feedings. B. Increase oral intake of water between feedings. C. Offer an exchange transfusion. D. Wrap the infant in triple blankets to prevent cold stress.

ANS: A Rationale: Frequent feedings prevent hypoglycemia, provide protein to maintain albumin levels in the blood and promote gastrointestinal motility and removal of bilirubin in the stools. More frequent breastfeeding should be encouraged. B- Avoid offering water between feedings, because the infant may decrease their milk intake. Breast milk or formula is more effective at removing bilirubin from the intestines. C- Exchange transfusions are seldom necessary; but, may be performed when phototherapy cannot reduce high bilirubin levels quickly enough. D- Wrapping the infant in blankets will prevent the phototherapy from getting to the skin and being effective. The infant should be uncovered and unclothed.

Which infant is most likely to have Rh incompatibility? A. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor B. Infant who is Rh negative and whose mother is Rh negative C. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor D. Infant who is Rh positive and whose mother is Rh positive

ANS: A Rationale: If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the offspring will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. B- Only the Rh-positive offspring of an Rh-negative mother are at risk. C- If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, there is a 50% chance that each infant born of the union will be Rh positive and a 50% chance that each will be born Rh negative. D- There is no risk for incompatibility with this scenario.

The procedure in which ova are removed by laparoscopy, mixed with sperm, and the embryo(s) returned to the woman's uterus is: a. in vitro fertilization. b. tubal embryo transfer. c. therapeutic insemination. d. gamete intrafallopian transfer.

ANS: A Rationale: In vitro fertilization is a procedure used to bypass blocked or absent fallopian tubes. Tubal embryo transfer places the conceptus into the fallopian tube. Therapeutic insemination uses the partner's sperm or that of a donor and places it directly into the woman. Gamete intrafallopian transfer is when the sperm and ova are placed in the fallopian tube.

An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. What is the nurse's most appropriate action at this time A. Listening to breath sounds, and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician B. Continuing to observe and making no changes until the saturations are 75% C. Continuing with the admission process to ensure that a thorough assessment is completed D. Notifying the parents that their infant is not doing well

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

Which data should alert the nurse that the neonate is postmature? A. Cracked, peeling skin B. Short, chubby arms and legs C. Presence of vernix caseosa D. Presence of lanugo

ANS: A Rationale: 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.

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

ANS: A Rationale: Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa, lethargy, and RDS are consistent with a very premature infant. The skin may be meconium stained, but the infant will most likely have long hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST is indicative of hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

During the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. In this situation, which condition should the nurse suspect A. Hypovolemia and/or shock B. Excessively cool environment C. Central nervous system (CNS) injury D. Pending renal failure

ANS: A Rationale: Other symptoms might include hypotension, prolonged capillary refill, and tachycardia, followed by bradycardia. Intervention is necessary. Preterm infants are susceptible to temperature instability. The goal of thermoregulation is to provide a neutral thermal environment. Hypoglycemia is likely to occur if the infant is attempting to conserve heat. CNS injury is manifested by hyperirritability, seizures, and abnormal movements of the extremities. Urine output and testing of specific gravity are appropriate interventions for the infant with suspected renal failure. This neonate is unlikely to be delivered with respiratory distress.

The nurse must continually assess the infant who has meconium aspiration syndrome (MAS) for the complication of A. Persistent pulmonary hypertension B. Bronchopulmonary dysplasia C. Transitory tachypnea of the newborn D. Left-to-right shunting of blood through the foramen ovale

ANS: A Rationale: Persistent pulmonary hypertension can result from the aspiration of meconium. B- Bronchopulmonary dysplasia is due to the use of positive pressure oxygenation that stretches the immature lung membranes. C- Transitory tachypnea of the newborn is due to delayed absorption of fetal lung fluid. D- This is a congenital defect that can be caused by atrial septal defects, ventricular septal defects, patent ductus arteriosus, or atrioventricular canal defects.

The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of: a. persistent pulmonary hypertension. b. bronchopulmonary dysplasia. c. transitory tachypnea of the newborn. d. left-to-right shunting of blood through the foramen ovale.

ANS: A Rationale: Persistent pulmonary hypertension can result from the aspiration of meconium. Bronchopulmonary dysplasia is caused by the use of positive-pressure oxygenation, which stretches the immature lung membranes. Transitory tachypnea of the newborn is caused by delayed absorption of fetal lung fluid. Left-to-right shunting of blood through the foramen ovale is a congenital defect that can be caused by atrial septal defects, ventricular septal defects, patent ductus arteriosus, or atrioventricular canal defects.

Nursing care of the infant with neonatal abstinence syndrome should include A. Positioning the infant's crib in a quiet corner of the nursery B. Feeding the infant on a 2-hour schedule C. Placing stuffed animals and mobiles in the crib to provide visual stimulation D. Spending extra time holding and rocking the infant

ANS: A Rationale: Placing the crib in a quiet corner helps avoid excessive stimulation of the infant. B-These infants have an increase calorie needs, but poor suck and swallow coordination. Feeding should occur to meet these needs. C- Stimulation should be kept to a minimum. D- The neonate needs to have reduced handling and disturbances.

Nursing care of the neonate undergoing jaundice phototherapy includes A. Keeping the infant's eyes covered under the light B. Keeping the infant supine at all times C. Restricting parenteral and oral fluids D. Keeping the infant dressed in only a T-shirt and diaper

ANS: A Rationale: Retinal damage from phototherapy should be prevented by using eye shields on the infant under the light. B- To ensure total skin exposure, the infant's position is changed frequently. C- Special attention to increasing fluid intake ensures that the infant is well hydrated. D- To ensure total skin exposure, the infant is not dressed.

A couple who has not achieved a successful pregnancy is scheduled to meet with a fertility specialist. Which simple evaluation is usually the first test to be performed? a. Semen analysis b. Testicular biopsy c. Endometrial biopsy d. Hysterosalpingography

ANS: A Rationale: Semen analysis is usually the first test to be performed because it is least costly and noninvasive. Endometrial biopsy determines whether the endometrium is responding to ovarian stimulation. A testicular biopsy is an invasive examination using a local anesthetic. Hysterosalpingography uses a contrast medium to evaluate the structure and patency of the uterus and tubes.

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

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

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

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

Decreased surfactant production in the preterm lung is a problem because: A. Surfactant keeps the alveoli open during expiration. B. Surfactant causes increased permeability of the alveoli. C. Surfactant dilates the bronchioles, decreasing airway resistance. D. Surfactant provides transportation for oxygen to enter the blood supply.

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

Which condition would be inappropriate to treat with exogenous progesterone (human chorionic gonadotropin) A. Thyroid dysfunction B. Recent miscarriage C. PCOD D. Oocyte retrieval

ANS: A Rationale: Synthroid is administered for anovulation associated with hypothyroidism. For women with polycystic ovulation syndrome or a history of miscarriage, oocyte retrieval may have insufficient progesterone and require exogenous progesterone until placental production is sufficient.

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

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

An infertility specialist prescribes clomiphene citrate (Clomid, Serophene) for a woman experiencing infertility. She is very concerned about the risk of multiple pregnancies. What is the nurse's most appropriate response A. "This is a legitimate concern. Would you like to discuss further the chances of multiple pregnancies before your treatment begins" B. "No one has ever had more than triplets with Clomid." C. "Ovulation will be monitored with ultrasound to ensure that multiple pregnancies will not happen." D. "Ten percent is a very low risk, so you don't need to worry too much."

ANS: A Rationale: The incidence of multiple pregnancies with the use of these medications is higher than 25%. The client's concern is legitimate and should be discussed so that she can make an informed decision. Stating that no one has ever had more than triplets with Clomid is inaccurate and negates the client's concerns. Ultrasound cannot ensure that a multiple pregnancy will not occur, and 10% is inaccurate. Furthermore, the client's concern is discredited with a statement such as, "...don't worry."

A physician prescribes clomiphene citrate (Clomid, Serophene) for a woman experiencing infertility. She is very concerned about the risk of multiple births. The nurse's most appropriate response is A. "This is a legitimate concern. Would you like to discuss this further before your treatment begins?" B. "No one has ever had more than triplets with Clomid." C. "Ovulation will be monitored with ultrasound so that this will not happen." D. "Ten percent is a very low risk, so you don't need to worry too much."

ANS: A Rationale: The incidence of multiple pregnancies with the use of these medications is increased. The patient's concern is legitimate and should be discussed so that she can make an informed decision. B- This statement is inaccurate and negates the patient's concerns. C- Ultrasound cannot ensure that a multiple pregnancy will not occur. D- The percentage quoted in this statement is inaccurate. Furthermore, the patient's concern is discredited with a statement such as "Don't worry."

The infant's vital signs include the following: *T 96.8 degrees F (36 degrees C) axillary *heart rate 136 beats/min, irregular with soft murmur * respiratory rate 42 breaths/min Which action should the nurse take? A. Document the findings in the electronic medical record (EMR). B. Stimulate the infant to breathe by stroking his feet. C. Notify the healthcare provider about the findings. D. Provide oxygen by tube or mask close to infant's nose.

ANS: A Rationale: The infant's vital signs are within normal parameters and the soft murmur is an expected finding with the infant. B- The respiratory rate is within normal limits, and stimulation is not needed. C- This action is not needed at this time. D- This action is not needed at this time.

After receiving report from the day shift, the night nurse begins making rounds. Upon entering the Ivys' room, the nurse finds Mrs. Ivy in the bathroom and the infant in the crib with a bottle propped on a towel. What action should the nurse take? A. Remove the bottle from the infant's mouth. B. Refer the Ivy family to social services for further evaluation. C. Instruct Mrs. Ivy not to leave the bottle propped on the towel. D. Take the infant to the newborn nursery.

ANS: A Rationale: The primary concern for the safety of the infant. Propping a bottle places the infant at risk for choking as well as ear infections. B- This is not indicated at this time. C- This should be done, but another intervention takes priority. D- This action is punitive, and other interventions should be done first.

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

ANS: A Rationale: These infant findings are consistent with a postmature infant. These findings would be consistent with a very premature infant. The skin may be meconium stained, but the infant would most likely have longer hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST would indicate hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

In the transitional care nursery, the nurse reviews the infant's prescriptions for vitamin K (Aquamephyton) 0.5 mg IM x one dose and erythromycin (Ilotycin Opthalmic Ointment) x one dose in each eye. While administering the vitamin K to the infant, which action should the nurse take? A. Select the middle part of the vastus lateralis for use. B. Place the infant on the abdomen for better visualization. C. Use the V technique after cleaning the ventral gluteal area. D. Administer the medication using a 22 gauge, 1/2 inch needle.

ANS: A Rationale: This muscle is the preferred site in infants for administration of injections. B- This action is not correct for the administration of vitamin K in infants. C- V technique is used for the ventral gluteal area, but injections are not given in this area for infants. D- This needle selection is too large for an infant.

A preterm infant is on a respirator, with intravenous lines and much equipment. When the parents come to visit for the first time, which is an important response by the nurse? A. Encourage the parents to touch their infant. B. Reassure the parents that the infant is progressing well. C. Discuss the care they will give their infant when the infant goes home. D. Suggest that the parents visit for only a short time to reduce their anxiety.

ANS: A Rationale: Touching the infant will increase the development of attachment. It is important to keep the parents informed about the infant's progress, but the nurse needs to be honest with the explanations. Discussing home care is an important part of parent teaching but is not the most important priority during the first visit. Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant.

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

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

The most important nursing action in preventing neonatal infection is A. Good handwashing B. Isolation of infected infants C. Separate gown technique D. Standard Precautions

ANS: A Rationale: Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. B- Overcrowding must be avoided in nurseries and infants with infectious processes should be isolated; however, the most important nursing action for preventing neonatal infection is effective handwashing. C- Separate gowns should be worn in caring for each individual infant. Soiled linens should be disposed of in an appropriate manner; however, the most important nursing action for preventing neonatal infection is effective handwashing. D- Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. The most important nursing action for preventing neonatal infection is effective handwashing.

What is the most important nursing action in preventing neonatal infection A. Good handwashing B. Isolation of infected infants C. Separate gown technique D. Standard Precautions

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

While caring for the postterm infant, the nurse recognizes that the fetus may have passed meconium prior to birth as a result of A. Hypoxia in utero B. NEC C. Placental insufficiency D. Rapid use of glycogen stores

ANS: A Rationale: When labor begins, poor oxygen reserves may cause fetal compromise. The fetus may passed meconium as a result of hypoxia before or during labor increasing the risk of meconium aspiration. B- Necrotizing enterocolitis (NEC) is a serious inflammatory condition of the intestinal tract that may lead to death of areas of the mucosa of the intestines. SGA infants are at increased risk for NEC. C- If placental insufficiency is present, decreased amniotic fluid volume and umbilical cord compression is likely to occur. This resulted in both hypoxia and malnourishment of the fetus. D- Postterm infants should be assessed for hypoglycemia because of the rapid use of glycogen stores.

To provide adequate care, the nurse should be cognitive of which important information regarding infertility A. Is perceived differently by women and men. B. Has a relatively stable prevalence among the overall population and throughout a woman's potential reproductive years. C. Is more likely the result of a physical flaw in the woman than in her male partner. D. Is the same thing as sterility.

ANS: A Rationale: Women tend to be more stressed about infertility tests and to place more importance on having children. The prevalence of infertility is stable among the overall population, but it increases with a woman's age, especially after age 40 years. Of cases with an identifiable cause, approximately 40% are related to female factors, 40% to male factors, and 20% to both partners. Sterility is the inability to conceive. Infertility or subfertility is a state of requiring a prolonged time to conceive.

Nursing actions that decrease the risk of skin breakdown include which of the following (Select all that apply.) a. Using gelled mattresses b. Using emollients in groin and thigh areas c. Using transparent dressings d. Drying thoroughly

ANS: A, B, C Rationale: a. Use of gelled mattresses decreases the risk of pressure sores. b. Use of emollients reduces the risk of irritation from urine. c. Use of transparent dressings reduces the risk of friction injuries. d. Drying thoroughly is important in maintaining body heat.

Which risk factors are associated with NEC (Select all that apply.) A. Polycythemia B. Anemia C. Congenital heart disease D. Bronchopulmonary dysphasia E. Retinopathy

ANS: A, B, C Rationale: Risk factors for NEC include asphyxia, RDS, umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus (PDA), congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection. Bronchopulmonary dysphasia and retinopathy are not associated with NEC.

Which medications can be taken by postmenopausal women to treat and/or prevent osteoporosis? Select all that apply. A. Calcium B. Evista C. Fosamax D. Actonel E. Vitamin C

ANS: A, B, C, D Correct: All of these medications can be used by postmenopausal women to treat or prevent osteoporosis. Calcitonin is another medication available for treatment of osteoporosis. Incorrect: Vitamin D is essential for calcium to be absorbed from the intestine. Recommended supplemental vitamin D Intake is 600 international units per day.

The nurse cautions that women with a history of which disorders are not candidates for HRT Select all that apply. A. Melanoma B. Estrogen-dependent breast cancer C. Hepatitis C D. Thromboembolic disease E. Hyperthyroidism

ANS: A, B, C, D Rationale: Persons who are absolutely restricted from HRT are those with melanoma, estrogen-dependent breast cancers, chronic liver disorders, thromboembolic disease, and seizure disorders.

A nurse is completing the initial assessment on a neonate of a mother with type I diabetes. Important assessment areas for this neonate include which of the following (Select all that apply.) a. Assessment of cardiovascular system b. Assessment of respiratory system c. Assessment of musculoskeletal system d. Assessment of neurological system

ANS: A, B, C, D Rationale: a. Neonates of mothers with type I diabetes are at higher risk for cardiac anomalies. b. Neonates of mothers with type I diabetes are at higher risk for RDS due to a delay in surfactant production related to high maternal glucose levels. c. Neonates of mothers with type I diabetes are usually large and are at risk for a fractured clavicle. d. Neonates of mothers with type I diabetes are at higher risk for neurological damage and seizures due to neonatal hyperinsulinism.

Which of the following are common assessment findings of postmature neonates (Select all that apply.) a. Dry and peeling skin b. Abundant vernix caseosa c. Hypoglycemia d. Thin, wasted appearance

ANS: A, B, C, D Rationale: a. Vernix caseosa covers the fetus's body around 17 to 20 weeks' gestation; as pregnancy advances, the amount of vernix decreases. Vernix prevents water loss from the skin to the amniotic fluid; as the amount of vernix decreases, an increasing amount of water is lost from the skin. This contributes to the dry and peeling skin seen in postmature neonates. b. Vernix caseosa covers the fetus's body around 17 to 20 weeks' gestation; as pregnancy advances, the amount of vernix decreases. c. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fat stores and glycemic stores. This results in the thin and wasted appearance of the neonate and risk for hypoglycemia during the first few hours post-birth. d. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fat stores and glycemic stores. This results in the thin and wasted appearance of the neonate and risk for hypoglycemia during the first few hours post-birth.

Many factors, male and female, contribute to normal fertility. Approximately 40% of cases of infertility are related to the female partner. Which factors are possible causes for female infertility (Select all that apply.) A. Congenital or developmental B. Hormonal or ovulatory C. Tubal or peritoneal D. Uterine E. Emotional or psychologic

ANS: A, B, C, D Rationale: Female infertility can be attributed to alterations in any one of these systems along with possible vaginal-cervical factors. Although the diagnosis and treatment of infertility require considerable emotional investment and may cause psychologic stress, these are not considered factors associated with infertility. Feelings connected with infertility are many and complex. Resolve is an organization that provides support, advocacy, and education for both clients and health care providers.

The patient who has been dealing with urge incontinence tells the nurse that the symptoms have gotten worse lately. The nurse reminds the patient that which food(s) and drug(s) can increase incontinence Select all that apply. A. Antihypertensive drugs B. Coffee C. Alcohol D. Diuretics E. Anticholinergics

ANS: A, B, C, D, E Rationale: Foods and drugs that increase the symptoms of urge incontinence are antidepressants, angiotensin converting enzyme (ACE) inhibitors, caffeine, alcohol, diuretics, and anticholinergics.

The nurse advises the woman with pelvic floor dysfunction that she can do what for relief of the associated discomfort Select all that apply. A. Lie down with feet elevated. B. Practice Kegel exercises. C. Assume knee-chest position periodically. D. Perform leg lift exercises. E. Prevent constipation.

ANS: A, B, C, E Rationale: Elevating the feet, performing Kegel exercises, assuming the knee-chest position, and preventing constipation will reduce the pelvic discomfort of pelvic floor dysfunction.

A nurse is caring for a 40 weeks' gestation neonate. The neonate is 12 hours post-birth and has been admitted to the NICU for meconium aspiration. The nurse recalls that the following are potential complications related to meconium aspiration (select all that apply): a. Obstructed airway b. Hyperinflation of the alveoli c. Hypoinflation of the alveoli d. Decreased surfactant proteins

ANS: A, B, D Rationale: a. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. b. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. c. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. d. The presence of meconium in the lungs can also cause a chemical pneumonitis and inhibit surfactant production.

While interviewing a 48-year-old patient during her annual physical examination, the nurse learns that she has never had a mammogram. The American Cancer Society recommends annual mammography screening starting at age 40. Before the nurse encourages this patient to begin annual screening, it is important for her to understand the reasons why women avoid testing. These reasons include (select all that apply) A. Reluctance to hear bad news B. Fear of x-ray exposure C. Belief that lack of family history makes this test unnecessary D. Expense of the procedure E. Having heard that the test is painful

ANS: A, B, D, E Correct: All of these are reasons for women to avoid having a mammogram done. Although the test is expensive, it is usually covered by health insurance, and many communities offer low-cost or free screening to women without insurance. It is important to acknowledge that some discomfort occurs with screening. Scheduling the test immediately at the end of a period makes it less painful. The risk of radiation exposure is minimal to none. Nurses play a vital role in providing information and reassurance to help women overcome these fears. Incorrect: Even patients with no family history should have regular screening done. The nurse should emphasize that a combination of breast self-examination and mammography needs to be performed at regular intervals. Women with a family history may need to begin screening at a younger age and have additional testing such as ultrasound performed.

The nurse knows that a postterm infant may experience which potential problem(s) Select all that apply. A. Seizures B. Asphyxia C. Paralysis D. Visual defects E. Polycythemia

ANS: A, B, E Rationale: The postterm infant should be assessed closely for indication of asphyxia, seizures, and polycythemia.

A nurse is caring for a 2-day-old neonate who was born at 31 weeks' gestation. The neonate has a diagnosis of respiratory distress syndrome (RDS). Which of the following medical treatments would the nurse anticipate for this neonate (Select all that apply.) a. Exogenous surfactant b. Corticosteroids c. Continuous positive airway pressure (CPAP) d. Bronchodilators

ANS: A, C Rationale: a. This is a common medical treatment for RDS. b. Corticosteroids are given to women in preterm labor to decrease the risk of RDS. c. CPAP is used to assist neonates with RDS. d. Bronchodilators are given to neonates with bronchopulmonary dysplasia (BPD).

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

ANS: A, C, D Correct: All of these conditions are related to immaturity and warrant close observation. After discharge the infant is at risk for rehospitalization related to these problems. AWHONN has recently launched the Near-Term Infant Initiative to study the problem and ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications. Incorrect: These infants are at risk for respiratory distress and hypoglycemia.

Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is similar to that of a full-term baby. These infants are at increased risk for which conditions (Select all that apply.) Problems with thermoregulation Cardiac distress Hyperbilirubinemia Sepsis Hyperglycemia

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

The nurse instructs the woman taking oral contraceptives to report which possible side effect(s) Select all that apply. A. Abdominal pain B. Weight gain C. Headache D. Eye or visual problems E. Speech disturbances

ANS: A, C, D, E Rationale: The memory aid ACHES is helpful: Abdominal pain, Chest pain, Headaches, Eye problems, Speech disturbances. Weight gain is an expected side effect of oral contraceptives.

A probable cause for increasing infertility is the societal delay in pregnancy until later in life. What are the natural reasons for the decrease in female fertility (Select all that apply.) A. Ovulation dysfunction B. Endocrine dysfunction C. Organ damage from toxins D. Endometriosis E. Tubal infections

ANS: A, C, D, E Rationale: All of these factors may result in a cumulative effect, decreasing fertility in women. Male infertility is more often caused by unfavorable sperm production attributable to endocrine dysfunction or cumulative metabolic disease.

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

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

You (the nurse) are reviewing the educational packet provided to a patient about tubal ligation. What is an important fact you should point out? Select all that apply. A. "It is highly unlikely that you will become pregnant after the procedure." B. "This is an effective form of 100% permanent sterilization. You won't be able to get pregnant." C. "Sterilization offers some form of protection against sexually transmitted diseases." D. "Sterilization offers no protection against sexually transmitted diseases." E. "Your menstrual cycle will greatly increase after your sterilization."

ANS: A, D Correct: A woman is unlikely to become pregnant after tubal ligation. Sterilization offers no protection against STDs. Incorrect: Tubal ligation is not 100% effective. Tubal ligation does not offer any protection against STDs. Typically, the menstrual cycle remains the same after a tubal ligation.

Which of the following factors increases the risk of necrotizing enterocolitis (NEC) in very premature neonates (Select all that apply.) a. Early oral feedings with formula b. Prolonged use of mechanical ventilation c. Hyperbilirubinemia d. Nasogastic feedings

ANS: A, D Rationale: a. Preterm neonates have a decreased ability to digest and absorb formula. Undigested formula can cause a blockage in the intestines leading to necrosis of the bowel. b. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. c. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. d. Bacterial colonization in the intestines can occur from contaminated feeding tubes causing an inflammatory response in the bowel.

The exact cause of breast cancer remains undetermined. Researchers have found that there are a number of common risk factors that increase a woman's chance of developing a malignancy. It is essential for the nurse who provides care to women of any age to be aware of which risk factors? Select all that apply. A. Family history B. Late menarche C. Early menopause D. Race E. Nulliparity or first pregnancy after age 30

ANS: A, D, E Correct: Family history, race, and nulliparity are known risk factors for the development of breast cancer. Others include age, personal history of cancer, high socioeconomic status, sedentary lifestyle, hormone replacement therapy, recent use of oral contraceptives, never having breastfed a child, and drinking more than one alcoholic beverage per day. Incorrect: Early menarche and late menopause are risk factors for breast malignancy, not late menarche and early menopause.

The bilirubin serum level comes back at 8 mg/dL. The infant is diagnosed with pathologic hyperbilirubinemia. The nurse prepares the inant for placement under a bilirubin light. Which actions should the nurse implement? Select all that apply. A. Remove the infant's clothing. B. Anticipate starting IV fluids. C. Keep the infant in one position. D. Place eye patches on the infant. E. Turn off the lights and allow parents to hold infant for feedings.

ANS: A, D, E Rationale: A- Although some agencies will leave a diaper in place, it is important to expose as much of the skin as possible. D- Eye covering is important during phototherapy to prevent retinal injury from the phototherapy lights. E- Removing the infant from phototherapy for feedings and interactions with parents for periods up to one hour at a time does not decrease effectiveness of phototherapy. This also provides needed sensory stimulation for the infant. B- IV fluids are not needed at this time. C- It is important to change the infant's position every 1 to 2 hours to expose as much skin as possible.

The nurse should be aware that a pessary is most effective in the treatment of what disorder? A. Cystocele B. Uterine prolapse C. Rectocele D. Stress urinary incontinence

ANS: B Rationale: A- A pessary is not used for the patient with a cystocele. B- A fitted pessary may be inserted into the vagina to support the uterus and hold it in the correct position. C- A rectocele cannot be corrected by the use of a pessary. D- It is unlikely that a pessary be the most effective treatment for stress incontinence.

During her annual gynecologic checkup, a 17-year-old woman states that recently she has been experiencing cramping and pain during her menstrual periods. The nurse should document this complaint as A. Amenorrhea B. Dysmenorrhea C. Dyspareunia D. PMS

ANS: B Rationale: A- Amenorrhea is the absence of menstrual flow. B- Dysmenorrhea is pain during or shortly before menstruation. Pain is described as sharp and cramping or sometimes as a dull ache. It may radiate to the lower back or upper thighs. C- Dyspareunia is pain during intercourse. D- PMS is a cluster of physical, psychologic, and behavioral symptoms that begin in the luteal phase of the menstrual cycle and resolve within a couple of days of the onset of menses.

The physician diagnoses a 3 cm ovarian cyst in a 28-year-old woman. The nurse expects the initial treatment to include A. Beginning hormone therapy B. Examining the woman after her next menstrual period C. Scheduling a laparoscopy as soon as possible, to remove the cyst D. Aspirating the cyst as soon as possible and sending the fluid to pathology

ANS: B Rationale: A- Cysts in women of childbearing age may decrease within one cycle, so treatment is not necessary at this point. B- Most ovarian cysts regress spontaneously. C- It is too early to anticipate removal of the cysts. Most ovarian cysts regress spontaneously within one cycle. D- A transvaginal ultrasound examination will help determine if the cyst is fluid filled or solid. The cyst can then be removed if warranted.

When assessing a woman for menopausal discomforts, the nurse expects the woman to describe the most frequently reported discomfort, which is A. Headaches B. Hot flashes C. Mood swings D. Vaginal dryness with dyspareunia

ANS: B Rationale: A- Headaches may be associated with a decline in hormone levels; however, it is not the most frequently reported discomfort for menopausal women. B- Vasomotor instability, in the form of hat flashes or flushing, is a result of fluctuating estrogen levels and is the most common disturbance of the perimenopausal woman. C- Mood swings may be associated with a decline in hormone levels; however, it is not the most frequently reported discomfort for menopausal women. D- Vaginal dryness and dyspareunia may be associated with a decline in hormone levels; however, it is not the most frequently reported discomfort for menopausal women.

In helping a patient manage PMS, the nurse should A. Recommend a diet with more body-building and energy food, such as red meat and sugar. B. Suggest herbal therapies, and massage. C. Tell the patient to push for medications from the physician as soon as symptoms occur so as to lessen their severity. D. Discourage the use of diuretics.

ANS: B Rationale: A- Limiting red meat, refined sugar, caffeinated beverages, and alcohol improves the diet and may mitigate symptoms. B- Herbal therapies, conscious relaxation and massage have all been reported to have a beneficial effect on PMS. C- Medication usually is begun only if lifestyle changes fail to provide significant relief. D- Natural diuretics may help reduce fluid retention.

Which statement by the patient indicates that she understands breast self-examination? A. "I will examine both breasts in two different positions." B. "I will perform breast self-examination 1 week after my menstrual period starts." C. "I will examine the outer upper area of the breast only." D. "I will use the palm of the hand to perform the examination."

ANS: B Rationale: A- She should use four positions: standing with arms at her sides, standing with arms raised above her head, standing with hands pressed against hips, and lying down. B- The woman should examine her breasts when hormonal influences are at a low level. C- The entire breast needs to be examined, including the outer upper area. D- She should use the sensitive pads of the middle three fingers.

A 49-year-old patient confides to the nurse that she has started experiencing pain with intercourse and asks, "Is there anything I can do about this?" The nurse's best response is "You need to be evaluated for a sexually transmitted disease." b. "Water-soluble vaginal lubricants may provide relief." c. "No, it is part of the aging process." d. "You may have vaginal scar tissue that is producing the discomfort."

ANS: B Rationale: A- This is a normal occurrence with the aging process and does not indicate STDs. B- Loss of lubrication with resulting discomfort in intercourse is a symptom of estrogen deficiency. C- It is part of the aging process, but the use of lubrication will help relieve the symptoms. D- It is due to loss of lubrication with the decrease in estrogen. Scar tissue problems would have occurred earlier.

The apnea monitor indicates that a preterm infant is having an apneic episode. The appropriate nursing action in this situation is to: A. administer oxygen via a nasal cannula. B. gently rub the infant's feet or back. C. ventilate with an Ambu bag. D. perform nasopharyngeal suctioning.

ANS: B Rationale: Gently rubbing the infant's back, ankles, or feet may stimulate the infant to breathe.

A woman asks the nurse, "How do oral contraceptives prevent pregnancy" The nurse explains that the combination of estrogen and progesterone in oral contraceptives: A. makes cervical mucus hostile to sperm. B. prevents ovulation. C. prohibits implantation of the egg. D. acts as a barrier by destroying sperm.

ANS: B Rationale: Oral contraceptives contain a combination of estrogen and progesterone that suppress ovulation.

At her 6-week postpartum checkup, a woman states, "I am wondering about birth control. I used oral contraceptives before, and I'm breastfeeding now. Can I use the pill again" The nurse's best response is: A. "You should know that oral contraceptives increase your milk production." B. "Oral contraceptives can be taken once lactation is well established." C. "You don't need to use any form of birth control as long as you are breastfeeding." D. "Oral contraceptives are contraindicated for the lactating woman."

ANS: B Rationale: Oral contraceptives decrease breast milk production and are contraindicated until lactation is well established. Women who breastfeed their infants usually will not ovulate for 10 weeks and do not need contraception until that time.

Which statement made by the nurse would teach an adolescent using tampons how to prevent toxic shock syndrome (TSS) Super-absorbency tampons are effective for overnight absorption. Tampons should be changed at least every 4 hours. Gloves should be worn when changing tampons. TSS can be prevented by using a pad for the first 2 days of menstrual flow.

ANS: B Rationale: Tampons should be changed every 4 hours because a blood-soaked tampon is an excellent environment for bacteria.

When a preterm infant is receiving an intravenous infusion containing calcium gluconate, the nurse would assess this infant for: A. seizures. B. bradycardia. C. dysrhythmias. D. tetany.

ANS: B Rationale: The infant receiving intravenous calcium gluconate should be monitored for bradycardia.

The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry. The nurse is aware that these are symptoms of: A. respiratory distress syndrome. B. hypoglycemia. C. necrotizing enterocolitis. D. renal failure.

ANS: B Rationale: The preterm infant, before 38 weeks, should be assessed for hypoglycemia because the infant's glycogen stores are not adequate.

The woman using a diaphragm correctly would tell the nurse that the diaphragm: A. does not require the use of a spermicidal cream or jelly with it. B. should be left in place for at least 6 hours after intercourse. C. is removed immediately after intercourse for douching. D. is effective for up to 48 hours if positioned properly.

ANS: B Rationale: To act as a barrier, the diaphragm must be left in place for at least 6 hours after intercourse and can be left in place up to 24 hours.

Which of the following neonatal signs or symptoms would the nurse expect to see in a neonate with an elevated bilirubin level a. Low glucose b. Poor feeding c. Hyperactivity d. Hyperthermia

ANS: B Rationale: a. Hypoglycemia is not a sign that is related to an elevated bilirubin level. b. The baby is likely to feed poorly. An elevated bilirubin level adversely affects the central nervous system. Babies are often sleepy and feed poorly when the bilirubin level is elevated. c. Hyperactivity is the opposite of the behavior one would expect the baby to exhibit. d. Hyperthermia is not directly related to an elevated bilirubin level.

A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and inconsolably cries until held. What is the correct nursing diagnosis beginning with "ineffective coping, related to" A. Severe immaturity B. Environmental stress C. Physiologic distress D. Behavioral responses

ANS: B Rationale: "Ineffective coping, related to environmental stress" is the most appropriate nursing diagnosis for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must closely monitor the environment for sources of overstimulation. Although the infant may be severely immature in this case, she is responding to environmental stress. Physiologic distress is the response to environmental stress. The result is stress cues such as increased metabolic rate, increased oxygen and caloric use, and depression of the immune system. The infant's behavioral response to the environmental stress is crying. The appropriate nursing diagnosis reflects the cause of this response.

To maintain optimal thermoregulation for the premature infant, the nurse should A. Bathe the infant once a day. B. Put an undershirt on the infant in the incubator. C. Assess the infant's hydration status. D. Lightly clothe the infant under the radiant warmer.

ANS: B Rationale: Air currents around an unclothed infant will result in heat loss. A- Bathing causes evaporative heat loss. C- This is an important assessment but will not maintain thermoregulation. D- Clothing is not worn when the infant is under a radiant warmer.

What is most helpful in preventing premature birth? A. High socioeconomic status B. Adequate prenatal care C. Transitional Assistance to Needy Families D. Women, Infants, and Children nutritional program

ANS: B Rationale: B- Prenatal care is vital in identifying possible problems A- People with higher socioeconomic status are more likely to seek adequate prenatal care. The care is the most helpful in prevention. 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.

The nurse instructing a man considering a vasectomy should state that after a vasectomy: A. intercourse should be delayed for 6 weeks. B. sperm will still be ejaculated for a month. C. erections will be difficult to maintain. D. monthly sperm counts for a year will be necessary.

ANS: B Rationale: Because sperm are distal to the severed vas deferens, sperm will be in the ejaculate for about a month. A sperm count after that period of time should be performed to confirm the absence of sperm. Intercourse does not have to be delayed, but an alternate method of contraception should be used. Erections and sexual pleasure are not affected by a vasectomy.

A woman who has a seizure disorder and takes barbiturates and phenytoin sodium daily asks the nurse about the pill as a contraceptive choice. The nurse's most appropriate response is A. "This is a highly effective method, but it has some side effects." B. "Your current medications will reduce the effectiveness of the pill." C. "The pill will reduce the effectiveness of your seizure medication." D. "This is a good choice for a woman of your age and personal history."

ANS: B Rationale: Because the liver metabolizes oral contraceptives, their effectiveness is reduced when they are taken simultaneously with anticonvulsants. A- This is a true statement, but it is not the most appropriate response. C- The anticonvulsant will reduce the effectiveness of the pill, not the other way around. D- This statement does not teach the patient that the effectiveness of the pill may be reduced because of her anticonvulsant therapy.

With regard to skeletal injuries sustained by a neonate during labor or birth, nurses should be aware that: A. A newborn's skull is still forming and fractures fairly easily. B. Unless a blood vessel is involved, linear skull fractures heal without special treatment. C. Clavicle fractures often need to be set with an inserted pin for stability. D. Other than the skull, the most common skeletal injuries are to leg bones.

ANS: B Rationale: Because the newborn skull is flexible, considerable force is required to fracture it. About 70% of neonatal skull fractures are linear. Clavicle fractures need no special treatment. The clavicle is the bone most often fractured during birth.

The goal of treatment of the infant with phenylketonuria (PKU) is to A. Cure mental retardation. B. Prevent central nervous system (CNS) damage, which leads to mental retardation. C. Prevent gastrointestinal symptoms. D. Cure the urinary tract infection.

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

In appraising the growth and development potential of a preterm infant, the nurse should be cognizant of the information that is best described in which statement A. Tell the parents that their child will not catch up until approximately age 10 years (for girls) to age 12 years (for boys). B. Correct for milestones, such as motor competencies and vocalizations, until the child is approximately 2 years of age. C. Know that the greatest catch-up period is between 9 and 15 months postconceptual age. D. Know that the length and breadth of the trunk is the first part of the infant to experience catch-up growth.

ANS: B Rationale: Corrections are made with a formula that adds gestational age and postnatal age. Whether a girl or boy, the infant experiences catch-up body growth during the first 2 to 3 years of life. Maximum catch-up growth occurs between 36 and 40 weeks of postconceptual age. The head is the first to experience catch-up growth.

Upon examining the infant's extremities, which finding should the nurse report to the HCP? A. Bilateral legs flexed. B. Diminished movement in one arm. C. The infant's arms resist extension. D. Equal movement in extremities in a random manner.

ANS: B Rationale: Diminished movement in an extremity may indicate nerve damage. A- The infant's legs should be flexed; this is a normal finding. C- This is a normal finding. D- This is a normal finding.

An unmarried young woman describes her sex life as "active" and involving "many" partners. She wants a contraceptive method that is reliable and does not interfere with sex. She requests an intrauterine device (IUD). The nurse's most appropriate response is A. "The IUD does not interfere with sex." B. "The risk of pelvic inflammatory disease will be higher for you." C. "The IUD will protect you from sexually transmitted diseases." D. "Pregnancy rates are high with the IUDs."

ANS: B Rationale: Disadvantages of IUDs include an increased risk of pelvic inflammatory disease (PID) in the first 20 days after insertion, as well as the risks of bacterial vaginosis and uterine perforation. The IUD offers no protection against sexually transmitted diseases (STDs) or the human immunodeficiency virus (HIV). Because this woman has multiple sex partners, she is at higher risk of developing an STD. The IUD does not protect against infection, as does a barrier method. A- Although this statement may be correct, it is not the most appropriate response. C- The IUD offers no protection from STDs. D- The typical failure rate of the IUD ranges from 0.8% to 2%.

A married couple is discussing alternatives for pregnancy prevention and has asked about fertility awareness methods (FAMs). The nurse's most appropriate reply is A. "They're not very effective, and it's very likely you'll get pregnant." B. "They can be effective for many couples, but they require motivation." C. "These methods have a few advantages and several health risks." D. "You would be much safer going on the pill and not having to worry."

ANS: B Rationale: FAMs are effective with proper vigilance about ovulatory changes in the body and with adherence to coitus intervals. A- Fertility awareness methods are effective if used correctly by a woman with a regular menstrual cycle. The typical failure rate for all FAMs is 25% during the first year of use. C- FAMs have no associated health risks. D- The use of birth control has associated health risks. In addition, taking a pill daily requires compliance on the patient's part.

With regard to the assessment of female, male, and couple infertility, nurses should be aware that A. The couple's religious, cultural, and ethnic backgrounds provide emotional clutter that does not affect the clinical scientific diagnosis. B. The investigation is lengthy and can be very costly. C. The woman is assessed first; if she is not the problem, the male partner is analyzed. D. Semen analysis is for men; the postcoital test is for women.

ANS: B Rationale: Fertility assessment and diagnosis take time, money, and commitment from the couple. A- Religious, cultural, and ethnic-bred attitudes about fertility and related issues always have an impact on diagnosis and assessment. C- Both partners are assessed systematically and simultaneously, as individuals and as a couple. D- Semen analysis is for men, but the postcoital test is for the couple.

With regard to the assessment of female, male, or couple infertility, the nurse should be aware of which important information A. The couple's religious, cultural, and ethnic backgrounds provide emotional clutter that does not affect the clinical scientific diagnosis. B. The investigation will take several months and can be very costly. C. The woman is assessed first; if she is not the problem, then the male partner is analyzed. D. Semen analysis is for men; the postcoital test is for women.

ANS: B Rationale: Fertility assessment and diagnosis take time, money, and commitment from the couple. Religious, cultural, and ethnic-bred attitudes about fertility and related issues always have an effect on diagnosis and assessment. Both partners are systematically and simultaneously assessed, first as individuals and then as a couple. Semen analysis is for men; however, the postcoital test is for the couple.

The most common cause of pathologic hyperbilirubinemia is A. Hepatic disease B. Hemolytic disorders in the newborn C. Postmaturity D. Congenital heart defect

ANS: B Rationale: Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. A- Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause. C- Prematurity is a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause. D- Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.

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

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

With regard to infants who are SGA and intrauterine growth restriction (IUGR), the nurse should be aware of which information A. In the first trimester, diseases or abnormalities result in asymmetric IUGR. B. Infants with asymmetric IUGR have the potential for normal growth and development. C. In asymmetric IUGR, weight is slightly larger than SGA, whereas length and head circumference are somewhat less than SGA. D. Symmetric IUGR occurs in the later stages of pregnancy.

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

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

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

An infant with hypocalcemia is receiving an intravenous bolus of calcium. Which sign signals the nurse to stop the administration of this medication? A. Tachypnea of the newborn B. Bradycardia C. Decrease of acrocyanosis D. Gastric irritation (diarrhea)

ANS: B Rationale: If bradycardia or dysrhythmias occur during administration, stop the drug infusion immediately. A- Tachypnea is seen in many neonates delivered by cesarean section, but it is not associated with the administration of calcium. C- Acrocyanosis is not a major problem of calcium administration. D- Gastric irritation is usually seen with administration of oral calcium.

The preterm infant who should receive gavage feedings instead of a bottle is the one who A. Sometimes gags when a feeding tube is inserted B. Is unable to coordinate sucking and swallowing C. Sucks on a pacifier during gavage feedings D. Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min

ANS: B Rationale: Infants less than 34 weeks of gestation or who weigh less than 1500 g generally have difficulty with bottle-feeding. A- The presence of the gag reflex is important before initiating bottle-feeding. C- Providing a pacifier during gavage feedings gives positive oral stimulation and helps associate the comfortable feeling of fullness with sucking. D- These vital signs are within expected limits and an indication that the infant is not having respiratory problems at that time.

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

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

The nurse working with clients who have infertility concerns should be aware of the use of leuprolide acetate (Lupron) as a gonadotropin-releasing hormone (GnRH) agonist. For which condition would this medication be prescribed A. Anovulatory cycles B. Uterine fibroids C. Polycystic ovary disease (PCOD) D. Luteal phase inadequacy

ANS: B Rationale: Leuprolide acetate is used to treat endometriosis and uterine fibroids. Anovulatory cycles are treated with Clomid, Serophene, Pergonal, or Profasi, all of which stimulate ovulation induction. Metrodin is used to treat PCOD. Progesterone is used to treat luteal phase inadequacy.

The infant responds well to oxygen, which is discontinued after 10 minutes. The family is provided time to hold and interact with their infant boy. After a time together, the infant is transferred to the transition care nursery and Mrs. Ivy is taken to the postpartum unit. The family plans on formula-feeding and rooming-in with the infant. The infant is immediately placed on the scale prior to being placed on the radiant warmer. After receiving the labor and delivery report, which information should direct the nurse to further assessment of the infant's head? A. Fourteen hours of labor. B. Low forceps delivery. C. Unusual cord length. D. Vaginal delivery

ANS: B Rationale: Low forceps delivery is usually done with minimal risk, but there is a potential for head trauma or damage to the facial nerve. A- Fourteen hours of labor is typical for a primigravida and should have minimal effects on the infant's head. C- A long cord can wrap around the neck (nuchal cord) and can possibly cause asphyxia, but further assessment of the head is not needed. D- Another piece of reported information is more important.

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

ANS: B Rationale: Macrosomic infants may have a complicated birth and are susceptible to birth injuries, such as fractured clavicles, cephalohematomas, and brachial palsy. A macrosomic infant would have the potential to be hypoglycemic. The macrosomic infant would be at risk for hypothermia. An increase in red blood cells would not be the priority assessment for a macrosomic infant.

The nurse's immediate action after the birth of a post-term infant with meconium stained amniotic fluid is to: a. stimulate the infant to cry. b. suction the infant's airways. c. complete the 1- and 5-minute Apgars. d. vigorously dry the infant's head and trunk.

ANS: B Rationale: Meconium in the upper airways may be pulled deep into the respiratory passages when the infant takes the first breath after birth. Stimulating the infant to cry may cause aspiration of meconium in the upper airways, completing the 1- and 5-minute Apgars would delay suctioning and allow initiation of respirations, and vigorously drying the infant would increase stimulation and crying.

The difference between physiologic and nonphysiologic jaundice is that nonphysiologic jaundice A. Usually results in kernicterus B. Appears during the first 24 hours of life C. Results from breakdown of excessive erythrocytes not needed after birth D. Begins on the head and progresses down the body

ANS: B Rationale: Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. A- Pathologic jaundice may lead to kernicterus, but it needs to be stopped before that occurs. C- Both jaundices are the result of the breakdown of erythrocytes. Pathologic jaundice is due to a pathologic condition, such as Rh incompatibility. D- Jaundice proceeds from the head down.

The difference between pathologic jaundice and physiologic jaundice is that pathologic jaundice: a. usually results in kernicterus. b. appears during the first 24 hours of life. c. begins on the head and progresses down the body. d. results from the breakdown of excessive erythrocytes not needed after birth.

ANS: B Rationale: Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. Pathologic jaundice may lead to kernicterus, but it needs to be stopped before that occurs. Jaundice proceeds from the head down. Both jaundices are the result of the breakdown of erythrocytes. Pathologic jaundice is caused by a pathologic condition, such as Rh incompatibility.

A woman inquires about herbal alternative methods for improving fertility. Which statement by the nurse is most appropriate when informing the client on which herbal preparations may improve ovulation induction therapy A. "You should avoid nettle leaf, dong quai, and vitamin E while you are trying to get pregnant." B. "You may want to try black cohosh or phytoestrogens." C. "You should take vitamins E and C, selenium, and zinc." D. "Herbs have no bearing on fertility."

ANS: B Rationale: Ovulation therapy may have better outcomes when supplemented by black cohosh, progesterone, or plant estrogens. Antioxidant vitamins E and C, selenium, zinc, coenzyme 10, and ginseng have been shown to improve male fertility. Although most herbal remedies have not been clinically proven, many women find them helpful. They should be prescribed by a health care provider who has knowledge of herbalism.

Which of the following medical conditions could possible affect a woman's fertility status? a. Past medical history of asthma during childhood that is presently under control with the use of an inhaler b. Recently diagnosed with PCOS c. Past surgical history of removal of external polyps on labial tissue d. History of frequent sinus headaches that is seasonal in nature treated with over-the-counter medication

ANS: B Rationale: PCOS (polycystic ovarian syndrome) is associated with infertility issues related to syndrome presentation—hormonal abnormalities, obesity, and dyslipidemia. The use of inhaler therapy for the treatment of asthma should not affect the client's fertility status. Removal of external polyps on the labia should not affect the client's fertility. A history of sinus headaches should not affect the client's fertility.

Parents of a newborn with phenylketonuria are anxious to learn about the appropriate treatment for their infant. The nurse should explain that treatment of PKU involves _____ diet. A. Sodium restrictions in the B. A phenylalanine-free C. A phenylalanine-enriched D. A protein-rich

ANS: B Rationale: Phenylketonuria is treated with a special diet that restricts phenylalanine intake. A- Sodium restriction is not an issue in phenyiketonuria. C- Phenylalanine is eliminated from the diet to prevent CNS damage. D- A specially prepared milk substitute is used to control the amount of protein in the infant's diet, thereby decreasing the amount of phenylalanine.

Significant advances have been made with most reproductive technologies. Which improvement has resulted in increased success related to preimplantation genetic diagnosis A. Embryos are transferred at the cleavage stage. B. Embryos are transferred at the blastocyst stage. C. More than two embryos can be transferred at a time. D. Two cells are removed from each embryo.

ANS: B Rationale: Preimplantation genetic diagnosis can be performed on a single cell removed from each embryo after 3 to 4 days. With the availability of extended culture mediums, embryos are transferred at the blastocyst stage (day 5), which increases the chance of a live birth, compared with the older practice of transferring embryos at the cleavage stage (day 3). No more than two embryos should be transferred at a time.

Which is most helpful in preventing premature birth? A. High socioeconomic status B. Adequate prenatal care C. Aid to Families with Dependent Children D. Women, Infants, and Children (WIC) nutritional program

ANS: B Rationale: Prenatal care is vital for identifying possible problems. People with higher socioeconomic status are more likely to seek adequate prenatal care, which is the most helpful for prevention. Lower socioeconomic groups do not seek out health care, and that puts them at risk for preterm labor. Aid to Families with Dependent Children and WIC aid in the nutritional status of the pregnant woman, but the most helpful aid for the prevention of premature births is adequate prenatal care.

The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. The purpose of these formula feedings or breastfeedings is to: a. prevent hyperglycemia. b. provide fluids and protein. c. decrease gastrointestinal motility. d. prevent rapid emptying of the bilirubin from the bowel.

ANS: B Rationale: Proteins help maintain the albumin level in the blood, and the extra fluids help eliminate the excess bilirubin from the infant's system. Feedings every 2 hours will help prevent hypoglycemia. Increased gastrointestinal motility can facilitate the prompt emptying of the bilirubin from the bowel. The feedings stimulate bowel movements and emptying of the bilirubin from the bowel.

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 Rationale: ROP is thought to occur as a result of high levels of oxygen in the blood. A- NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. 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.

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

ANS: B Rationale: ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. IVH is caused by 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. BPD is caused by the use of positive-pressure ventilation against the immature lung tissue.

The nurse notes that the infant has been feeding poorly over the last 24 hours. She should immediately assess for other signs of: a. hyperglycemia. b. neonatal infection. c. hemolytic anemia. d. increased bilirubin levels.

ANS: B Rationale: Signs of neonatal infection (sepsis) in the newborn are subtle. Temperature instability, respiratory problems, and changes in feeding habits may be common. Hyperglycemia, hemolytic anemia, and increased bilirubin levels are not associated with poor infant feeding.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. What are generalized signs and symptoms of this condition A. Hypertonia, tachycardia, and metabolic alkalosis B. Abdominal distention, temperature instability, and grossly bloody stools C. Hypertension, absence of apnea, and ruddy skin color D. Scaphoid abdomen, no residual with feedings, and increased urinary output

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

?? The first sign of hypovolemic shock from postpartum hemorrhage is likely to be: A. cold, clammy skin. B. tachycardia. C. hypotension. D. decreased urinary output.

ANS: B Rationale: Tachycardia is usually the first sign of inadequate blood volume.

The nurse measures the infant's head and chest. What action should the nurse take when finding that the head measures 36 cm and the chest circumference measures 35 cm? A. Notify the HCP. B. Document the findings in the EMR. C. Monitor for excessively wide sutures. D. Verify the findings with another nurse.

ANS: B Rationale: The head and chest circumference are within normal limits.

Newborns whose mothers are substance abusers frequently have what behavior? A. Circumoral cyanosis, hyperactive Babinski reflex, and constipation B. Decreased amounts of sleep, hyperactive Moro (startle) reflex, and difficulty feeding C. Hypothermia, decreased muscle tone, and weak sucking reflex D. Excessive sleep, weak cry, and diminished grasp reflex

ANS: B Rationale: The infant exposed to drugs in utero often has poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behavior. A- They will have diarrhea and increased muscle tone. C- They will have an uncoordinated sucking and swallowing reflex and decreased muscle tone. D- They will have poor sleeping patterns, increased reflexes, and a high-pitched cry.

After clearing the airway with a bulb syringe and drying the infant with warm blankets, the nurse assesses that the infant is breathing and has a heart rate of 124 beats/min, but remains cyanotic. What action should the nurse take? A. Apply temperature probe. B. Prepare to give oxygen. C. Wrap the infant warmly. D. Secure a suction catheter.

ANS: B Rationale: The infant is breathing and has a heart rate. However, oxygen given during this critical transition can increase oxygenation to the rest of the body. Oxygen is usually given by having the nurse cup her hands around the infant's nose and mouth at the O2 tube. A- Further action is needed. C- Wrapping the infant is not the best response for this situation. D- Further suctioning is not needed since the infant is breathing on his own. Another response is best.

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

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

While the infant receives phototherapy, his stools become loose and green. What action should the nurse take? A. Change from formula to electrolyte solution. B. Document the findings in the EMR. C. Send a stool specimen to the laboratory. D. Reduce the amount of formula feedings.

ANS: B Rationale: The loose green stools are a typical response to phototherapy, so stools should continue to be monitored and results documented. A- This action is not necessary at this time. C- This action is not necessary at this time. D- The amount of fluids should be increased, not decreased, at this time.

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

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

The role of the nurse in family planning is to A. Advise couples on which contraceptive to use. B. Educate couples on the various methods of contraception. C. Decide on the best method of contraception for the couple. D. Refer the couple to a reliable physician.

ANS: B Rationale: The nurse's role is to provide information to the couple so that they can make an informed decision about family planning. A- The nurse should not advise the couple, only educate them. C- The nurse cannot decide on the best method for the couple; only they can decide which method is best for them. D- The nurse can educate and if the couple decides on a method that requires a physician visit, the nurse can then assist the couple in selecting an appropriate physician or primary health care provider.

The Ivy family is preparing to go home with their infant. The HCP prescribes a home phototherapy blanket since the infant's hyperbilirubinemia has not resolved. The parents appear confused and scared of using the phototherapy blanket. Which instructions should the nurse include in the discharge planning? A. The phototherapy blanket is placed over the infant's clothing. B. Holding the infant does not interrupt the phototherapy process. C. A phototherapy blanket is more effective than the overhead lights. D. The length of time required for phototherapy intervention is decreased.

ANS: B Rationale: The phototherapy blanket allows the infant to be held while the process is continued. A- Although diapers can be worn, the blanket is placed next to the skin on the trunk of the body to expose as much skin as possible to the light. C- Both are equally effective. D- The length of time is not decreased by the blanket.

With regard to the use of intrauterine devices (IUDs), nurses should be aware that A- Return to fertility can take several weeks after the device is removed. B- IUDs containing copper can provide an emergency contraception option if inserted within a few days of unprotected intercourse. C- IUDs offer the same protection against sexually transmitted diseases as the diaphragm. D- Consent forms are not needed for IUD insertion.

ANS: B Rationale: The woman has up to 5 days to insert the IUD after unprotected sex. A- Return to fertility is immediate after removal of the IUD. C- IUDs offer no protection for sexually transmitted diseases. D- A consent form is required for insertion, as is a negative pregnancy test.

Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority? a. Notify the clinician stat. b. Test for the blood glucose level. c. Start an intravenous line with D5W. d. Document the event in the nurses' notes.

ANS: B Rationale: These symptoms are signs of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain, but it is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer. Determine the blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results. Documentation can wait until the infant has been tested and treated if a problem is present.

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

ANS: B Rationale: This is the designation for very low birth rate; ELBW is less than 1000 g. At this weight, problems are so numerous that ethical issues regarding when to treat arise. This weight is less than low but too high for extremely low, which is less than 1000 g. Gestational age is a factor related to weight and the condition of the preterm birth, but it is not part of the birth weight categorization.

A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and cries inconsolably until held. The correct nursing diagnosis is ineffective coping related to A. Severe immaturity B. Environmental stress C. Physiologic distress D. Behavioral responses

ANS: B Rationale: This nursing diagnosis is the most appropriate for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must monitor the environment closely for sources of overstimulation. A- Although the infant may be severely immature in this case she is responding to environmental stress. C- Physiologic distress is the response to environmental stress. The result is stress cues such as increased metabolic rate, increased oxygen and caloric use and depression of the immune system. D- The infant's behavioral response in the case is crying. The nursing diagnosis should reflect the cause of this response, which is environmental stress.

Which test is performed around the time of ovulation to diagnose the basis of infertility A. Hysterosalpingogram B. Ultrasonography C. Laparoscopy D. Follicle-stimulating hormone (FSH) level

ANS: B Rationale: Ultrasonography is performed around the time of ovulation to assess pelvic structures for abnormalities, to verify follicular development, and to assess the thickness of the endometrium. A hysterosalpingogram is scheduled 2 to 5 days after menstruation to avoid flushing a potentially fertilized ovum out through a uterine tube into the peritoneal cavity. Laparoscopy is usually scheduled early in the menstrual cycle. Hormone analysis is performed to assess endocrine function of the hypothalamic-pituitary-ovarian axis when menstrual cycles are absent or irregular.

When a woman starts hormone replacement therapy (HRT), the nurse would instruct her to look for the side effect of: A. fatigue. B. headache. C. weight loss. D. amenorrhea.

ANS: B Rationale: Patients initiating HRT are reminded to have regular follow-up care and report headaches, vision changes, and symptoms of thrombophlebitis or cardiac symptoms.

A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal problems could have resulted in this complication (Select all that apply.) a. Cholecystitis b. Hypertension c. Cigarette smoker d. Candidiasis e. Cerebral palsy

ANS: B, C Rationale: Babies born to women with cholecystitis are not especially high risk for IUGR. Babies born to women with PIH or who smoke are high risk for IUGR. Babies born to women with candidiasis or cerebral palsy are not especially high risk for IUGR.

The perinatal nurse caring for Emily, a 24-year-old mother of an infant born at 26 weeks' gestation, is providing discharge teaching. Emily is going to travel to the specialty center approximately 200 miles away where her daughter is receiving care. The nurse tells Emily that it is normal for Emily to feel (select all that apply): a. In control b. Anxious c. Guilty d. Overwhelmed

ANS: B, C, D

What are anonymous sperm donors screened for (Select all that apply.) A. Particular physical features B. Genetic defects C. Infections D. High-risk behaviors E. Nationality

ANS: B, C, D Rationale: Sperm donors are screened for genetic defects, infections, and high-risk behaviors. As an added precaution, the sperm are kept frozen for 6 months before the sample is used.

Women who have undergone an oophorectomy, have ovarian failure, or a genetic defect may be eligible to receive donor oocytes (eggs). Which statements regarding oocyte donation are accurate (Select all that apply.) A. Donor is inseminated with semen from the parent. B. Donor eggs are fertilized with the male partner's sperm. C. Donors are under 35 years of age. D. Recipient undergoes hormonal stimulation. E. Ovum is placed into a surrogate.

ANS: B, C, D Rationale: Oocyte donation is usually provided by healthy women under the age of 35 years, who are recruited and paid to undergo ovarian stimulation and oocyte retrieval. The donor eggs are fertilized in a laboratory with the male partner's sperm. The woman undergoes hormonal stimulation to allow the development of the uterine lining. Embryos are then transferred. A donor that is inseminated with the male partner's semen or receives the fertilized ovum and then carries it to gestation is known as a surrogate mother.

Some infants develop hypoxic-ischemic encephalopathy after asphyxia. Therapeutic hypothermia has been used to improve neurologic outcomes for these infants. Criteria for the use of this modality include (select all that apply) A. The infant must be 28 weeks gestation or greater. B. Have evidence of an acute hypoxic event. C. Be in a facility they can initiate treatment within 6 hours. D. The infant must be 36 or more weeks gestation. E. The treatment must be initiated within the first 12 hours of life.

ANS: B, C, D Rationale: These criteria are all correct. Incorrect: The infant must be at least 36 weeks of gestation to meet the criteria for therapeutic hypothermia. Treatment should be initiated within the first 6 hours of life, ideally at a tertiary care center.

An important nursing factor during the care of the infant in the NICU is assessment for signs of adequate parental attachment. The nurse must observe for signs that bonding is not occurring as expected. These include (select all that apply) A. Using positive terms to describe the infant B. Showing interest in other infants equal to that of their own C. Naming the infant D. Decreasing the number and length of visits E. Refusing offers to hold and care for the infant

ANS: B, D, E Correct: These are all indications that parental attachment may be delayed. The parent may also show a decrease in or lack of eye contact and spend last time talking to or smiling at their infant. Incorrect: Failing to give the infant a name or use their name is a sign that bonding may be delayed. Refusing offers to hold their infant or learn how to care for them may initially be an expression of fear; however, over time this may indicate delayed bonding.

Which factors would contribute to abnormalities of the fallopian tube associated with the development of infertility? (Select all that apply.) a. History of conization of the cervix b. History of pelvic surgical procedures c. Incompetent cervix d. Past treatments of STD with follow-up test of cure e. Endometriosis

ANS: B, D, E Rationale: Surgical procedures related to the cervix, along with an incompetent cervix, would not affect the fallopian tubes in terms of infertility. It would affect fertility issues related to the cervix as a result of potential scarring (conization) and an inability to maintain the pregnancy in the presence of an incompetent cervix. A history of pelvic surgical procedures could result in the development of pelvic adhesions, which would affect the fallopian tube. Also, the presence of STDs, even with effective treatment, along with the clinical diagnosis, would affect the fallopian tube and possibly result in infertility.

In the week before her menstrual period, a woman experiences irritability, anxiety, and difficulty concentrating. The nurse suggests that a remedy to relieve these symptoms is to: A. drink tea or hot chocolate before going to bed. B. take a daily folic acid and vitamin C supplement. C. include complex carbohydrates and fiber in the diet. D. avoid exercise when symptoms occur.

ANS: C Rationale: A diet rich in complex carbohydrates and fiber is recommended for premenstrual dysmorphic disorder.

The nurse would tell the patient to expect what after she had an intrauterine device (IUD) inserted A. Menstrual flow will be lighter. B. Menstrual cramps will be eliminated. C. A string should be felt in the vagina. D. The device should be changed every 2 years.

ANS: C Rationale: A woman should feel for the string periodically, especially after her period, to confirm the presence of the IUD.

The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant or malignant cells is called A. Bimanual palpation B. Rectovaginal palpation C. A Papanicolaou test D. DNA testing

ANS: C Rationale: A- Bimanual palpation is a physical examination of the vagina; the Pap test is a microscopic examination for cancer. B- Rectovaginal palpation is a physical examination performed through the rectum; the Pap test is a microscopic examination for cancer. C- The Pap test is a microscopic examination for cancer that should be performed regularly, depending on the patient's age. D- DNA testing for the various types of HPV that cause cervical cancer is now available. Samples are collected in the same way as a Pap test.

Which patient is most at risk for fibroadenoma of the breast? A. A 38-year-old woman B. A 50-year-old woman C. A 16-year-old woman D. A 27-year-old woman

ANS: C Rationale: A- Ductal ectasia becomes more common as a woman approaches menopause. B- Intraductal papilloma develops most often just before or during menopause. C- Although it may occur at any age, fibroadenoma is most common in the teenage years. D- Fibrocystic breast changes are more common during the reproductive years.

The nurse providing education regarding breast care should explain to the woman that fibrocystic changes in breasts are A. A disease of the milk ducts and glands in the breasts B. A pre-malignant disorder characterized by lumps found in the breast tissue C. Lumpiness with pain and tenderness found in varying degrees in the breast tissue of healthy women during menstrual cycles D. Lumpiness accompanied by tenderness after menses

ANS: C Rationale: A- Fibrocystic changes are palpable thickenings in the breast. B- Fibrocystic changes are no pre-malignant changes. This information is inaccurate. C- Fibrocystic changes are palpable thickenings in the breast usually associated with pain and tenderness. The pain and tenderness fluctuate with the menstrual cycle. D- Fibrocystic changes are palpable thickenings in the breast usually associated with pain and tenderness. Most often tenderness occurs prior to menses.

A 36-year-old woman has been diagnosed as having uterine fibroids. When planning care for this patient, the nurse should know that A. Fibroids are malignant tumors of the uterus that require radiation or chemotherapy. B. Fibroids will increase in size during the perimenopausal period. C. Abnormal uterine bleeding is a common finding. D. Hysterectomy should be performed.

ANS: C Rationale: A- Fibroids are benign tumors of the smooth muscle of the uterus, and their etiology is unknown. B- Fibroids are estrogen-sensitive and shrink as levels of estrogen decline. C- The major symptoms associated with fibroids are menorrhagia and the physical effects produced by large leimyomas. D- A hysterectomy may be performed if the woman does not want more children and other therapies are not successful.

Which woman is most likely to have osteoporosis? A. A 50-year-old woman receiving estrogen therapy B. A 60-year-old woman who takes supplemental calcium C. A 55-year-old woman with a sedentary lifestyle D. A 65-year-old woman who walks 2 miles each day

ANS: C Rationale: A- Hormone therapy may prevent bone loss. B- Supplemental calcium will help prevent bone loss, especially when combined with vitamin D. C- Risk factors for the development of osteoporosis include smoking, alcohol consumption, sedentary lifestyle, family history of the disease, and a high-fat diet. D- Weight-bearing exercises have been shown to increase bone density.

Which statement is true about primary dysmenorrhea? A. It occurs in young multiparous women. B. It is experienced by all women. C. It may be due to excessive endometrial prostaglandin. D. It is unaffected by oral contraceptives.

ANS: C Rationale: A- It occurs in young nulliparous women. B- It is not experienced by all women. C- Some women produce excessive endometrial prostaglandin during the luteal phase of the menstrual cycle. Prostaglandin diffuses into endometrial tissue and causes uterine cramping. D- Oral contraceptives can be a treatment choice.

Which diagnostic test is used to confirm a suspected diagnosis of breast cancer? A. Mammogram B. Ultrasound C. Core needle biopsy D. CA 15-3

ANS: C Rationale: A- Mammography is a clinical screening tool that may aid early detection of breast cancers. B- Transillumination, thermography, and ultrasound breast imaging are being explored as methods of detecting early breast carcinoma. C- When a suspicious mammogram is noted or a lump is detected, diagnosis is confirmed by either a core needle biopsy or needle localization biopsy. D- CA-15 is a serum tumor marker that is used to test for the presence of breast cancer.

The drug of choice to treat gonorrhea is A. Penicillin G B. Tetracycline C. Ceftriaxone D. Acyclovir

ANS: C Rationale: A- Penicillin is used to treat syphilis. B- Tetracycline is used to treat chlamydial infections. C- Ceftriaxone is effective for treatment of all gonococcal infections. D- Acyclovir is used to treat herpes genitalis.

Management of primary dysmenorrhea often requires a multifaceted approach. The nurse who provides care for a patient with this condition should be aware that the optimal pharmacologic therapy for pain relief is A. Acetaminophen B. Oral contraceptives (OCPs) C. Nonsteroidal antiinflammatory drugs (NSAIDs) D. Aspirin

ANS: C Rationale: A- Preparations containing acetaminophen are less effective for dysmenorrhea because they lack the antiprostaglandin properties of NSAIDs. B- OCPs are a reasonable choice for women who also want birth control. The benefit of OCPs is the reduction of menstrual flow and irregularities. OCPs may be contradicted for some women and have a number of potential side effects. C- This pharmacologic agent has the strongest research results for pain relief. Often, if one NSAID is not effective, another one will provide relief. D- NSAIDs are the drug of choice. However, if a woman is taking an NSAID, she should avoid taking aspirin as well.

With regard to endometriosis, nurses should be aware that A. It is characterized by the presence and growth of endometrial tissue inside the uterus. B. It affects 25% of all women. C. It may worsen with repeated cycles or remain asymptomatic and disappear after menopause. D. It is unlikely to affect sexual intercourse or fertility.

ANS: C Rationale: A- With endometriosis, the endometrial tissue is outside the uterus. Symptoms vary among women, ranging from nonexistent to incapacitating. B- Endometriosis affects 10% of all women and is found equally in Caucasian and African-American women. C- Symptoms vary among women, ranging from nonexistent to incapacitating. D- Women can experience painful intercourse and impaired fertility.

The nurse is assessing a baby girl on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist a. Intermittent strabismus b. Startling c. Grunting d. Vaginal bleeding

ANS: C Rationale: A. Pseudostrabismus is a normal finding. B. Startling is a normal finding. C. Grunting is a sign of respiratory distress. The neonatologist should be notified. D. Vaginal bleeding is a normal finding.

When a woman asks what she can do to reduce the discomfort of hot flashes, the nurse advises: A. "Aerobic exercise helps control hot flashes." B. "Increase the amount of calcium and vitamin D in your diet." C. "Dress in layers of cotton clothing." D. "Drink plenty of fluids, particularly caffeinated beverages."

ANS: C Rationale: Cotton allows easier passage of air than synthetic fabrics. Layering allows the woman to take off or put on clothes when symptoms occur.

A 17-year-old girl comes to the emergency department complaining of severe pain in her left lower quadrant. When an ovarian cyst is suspected, the nurse explains that the diagnosis is confirmed by: A. laparotomy. B. oophorectomy. C. transvaginal ultrasound. D. hysteroscopy.

ANS: C Rationale: Diagnosis of an ovarian cyst is made by transvaginal ultrasound.

Parents of a preterm infant come to the NICU every day to see their infant, who is being gavage fed. The nurse teaching about stimulating the infant would tell the parents: A. to bring in colorful pictures and toys to place in the incubator. B. that stimulating the infant during feedings increases intake. C. to stroke the infant during feeding to increase intake. D. not to disturb the infant between feedings.

ANS: C Rationale: During gavage feedings, stroking the infant gently can provide stimulation.

The nurse planning to teach a woman about perimenopause would include that lowered estrogen levels: A. prevent osteoporosis. B. decrease vaginal lubrication. C. raise the level of low-density lipoproteins. D. raise the level of high-density lipoproteins.

ANS: C Rationale: Estrogen increases the amount of high-density lipoproteins that carry cholesterol from body cells to the liver for excretion. With lowered levels of estrogen, low-density lipoproteins increase, causing an increase in the incidence of heart attacks and strokes.

At her regular gynecological examination, a woman tells the nurse that she is concerned about osteoporosis. The nurse could suggest to the patient to: take a vitamin E supplement daily. do isometric exercises that can be practiced every day. include more dairy products and green, leafy vegetables in her diet. try to limit her intake of caffeine.

ANS: C Rationale: Foods rich in calcium include milk, dairy products, and green, leafy vegetables in her diet.

A preterm infant has a yellow skin color and a rising bilirubin level. The nurse is aware that this infant is at risk for: A. skin breakdown. B. renal failure. C. brain damage. D. heart failure.

ANS: C Rationale: The higher the bilirubin level and the deeper the jaundice, then greater is the risk for neurological damage.

The nurse clarifies that a preterm infant born at 34 weeks of gestation is placed in an incubator because: A. the infant has a small body surface-to-weight ratio. B. heat increases the flow of oxygen to the extremities. C. the infant's temperature control mechanism is immature. D. heat within the incubator facilitates drainage of mucus.

ANS: C Rationale: The preterm infant is at risk for heat loss for several reasons, one of which is that the heat regulating center in the brain is immature.

A NICU nurse is caring for a full-term neonate being treated for group B streptococcus. The mother of the neonate is crying and shares that she cannot understand how her baby became infected. The best response by the nurse is: a. "Newborns are more susceptible to infections due to an immature immune system. Would you like additional information on the newborn immune system" b. "The infection was transmitted to your baby during the birthing process. Do you have a history of sexual transmitted infections" c. "Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the vaginal area. What other questions do you have regarding your baby's health" d. "I see that this is very upsetting for you. I will come back later and answer your questions."

ANS: C Rationale: This response answers her questions and allows her to ask additional questions about her baby's health

The nurse's safest action to ensure tube placement when preparing to initiate a gavage feeding is to: A. check tube placement by injecting air into the stomach. B. weigh the infant before the feeding. C. aspirate stomach contents. D. check serum glucose level.

ANS: C Rationale: When the preterm infant is gavage fed, the contents of the stomach should be aspirated before the feeding is started. Aspiration of the stomach contents ensures tube placement and also allows the nurse to assess the amount of feeding in the stomach.

A 1-day-old neonate in the well-baby nursery is suspected of suffering from drug withdrawal because he is markedly hyperreflexic and is exhibiting which of the following additional sign or symptom a. Prolonged periods of sleep b. Hypovolemic anemia c. Repeated bouts of diarrhea d. Pronounced pustular rash

ANS: C Rationale: a. Babies who are withdrawing from drugs have disorganized behavioral states and sleep very poorly. b. There is nothing in the scenario that indicates that this child is hypovolemic or anemic. c. Babies who are experiencing withdrawal often experience bouts of diarrhea. d. A pustular rash is characteristic of an infectious problem, not of neonatal abstinence syndrome.

A multipara, 26 weeks' gestation and accompanied by her husband, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time a. Encourage the parents to pray for the baby's soul. b. Advise the parents that it is better for the baby to have died than to have had to live with a defect. c. Encourage the parents to hold the baby. d. Advise the parents to refrain from discussing the baby's death with their other children.

ANS: C Rationale: a. It is inappropriate for the nurse to advise prayer. The parents must decide for themselves how they wish to express their spirituality. b. This is an inappropriate suggestion. c. This is an appropriate suggestion. Encouraging parents to spend time with their baby and hold their baby is an action that supports the parents during the grieving process. d. This is an inappropriate suggestion. It is very important for the parents to clearly communicate the baby's death with their other children.

The NICU nurse recognizes that respiratory distress syndrome results from a developmental lack of: a. Lecithin b. Calcium c. Surfactant d. Magnesium

ANS: C Rationale: a. The ratio of lecithin to sphingomyelin in the amniotic fluid is used to assess maturity of fetal lungs. b. Calcium is needed to prevent undermineralization of bones. c. Respiratory distress syndrome (RDS) is a developmental respiratory disorder that affects preterm newborns due to lack of lung surfactant. The pathology of RDS is that there is diffuse atelectasis with congestion and edema in the lung spaces. On deflation, the alveoli collapse, and there is decreased lung compliance. d. Magnesium is needed to prevent undermineralization of bones.

It is noted that the amniotic fluid of a 42-week gestation baby, born 30 seconds ago, is thick and green. Which of the following actions by the nurse is critical at this time a. Perform a gavage feeding immediately. b. Assess the brachial pulse. c. Assist a physician with intubation. d. Stimulate the baby to cry.

ANS: C Rationale: a. This action is not appropriate. The baby needs tracheal suctioning. b. The baby needs to have tracheal suctioning. The most important action to promote health for the baby is for the health-care team to establish an airway that is free of meconium. c. This action is appropriate. The baby needs to be intubated in order for deep suctioning to be performed by the physician. A nurse would not intubate and suction but rather would assist with the procedures. d. It is strictly contraindicated to stimulate the baby to cry until the trachea has been suctioned. The baby would aspirate the meconium-stained fluid, which could result in meconium-aspiration syndrome.

The nurse present at the delivery is reporting to the nurse who will be caring for the neonate after birth. What information might be included for an infant who had thick meconium in the amniotic fluid? A. The infant needed vigorous stimulation immediately after birth to initiate crying. B. An IV was started immediately after birth to treat dehydration. C. No meconium was found below the vocal cords when they were examined. D. The parents spent an hour bonding with the baby after birth.

ANS: C Rationale: A laryngoscope is inserted to examine the vocal cords. If no meconium is below the cords, probably no meconium is present in the lower air passages, and the infant will not develop meconium aspiration syndrome. A- Vigorous stimulation in the presence of meconium fluid is contraindicated to prevent aspiration. B- There is no relationship between dehydration and meconium fluid. D- This is an expected occurrence.

The nurse present at the birth is reporting to the nurse who will be caring for the neonate after birth. Which information should be included for an infant who had thick meconium in the amniotic fluid? a. The parents spent an hour bonding with the baby after birth. b. An IV was started immediately after birth to treat dehydration. c. There was no meconium below the vocal cords when they were visualized. d. The infant needed vigorous stimulation immediately after birth to initiate crying.

ANS: C Rationale: A laryngoscope is inserted to examine the vocal cords. If no meconium is below the cords, probably no meconium is present in the lower air passages, and the infant will not develop meconium aspiration syndrome. Bonding after birth is an expected occurrence. There is no relationship between dehydration and meconium fluid. Vigorous stimulation in the presence of meconium fluid is contraindicated to prevent aspiration.

Injectable progestins (DMPA, Depo-Provera) are a good contraceptive choice for women who A. Want menstrual regularity and predictability B. Have a history of thrombotic problems or breast cancer C. Have difficulty remembering to take oral contraceptives daily D. Are homeless or mobile and rarely receive health care

ANS: C Rationale: Advantages of DMPA include a contraceptive effectiveness comparable to that of combined oral contraceptives with the requirement of only four injections a year. A- Disadvantages of injectable progestins are prolonged amenorrhea and uterine bleeding. B- Use of injectable progestin carries an increased risk of venous thrombosis and thromboembolism. D- To be effective, DMPA injections must be administered every 11 to 13 weeks. Access to health care is necessary to prevent pregnancy or potential complications.

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

ANS: C Rationale: All 3 of these complications are common in LGA infants. A- LGA infants are determined by their weight compared to their age. B- They are above the 90th percentile on the gestational growth charts. D- Both injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

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

ANS: C Rationale: Although it is impossible to predict with complete accuracy the growth and development potential of each preterm infant, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. The growth and developmental milestones are corrected for gestational age until the child is approximately 2½ years old. This statement is inaccurate. Development will need to be evaluated over time. The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant's responses are evaluated accordingly against the norm expected for the corrected age of the infant. The growth and developmental milestones are corrected for gestational age until the child is approximately 2½ years old.

While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth? a. Risk for infection related to release of meconium b. Risk for injury related to high-risk birth interventions, such as amino infusion c. Risk for aspiration related to retained secretions d. Risk for thermoregulation because of high-risk labor status

ANS: C Rationale: Because the fetus has already passed meconium in utero, the labor and birth take on a high-risk management perspective. The likelihood that the infant will develop meconium aspiration syndrome (MAS) is increased, so airway abnormalities take precedence in terms of nursing diagnosis and medical management.

The nurse conducts the change of shift assessment of the infant. Which finding by the nurse is consistent with a cephalhematoma? A. Head shaped into the appearance of a dunce cap. B. Swelling of the scalp that crosses the suture line. C. Well-outlined swelling that does not cross suture lines. D. Softening of the cranial bones that indent with pressure.

ANS: C Rationale: Cephalhematoma is caused by increased pressure or trauma at birth from blood collecting beneath the periosteum of the bone and therefore does not cross the suture line. A- This describes molding. B- This describes caput succedaneum. D- This describes craniotabes.

Mrs. Ivy asks how she will know the phototherapy is working. How should the nurse respond? A. Stools are loose and bright green. B. Formula feedings increase. C. Serum bilirubin level decreases. D. Skin is resilient with no indications of jaundice.

ANS: C Rationale: Decreasing bilirubin levels are the best indicator of phototherapy effectiveness. A- Although this occurs, it is not the best indicator of phototherapy effectiveness. B- The appetite will not be changed. D- This is not the best indicator of effectiveness.

Transitory tachypnea of the newborn (TTN) is thought to occur as a result of: a. a lack of surfactant. b. hypoinflation of the lungs. c. delayed absorption of fetal lung fluid. d. a slow vaginal birth associated with meconium-stained fluid.

ANS: C Rationale: Delayed absorption of fetal lung fluid is thought to be the reason for TTN. Lack of surfactant causes respiratory distress syndrome. A slow vaginal birth will help prevent TTN.

What is important in instructing a patient in the use of spermicidal foams or gels? A. Insert 1 to 2 hours before intercourse. B. One application is effective for several hours. C. Avoid douching for at least 6 hours. D. Effectiveness is about 85%.

ANS: C Rationale: Douching within 6 hours of intercourse removes the spermicide and increases the risk of pregnancy. A- Foams or gels should be inserted just before intercourse and are effective for about 1 hour. B- Each application is effective for about 1 hour. D- Effectiveness is about 74% when used alone.

The nurse is having her first meeting with a couple experiencing infertility. The nurse has formulated the nursing diagnosis, "Deficient knowledge, related to lack of understanding of the reproductive process with regard to conception." Which nursing intervention does not apply to this diagnosis A. Assess the current level of factors promoting conception. B. Provide information regarding conception in a supportive manner. C. Evaluate the couple's support system. D. Identify and describe the basic infertility tests.

ANS: C Rationale: Evaluating the couple's support system would be a nursing action more suitable to the diagnosis, "Ineffective individual coping, related to the ability to conceive."

An infant with severe meconium aspiration syndrome is not responding to conventional treatment. Which method of treatment may be available at a level III facility for use with this infant? a. Insertion of an endotracheal tube b. Respiratory support with a ventilator c. Extracorporeal membrane oxygenation d. Insertion of a laryngoscope and suctioning of the trachea

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

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

ANS: C Rationale: Feedings by gravity are slowly accomplished over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Applying warm cloths to the abdomen would not be appropriate because the environment is not thermoregulated. In addition, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

Five hours after delivery, the infant's vital signs are stable and he is taken to his family. While the nurse discusses care with Mrs. Ivy, the infant starts gagging. Which action should the nurse implement first? A. Support the infant in side-lying position. B. Place the infant supine in the crib. C. Use a bulb syringe to clear the mouth and nose. D. Secure a delee catheter to wall suction for use.

ANS: C Rationale: Gagging due to excessive mucus is a typical response during the transition period. Suctioning the mouth and nose should be done first.

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 Rationale: Grunting increases the pressure inside the alveoli to keep them open when surfactant is insufficient.

With regard to an eventual discharge of the high-risk newborn or the transfer of the newborn to a different facility, which information is essential to provide to the parents A. Infants stay in the NICU until they are ready to go home. B. Once discharged to go home, the high-risk infant should be treated like any healthy term newborn. C. Parents of high-risk infants need special support and detailed contact information. D. If a high-risk infant and mother need to be transferred to a specialized regional center, then waiting until after the birth and until the infant is stabilized is best.

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

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

ANS: C Rationale: Hypoglycemia, polycythemia, and birth injuries are all common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on gestational growth charts. Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

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

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

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

ANS: C Rationale: 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. 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. D- The body, arms, and legs have lost subcutaneous fat so they will look small compared to the head.

Which preterm infant should receive gavage feedings instead of bottle feedings? A. Sucks on a pacifier during gavage feedings B. Sometimes gags when a feeding tube is inserted C. Has a sustained respiratory rate of 70 breaths/min D. Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min

ANS: C Rationale: Infants less than 34 weeks of gestation or those who weigh less than 1500 g generally have difficulty with bottle feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths/min. Providing a pacifier during gavage feedings gives positive oral stimulation and helps the infant associate the comfortable feeling of fullness with sucking. The presence of the gag reflex is important before initiating bottle feeding. Axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min are within expected limits and an indication that the infant is not having respiratory problems at that time.

A mother with diabetes has done some reading about the effects of her condition on a newborn. Which statement shows a misunderstanding that should be clarified by the nurse? a. "The red appearance of my baby's skin is due to an excessive number of red blood cells." b. "My baby will be watched closely for signs of low blood sugar, especially during the early days after birth." c. "My baby's pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy." d. "Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be."

ANS: C Rationale: Infants of diabetic mothers may have hypertrophy of the islets of Langerhans, which may cause them to produce more insulin than they need. High hematocrit values in neonates of diabetic mothers cause them to have a have a ruddy look. Neonates of diabetic mothers are prone to hypoglycemia. It is correct that some women with diabetes have very small babies because of poor blood flow through the placenta.

Which newborn should the nurse recognize as being most at risk for developing respiratory distress syndrome? a. A 35-week-gestation male baby born vaginally to a mother addicted to heroin b. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes c. A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes d. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension

ANS: C Rationale: Infants of mothers with diabetes have delayed production of surfactant, thus placing the infant at risk for respiratory distress syndrome. A 35-week-gestation male baby born vaginally to a mother addicted to heroin is at risk for withdrawal. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes is at risk for infection because of the prolonged rupture of membranes. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension is at risk for hypoxia.

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

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

What options for saying goodbye would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl A. The nurse shouldn't discuss any options at this time; there is plenty of time after the baby is born. B. "Would you like a picture taken of your baby after birth" C. "When your baby is born, would you like to see and hold her" D. "What funeral home do you want notified after the baby is born"

ANS: C Rationale: Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. Although this may be an intervention, the initial intervention should be related directly to the parents' wishes with regard to seeing or holding their dead infant. Mothers and fathers may find it helpful to see the infant after delivery. The parents' wishes should be respected. Although this information may be relevant, it is not the most appropriate option at this time. Burial arrangements can be discussed after the infant is born.

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

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

A nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. Which statement regarding this intervention is most appropriate A. Kangaroo care was adopted from classical British nursing traditions. B. This intervention helps infants with motor and CNS impairments. C. Kangaroo care helps infants interact directly with their parents and enhances their temperature regulation. D. This intervention gets infants ready for breastfeeding.

ANS: C Rationale: Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent's bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits. Kangaroo care was established in Bogota, Colombia, assists the infant in maintaining an organized state, and decreases pain perception during heelsticks. Even premature infants who are unable to suckle benefit from kangaroo care. This practice fosters increased vigor and an enhanced breastfeeding experience as the infant matures.

An infertile woman is about to begin pharmacologic treatment. As part of the regimen, she will take purified FSH (Metrodin). The nurse instructs her that this medication is administered in the form of what A. Intranasal spray B. Vaginal suppository C. Intramuscular (IM) injection D. Tablet

ANS: C Rationale: Metrodin is only administered by IM injection, and the dose may vary. An intranasal spray or a vaginal suppository are not appropriate routes for Metrodin, nor can Metrodin be given by mouth in tablet form.

When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find: a. cyanosis. b. diuresis. c. signs of pulmonary congestion. d. increased oxygenation of the tissues.

ANS: C Rationale: Mixing of the blood in the right side of the heart will cause excessive blood flow to the lungs and pulmonary congestion. Cyanosis is seen more frequently with right-to-left shunts. Diuresis is not a common finding with cardiac defects. Increased oxygenation of the tissues is not seen with this type of cardiac defect.

While instructing a couple regarding birth control, the nurse should be aware that the method called natural family planning A. Is the same as coitus interruptus, or "pulling out" B. Uses the calendar method to align the woman's cycle with the natural phases of the moon C. Is the only contraceptive practice acceptable to the Roman Catholic Church D. Relies on barrier methods during fertility phases

ANS: C Rationale: Natural family planning is the only contraceptive practice acceptable to the Roman Catholic Church. A- "Pulling out" is not the same as periodic abstinence, another name for natural family planning. B- The phases of the moon are not part of the calendar method or any method. D- Natural family planning is another name for periodic abstinence, which is the accepted way to pass safely through the fertility phases without relying on chemical or physical barriers.

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

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

When helping the mother, father, and other family members actualize the loss of the infant, nurses should: A. Use the words lost or gone rather than dead or died. B. Make sure that the family understands that it is important to name the baby. C. If the parents choose to visit with the baby, apply powder and lotion to the baby and wrap the infant in a pretty blanket. D. Set a firm time for ending the visit with the baby so the parents know when to let go.

ANS: C Rationale: Nurses must use dead and died to assist the bereaved in accepting reality. Although naming the baby can be helpful, it is important not to create the sense that parents have to name the baby. In fact, some cultural taboos and religious rules prohibit the naming of an infant who has died. Presenting the baby in a nice way stimulates the parents' senses and provides pleasant memories of their baby. Parents need different time periods with their baby to say goodbye. Nurses need to be careful not to rush the process.

Which contraceptive method provides protection against sexually transmitted diseases? A. Oral contraceptives B. Tubal ligation C. Male or female condoms D. Intrauterine device (IUD)

ANS: C Rationale: Only the barrier methods provide some protection from sexually transmitted diseases. Because latex condoms provide the best protection available, they should be used during any potential exposure to a sexually transmitted disease. A- Oral contraceptives do not provide any barrier protection against sexually transmitted diseases because they work systemically. B- A tubal ligation is considered a permanent contraceptive method but does not offer any protection against sexually transmitted diseases. The male condom is inexpensive and offers the best protection available. D- IUDs are inserted in the uterus but do not block or inhibit sexually transmitted diseases.

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

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

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

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

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

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

An infant girl is preterm and on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time. It is important for the nurse to A. Suggest that the parents visit for only a short time to reduce their anxieties. B. Reassure the parents that the baby is progressing well. C. Encourage the parents to touch her. D. Discuss the care they will give her when she comes home.

ANS: C Rationale: Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the care giving responsive to the needs of both the parents and the infant. This is the most appropriate response by the nurse. A- Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant. B- It is important to keep the parents informed about the infant's progression, but the nurse needs to be honest with the explanations. D- This is an important part of parent teaching, but it is not the most important priority during the first visit.

Chandra demonstrates BSE technique for the nurse using a practice model. She uses her fingerpads and states that when lying down, her arm should be relaxed at her side. What instructions should the nurse provide? A. "You have demonstrated BSE successfully; practice this every month." B. "Use your fingertips rather than the pads of your fingers." C. "When you are lying down, your arm should be positioned over your head." D. "Place your hand on your hip and flex your arm while lying down."

ANS: C Rationale: Placing the arm over the head when lying down helps spread the breast tissue over the chest wall, making palpation more effective. Chandra did correctly use her fingerpads, which are more sensitive than the fingertips.

For clinical purposes, the most accurate definition of preterm and postterm infants is defined as what A. Preterm: Before 34 weeks of gestation if the infant is appropriate for gestational age (AGA); before 37 weeks if the infant is small for gestational age (SGA) B. Postterm: After 40 weeks of gestation if the infant is large for gestational age (LGA); beyond 42 weeks if the infant is AGA C. Preterm: Before 37 weeks of gestation and postterm beyond 42 weeks of gestation; no matter the size for gestational age at birth D. Preterm: Before 38 to 40 weeks of gestation if the infant is SGA; postterm, beyond 40 to 42 weeks gestation if the infant is LGA

ANS: C Rationale: Preterm and postterm are strictly measures of time—before 37 weeks and beyond 42 weeks, respectively—regardless of the size for gestational age.

A woman undergoing evaluation of infertility states, "At least when we're through with all of these tests, we will know what is wrong." The nurse's best response is: a. "I know the test will identify what is wrong." b. "I'm sure that once you finish these tests, your problem will be resolved." c. "Even with diagnostic testing, infertility remains unexplained in about 20% of couples." d. "Once you've identified your problem, you may want to look at the option of adoption."

ANS: C Rationale: Problems with infertility must be approached realistically. Nurses should not make judgments or give false reassurance. Providing accurate information to the couple is the best response. The nurse should not make statements indicating that problems will be resolved, because this gives a false impression. The tests are not always definitive, so the nurse should not give false reassurance. The nurse should not offer her view or opinion but should state the facts.

Chromosome analysis is a diagnostic test that should be offered to which couple? a. Never conceived b. Has long-standing infertility c. Has had repeated pregnancy losses d. Has a normal child but has not conceived again

ANS: C Rationale: Repeated failures to carry a pregnancy to term may indicate genetic defects in the fetus that are incompatible with life. A couple who has never conceived would not be offered chromosome analysis. Long-standing infertility is not an indicator for chromosome analysis. Secondary infertility with an existing normal child would not be an indicator for chromosome analysis.

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

ANS: C Rationale: SGA infants are defined as below the tenth percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are defined as preterm. There are many causes of SGA infants.

A couple arrives for their first appointment at an infertility center. Which of the following is a noninvasive test performed during the initial diagnostic phase of testing A. Hysterosalpingogram B. Endometrial biopsy C. Sperm analysis D. Laparoscopy

ANS: C Rationale: Sperm analysis is the basic noninvasive test performed during initial diagnostic phase of testing for male infertility. Radiographic film examination allows visualization of the uterine cavity after the instillation of a radiopaque contrast medium through the cervix. The endometrial biopsy is an invasive procedure, during which a small cannula is introduced into the uterus and a portion of the endometrium is removed for histologic examination. Laparoscopy is useful to view the pelvic structures intraperitoneally and is an invasive procedure.

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

ANS: C Rationale: Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. 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. D- It does not affect the bronchioles.

Which defect is present with tetralogy of Fallot? a. Patent ductus arteriosus b. Coarctation of the aorta c. Hypertrophy of the right ventricle d. Transposition of the great arteries

ANS: C Rationale: Tetralogy of Fallot has four characteristics—ventricular septal defect, positioning of the aorta over the defect, pulmonary stenosis, and hypertrophy of the right ventricle. Patent ductus arteriosus is a result of the failure of the ductus arteriosus to close after birth. Blood flow is impeded, though this constricted area of the aorta is not a characteristic of tetralogy of Fallot. In transposition of the great arteries, the positions of the aorta and pulmonary artery are reversed.

An infant is being discharged from the NICU after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including RDS, mild bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP), requiring surgical treatment. During discharge teaching, the infant's mother asks the nurse if her baby will meet developmental milestones on time, as did her son who was born at term. What is the nurse's most appropriate response A. "Your baby will develop exactly like your first child." B. "Your baby does not appear to have any problems at this time." C. "Your baby will need to be corrected for prematurity." D. "Your baby will need to be followed very closely."

ANS: C Rationale: The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant's responses are accordingly evaluated against the norm expected for the corrected age of the infant. The baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing. Although predicting with complete accuracy the growth and development potential of each preterm infant is impossible, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. Development needs to be evaluated over time. The growth and developmental milestones are corrected for gestational age until the child is approximately years old.

Which contraceptive method is contraindicated in a woman with a history of toxic shock syndrome? A. Condom B. Spermicide C. Cervical cap D. Norplant

ANS: C Rationale: The cervical cap may increase the risk of toxic shock syndrome, because it may be left in the vagina for a prolonged period. A- The condom is worn by the man and does not stay in the vagina for prolonged periods of time. B- Spermicides dissolve slowly, but do not stay in the vagina for prolonged periods of time. D- Norplant is a systemic contractive that is implanted into the arm. Therefore, there is no risk for toxic shock due to devices left in the vagina for prolonged periods of time.

Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring and slight retractions are noted. The newborn is admitted to the neonatal intensive care unit (NICU) for closer observation, with a diagnosis of transient tachypnea (TTN). The parents are notified and become anxious because they have no idea what this means in terms of medical condition. The best action that the nurse can take at this time is to: a. refer them to the neonatologist for more information. b. tell them not to worry because their infant will be monitored closely by trained staff. c. explain to them that this often occurs following a birth but it will most likely resolve in the next 24 to 48 hours. d. tell them that they will be able to come and see their baby, which will help make them feel better.

ANS: C Rationale: The clinical diagnosis of TTN has been established, and the nurse should provide factual information relative to the clinical condition. The RN should be able to provide information to clarify the parents' concern. Telling someone not to worry usually has the opposite effect in terms of a medical crisis. Facilitating an interaction with the newborn and parents may help ease anxiety but does not address the parents' knowledge deficit.

Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant? a. Direct Coombs test based on maternal blood sample b. Indirect Coombs test based on infant cord blood sample c. Infant bilirubin level d. Maternal blood type

ANS: C Rationale: The direct Coombs test is based on cord blood drawn from the infant, whereas the indirect Coombs test is based on maternal blood samples. Although maternal blood type is important in determining whether there is a potential ABO incompatibility, the infant's bilirubin level provides the best evidence of whether the infant has hyperbilirubinemia or pathologic jaundice.

By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. Which significant symptoms will the infant display when experiencing cold stress A. Decreased respiratory rate B. Bradycardia, followed by an increased heart rate C. Mottled skin with acrocyanosis D. Increased physical activity

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

The infant has a reddish papular rash across his face. How should the nurse respond when Mrs. Ivy asks about the rash? A. Don't worry about it. This rash will go away in a couple of days. B. I see you are concerned, so I will call your pediatrician. C. A newborn rash is very common, but it will disappear soon. D. Good question. Let me take the infant's vital signs and examine him.

ANS: C Rationale: The infant rash, erythema toxicum, is very common and usually disappears by the third day of life. A- Although the rash will disappear, another response is better. B- It is not necessary to call the pediatrician to respond to the mother's question. D- Vital signs and another physical assessment is not indicated at this time.

Which action should the nurse take prior to weighing the infant? A. Provide a pacifier. B. Place a diaper on the infant. C. Place a cover on the scale. D. Keep the cap on the infant's head.

ANS: C Rationale: The infant should be weighed nude, and covering the scale prevents conductive heat loss. A- Pacifiers are not usually provided at delivery. B- A diaper may add to the infant's initial weight and should not be in place. D- Although a cap will prevent heat loss, it may add to the infant's initial weight should not be in place.

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

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

An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths/min with marked substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure. Which arterial oxygen level would indicate hypoxia A. PaO2 of 67 B. PaO2 of 89 C. PaO2 of 45 D. PaO2 of 73

ANS: C Rationale: The normal range for PaO2 for the neonate is 60 to 80 mm Hg. A laboratory value below this range would indicate hypoxia. The normal range for PaO2 for the neonate is 60 to 80 mm Hg. A laboratory value below this range would indicate hypoxia. A PaO2 of 45 is below the normal range for a normal neonate. The range for arterial oxygen pressure is 60 to 80 mm Hg. The laboratory value of PaO2 of 45 indicates hypoxia in this infant. The normal range for PaO2 for the neonate is 60 to 80 mm Hg. A laboratory value below this range would indicate hypoxia.

Large amounts of leukocytes in the seminal fluid suggest: a. inadequate fructose. b. inflammation of the testes. c. an infection of the genital tract. d. an obstruction in the vas deferens.

ANS: C Rationale: The presence of large amounts of leukocytes suggests an infection. Adequate fructose must be present to supply energy for the sperm. An inflammatory process would be diagnosed by abnormal consistency or chemical composition. If an obstruction is present, the total amount of the seminal fluid would be abnormal.

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

ANS: C Rationale: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities.

A couple comes in for an infertility workup, having attempted to get pregnant for 2 years. The woman, 37, has always had irregular menstrual cycles but is otherwise healthy. The man has fathered two children from a previous marriage and had a vasectomy reversal 2 years ago. The man has had two normal semen analyses, but the sperm seem to be clumped together. What additional test is needed? A. Testicular biopsy B. Antisperm antibodies C. FSH level D. Examination for testicular infection

ANS: C Rationale: The woman has irregular menstrual cycles. The scenario does not indicate that she has had any testing related to this irregularity. Hormone analysis is performed to assess endocrine function of the hypothalamic-pituitary-ovarian axis when menstrual cycles are absent or irregular. Determination of blood levels of prolactin, FSH, luteinizing hormone (LH), estradiol, progesterone, and thyroid hormones may be necessary to diagnose the cause of irregular menstrual cycles. A- A testicular biopsy would be indicated only in cases of azoospermia (no sperm cells) or severe oligospermia (low number of sperm cells). B- Antisperm antibodies are produced by a man against his own sperm. This is unlikely to be the case here, because the husband has already produced children. D- Examination for testicular infection should be done before semen analysis. Furthermore, infection affects spermatogenesis.

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of A. Gonorrhea B. Herpes simplex virus infection C. Congenital syphilis D. HIV

ANS: C Rationale: This rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. A- This rash is not an indication that the neonate has contracted gonorrhea. The neonate with gonorrheal infection might present with septicemia, meningitis, conjunctivitis and scalp abscesses. B- Infants affected with HSV will display growth restriction, skin lesions, microcephaly, hypertonicity and seizures. D- Typically the HIV infected neonate is asymptomatic at birth. Most often the infant will develop an opportunistic infection and rapid progression of immunodeficiency.

A couple comes in for an infertility workup, having attempted to achieve pregnancy for 2 years. The woman, 37 years of age, has always had irregular menstrual cycles but is otherwise healthy. The man has fathered two children from a previous marriage and had a vasectomy reversal 2 years ago. The man has had two normal semen analyses, but the sperm seem to be clumped together. What additional testing is needed A. Testicular biopsy B. Antisperm antibodies C. FSH level D. Examination for testicular infection

ANS: C Rationale: This scenario does not indicate that the woman has had any testing related to her irregular menstrual cycles. Hormone analysis is performed to assess endocrine function of the hypothalamic-pituitary-ovarian axis when menstrual cycles are absent or irregular. Determining the blood levels of prolactin, FSH, luteinizing hormone (LH), estradiol, progesterone, and thyroid hormones may be necessary to diagnose the cause of the woman's irregular menstrual cycles. A testicular biopsy is indicated only in cases of azoospermia (no sperm cells) or severe oligospermia (low number of sperm cells). Although unlikely to be the case because the husband has already produced children, antisperm antibodies may be produced by the man against his own sperm. Examination for testicular infection would be performed before semen analysis. Furthermore, infection would affect spermatogenesis.

A woman will be taking oral contraceptives using a 28-day pack. The nurse should advise this woman to protect against pregnancy by A. Limiting sexual contact for one cycle after starting the pill B. Using condoms and foam instead of the pill for as long as she takes an antibiotic C. Taking one pill at the same time every day D. Throwing away the pack and using a backup method if she misses two pills during week 1 of her cycle

ANS: C Rationale: To maintain adequate hormone levels for contraception and to enhance compliance, patients should take oral contraceptives at the same time each day. A- If contraceptives are to be started at any time other than during normal menses or within 3 weeks after birth or abortion, another method of contraception should be used through the first week to prevent the risk of pregnancy. Taken exactly as directed, oral contraceptives prevent ovulation, and pregnancy cannot occur. B- No strong pharmacokinetic evidence indicates a link between the use of broad-spectrum antibiotics and altered hormonal levels in oral contraceptive users. D- If the patient misses two pills during week 1, she should take two pills a day for 2 days and finish the package and use a backup method the next 7 consecutive days.

A couple is trying to cope with an infertility problem. They want to know what they can do to preserve their emotional equilibrium. The nurse's most appropriate response is A. "Tell your friends and family so that they can help you." B. "Talk only to other friends who are infertile, because only they can help." C. "Get involved with a support group. I'll give you some names." D. "Start adoption proceedings immediately, because obtaining an infant is very difficult."

ANS: C Rationale: Venting negative feelings may unburden the couple. A support group may provide a safe haven for the couple to share their experiences and gain insight from others' experiences. A- Although talking about their feelings may unburden them of negative feelings, infertility can be a major stressor that affects the couple's relationships with family and friends. B- Limiting their interactions to other infertile couples may be a beginning point for addressing psychosocial needs, but depending on where the other couple is in their own recovery process, this may or may not be of assistance to them. D- This statement is not supportive of the psychosocial needs of this couple and may be detrimental to their well-being.

A couple is attempting to cope with an infertility problem. They want to know what they can do to preserve their emotional equilibrium. What is the nurse's most appropriate response "Tell your friends and family so that they can help you." "Talk only to other friends who are infertile, because only they can help." "Get involved with a support group. I'll give you some names." "Start adoption proceedings immediately, because adopting an infant can be very difficult."

ANS: C Rationale: Venting negative feelings may unburden the couple. A support group may provide a safe haven for the couple to share their experiences and gain insight from others' experiences. Although talking about their feelings may unburden them of negative feelings, infertility can be a major stressor that affects the couple's relationships with family and friends. Limiting their interactions to other infertile couples may be a beginning point for addressing psychosocial needs. However, depending on where the other couple is in their own recovery process, limiting their interactions may not be of assistance to them. Telling the couple to start adoption proceedings immediately is not supportive of the psychosocial needs of this couple and may be detrimental to their well-being.

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

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

With regard to eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that A. Infants will stay in the NICU until they are ready to go home. B. Once discharged to home, the high risk infant should be treated like any healthy term newborn. C. Parents of high risk infants need special support and detailed contact information. D. If a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.

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

At 1 minute the infant has a heart rate of 130 beats/min, has a slow weak cry, is grimacing, and has sluggish movements with acrocyanosis. What Apgar score should the nurse assign? A. 10 B. 9 C. 6 D. 8

ANS: C Rationale: One point each is deducted for acrocyanosis (blue hands and feet), sluggish movement, a slow weak cry, and grimacing.

A baby was born 4 days ago at 34 weeks' gestation. She is receiving phototherapy as ordered by the physician for physiological jaundice. She has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability. The nurse's priority nursing action(s) is (are) to (select all that apply): a. Verify laboratory results to check for hypomagnesia. b. Verify laboratory results to check for hypoglycemia. c. Monitor the baby's temperature to check for hypothermia. d. Calculate 24-hour intake and output to check for dehydration.

ANS: C, D Rationale: There are two priority nursing interventions for hyperbilirubinemia. Hydration status is important if the newborn shows signs of dehydration such as dry skin and mucus membranes, poor intake, concentrated urine or limited urine output, and irritability. The newborn should also be kept warm while receiving phototherapy. When an infant is under phototherapy, the temperature needs to be monitored closely because the lights give off extra heat, but if the newborn is in an open crib and undressed, hypothermia may occur. Hypomagnesia and hypoglycemia are not related to phototherapy.

Nursing actions that minimize oxygen demands in the neonate include which of the following (Select all that apply.) a. Providing frequent rest breaks when feeding b. Placing neonate on back for sleeping c. Maintaining a neutral thermal environment (NTE) d. Clustering nursing care

ANS: C, D Rationale: a. A prolonged feeding session increases energy consumption that increases oxygen consumption. b. Placing the neonate on the back for sleeping has no effect on oxygen consumption. c. A decrease in environmental temperature leads to a decrease in the neonate's body temperature which leads to an increase in respiratory and heart rate that leads to an increase in oxygen consumption. d. Clustering of nursing care decreases stress which decreases oxygen requirements.

When the nurse conducts a gestational age assessment, which findings may indicate postmaturity? Select all that apply. A. Testes descended, good rugae. B. Formed ears with instant recall. C. Peeling, parchment-like skin. D. Thin with loose skin and little subcutaneous fat. E. Deep creases at the base of the toes extending to the heels.

ANS: C, D, E Rationale: C- This is one indicator of postmaturity because vernix caseosa disappears. D- Subcutaneous fat, which had been used for nourishment, is lost prior to birth. This results in the infant's low temperature. E- Postterm infants develop deep creases on the feet, extending from the base of the toes to the heels. A- This finding occurs as early as 38 weeks' gestation. B- This finding is not related to postmaturity.

The nurse realizes that a man considering a vasectomy needs further information if he says: A. "Sterility does not occur immediately after the procedure." B. "We will need to use some form of birth control for about a month afterward." C. "The procedure involves the use of local anesthesia." D. "I'll need to remain in the hospital for a few days."

ANS: D Rationale: A vasectomy takes about 20 minutes and is performed on an outpatient basis under local anesthesia.

The nurse providing care in a women's health care setting must be aware that which sexually transmitted disease (STD) can be cured? A- Herpes B- Acquired immunodeficiency syndrome (AIDS) C- Venereal warts D- Chlamydia

ANS: D Rationale: A- Because no cure is known for herpes, treatment focuses on pain relief and preventing secondary infections. B- Because no cure is known for AIDS, prevention and early detection are the main focus. C- Condylomata acuminata is caused by the human papillomavirus. No treatment eradicates the virus. D- The usual treatment for chlamydia bacterial infection is doxycycline or azithromycin. Concurrent treatment of all sexual partners is needed to prevent recurrence.

When a nurse is counseling a woman for primary dysmenorrhea, which non-pharmacologic intervention might be recommended? A. Increasing the intake of red meat and simple carbohydrates B. Reducing the intake of diuretic foods, such as peaches and asparagus C. Temporarily substituting physical activity for a sedentary lifestyle D. Using a heating pad on the abdomen to relieve cramping

ANS: D Rationale: A- Dietary changes such as eating less red meat may be recommended for women experiencing dysmenorrhea. B- Increasing the intake of diuretics, including natural diuretics such as asparagus, cranberry juice, peaches, parsley, and watermelon may help ease the symptoms associated with dysmenorrhea. C- Exercise has been found to help relieve menstrual discomfort through increased vasodilation and subsequent decreased ischemia. D- Heat minimizes cramping by increasing vasodilation and muscle relaxation and minimizing uterine ischemia.

A woman with a history of a cystocele should contact the physician if she experiences A. Involuntary loss of urine when she coughs B. Constipation C. Backache D. Urinary frequency and burning

ANS: D Rationale: A- Involuntary loss of urine during coughing is stress incontinence and is not an emergency. B- Constipation may be a problem with rectoceles. C- Back pain is a symptom of uterine prolapse. D- Urinary frequency and burning are symptoms of cystitis, a common problem associated with cystocele.

Which statement by a woman diagnosed with premenstrual syndrome indicates that further health teaching is needed? A- "I will not eat chips or pickles." B- "Coffee and chocolate can make me more irritable and nervous." C- "Drinking alcohol makes me more depressed." D- "I'll eat only three meals per day."

ANS: D Rationale: A- Less intake of salty foods helps decrease fluid retention. B- Caffeine consumption increases irritability, insomnia, anxiety, and nervousness. C- Alcohol consumption aggravates depression. D- The woman should be encouraged to eat six small meals a day to decrease risk of hypoglycemia.

Nafarelin (Synarel) is currently used as a treatment for mild to severe endometriosis. The nurse should tell the woman taking this medication that the drug A. Stimulates the secretion of gonadotropin-releasing hormone (GnRH), thereby stimulating ovarian activity B. Should be sprayed into one nostril every other day C. Should be injected into subcutaneous tissue BID D. Can cause her to experience some hot flashes and vaginal dryness

ANS: D Rationale: A- Nafarelin is a GnRH agonist that suppresses the secretion of gonadotrophin-releasing hormone. B- Nafarelin is administered twice daily by nasal spray. C- Nafarelin is administered intranasally. D- Nafarelin is a GnRH agonist, and its side effects are similar to those of menopause. The hypoestrogenism effect results in hot flashes and vaginal dryness.

The nurse who is teaching a group of women about breast cancer should tell the women that A. Risk factors identify almost all women who will develop breast cancer. B. African-American women have a higher rate of breast cancer. C. One in 10 women in the United States will develop breast cancer in her lifetime. D. The exact cause of breast cancer is unknown.

ANS: D Rationale: A- Risk factors help identify a small percentage of women in whom breast cancer eventually will develop. B- Caucasian women have a higher incidence of breast cancer; however, African-American women have a higher rate of dying of breast cancer after they are diagnosed. C- One in eight women in the United States will develop breast cancer in her lifetime. D- The exact cause of breast cancer in unknown.

Adjuvant treatment with tamoxifen may be recommended for patients with breast cancer if the tumor is A. Smaller than 5 cm B. Located in the upper outer quadrant only C. Contained only in the breast D. Estrogen receptive

ANS: D Rationale: A- Tamoxifen is used depending on age, stage, and hormone receptor status, not size. B- Location of the cancer does not determine the usefulness of tamoxifen. C- Stage of the cancer is a consideration, but more important is its sensitivity to estrogen. D- Tamoxifen is antiestrogen therapy for tumors stimulated by estrogen.

Which piece of the usual equipment setup for a pelvic examination is omitted with a Pap test? A. Gloves and eye protectors B. Speculum C. Fixative agent D. Lubricant

ANS: D Rationale: A- The examiner should always use Standard Precautions. B- A speculum is needed to see the cervix. C- A fixative agent is applied to the slide to prevent drying or disruption of the specimen. D- Lubricants interfere with the accuracy of the cytology report.

While evaluating a patient for osteoporosis, the nurse should be aware of what risk factor? A. African-American race B. Low protein intake C. Obesity D. Cigarette smoking

ANS: D Rationale: A- Women at risk for osteoporosis are likely to be Caucasian or Asian. B- Inadequate calcium intake is a risk factor for osteoporosis. C- Women at risk for osteoporosis are likely to be small boned and thin. Obese women have higher estrogen levels as a result of the conversion of androgens in the adipose tissue. Mechanical stress from extra weight also helps preserve bone mass. D- Smoking is associated with earlier and greater bone loss and decreased estrogen production.

The nurse warns that the effectiveness of oral contraceptives is decreased in women who are taking: A. antihistamines for seasonal allergies. B. iron preparations for treatment of anemia. C. appetite suppressants for weight reduction. D. anticonvulsants for treatment of epilepsy.

ANS: D Rationale: Anticonvulsants decrease the effectiveness of oral contraceptives.

The nurse explains that the postterm neonate is especially at risk for cold stress due to: A. inadequate vernix caseosa. B. hypoxia from a deteriorated placenta. C. polycythemia. D. fat stores have been used in utero for nourishment.

ANS: D Rationale: Fat stores have been used in utero for nourishment during the extended pregnancy.

The mother of a 4-month-old infant, born prematurely, asks the nurse if her daughter will always be small for her age. An appropriate nursing response would be: A. "Preterm infants usually remain smaller than term infants throughout childhood." B. "Your daughter will be the same size as other children by the time she is 1-year-old." C. "Prematurity is associated with short stature but does not affect weight gain." D. "It takes about two years for the preterm infant to catch up to a full-term infant."

ANS: D Rationale: In the absence of severe birth defects and complications, the growth rate of the preterm newborn nears that of the term infant by about the second year.

The nurse recognizes symptoms of cold stress in a preterm infant as: A. tremors and weak cry. B. plasma glucose level <40 mg/dL. C. warm skin with low core temperature. D. increased respiratory rate and periods of apnea.

ANS: D Rationale: Signs of cold stress include increased respiratory rate with periods of apnea, decreased skin temperature, bradycardia, mottling of skin, and lethargy.

The nurse explains that when a preterm delivery is anticipated, fetal lung maturity can be accelerated before delivery by the administration of: A. prostaglandins. B. oxytocin. C. magnesium sulfate. D. corticosteroids.

ANS: D Rationale: Surfactant production can be increased by administering corticosteroids to the mother before delivery.

A 25-year-old woman has a family history of breast cancer. The nurse reviews the procedure for breast self-examination (BSE) and tells her that the best time for a woman to perform a breast self-examination is: A. a few days before her period. B. during her menstrual period. C. on the last day of menstrual flow. D. one week after the beginning of her period.

ANS: D Rationale: The best time for BSE is 1 week after the beginning of the menstrual period.

The nurse is caring for an infant born at 35 weeks of gestation. A physical characteristic that the nurse might expect this infant to exhibit is: A. thin, long extremities. B. large genitals for its size. C. minimal vernix caseosa. D. loose, transparent skin.

ANS: D Rationale: The growth and development of the fetus are abruptly halted by a preterm birth. One of the characteristics of the preterm infant is skin that is loose and transparent.

The nurse tells a woman ho is trying to conceive to check her cervical mucus for changes. A few days before ovulation, the cervical mucus is: A. cloudy and tacky. B. scant and thick. C. thin and white. D. clear and slippery.

ANS: D Rationale: Within a few days of ovulation, cervical mucus will become clear and slippery to aid the passage of sperm into the cervix.

The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist as soon as possible a. 1-day-old, HR 170 bpm, crying b. 2-day-old, T 98.9°F, slightly jaundice c. 3-day-old, breastfeeding q 2 h, rooting d. 4-day-old, RR 70 rpm, dusky coloring

ANS: D Rationale: a. A slight tachycardia—170 bpm—is normal when a baby is crying. b. Slight jaundice on day 2 is within normal limits. c. It is normal for a breastfed baby to feed every 2 hours. d. A dusky skin color is abnormal in any neonate, whether or not the respiration rate is normal, although this baby is also slightly tachypneic.

A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia, and tremors and is extremely irritable. Based on these observations, the nurse suspects which of the following a. Hypoglycemia b. Hypercalcemia c. Cold stress d. Neonatal withdrawal

ANS: D Rationale: a. Signs and symptoms of hypoglycemia are jitteriness, hypotonia, irritability, apnea, lethargy, and temperature instability, but not nasal congestion. b. Signs and symptoms of hypercalcemia are vomiting, constipation, and cardiac arrhythmias. c. Signs and symptoms of cold stress are decreased temperature, cool skin, lethargy, pallor, tachypnea, hypotonia, jitteriness, weak cry, and grunting. d. These are common signs and symptoms of neonatal withdrawal.

The NICU nurse is providing care to a 35-week-old infant who has been in the neonatal intensive care unit for the past 3 weeks. His mother wants to breastfeed her son naturally but is currently pumping her breasts to obtain milk. His mother is concerned that she is only producing about 1 ounce of milk every 3 hours. The nurse's best response to the patient's mother would be: a. "Pumping is hard work and you are doing very well. It is good to get about 1 ounce of milk every 3 hours." b. "Natural breastfeeding will be a challenging goal for your baby. Beginning today, you will need to begin to pump your breasts more often." c. "Your baby will not be ready to go home for at least another week. You can begin to pump more often in the next few days in preparation for taking your child home." d. "You have been working hard to give your son your breast milk. We can map out a schedule to help you begin today to pump more often to prepare to take your baby home."

ANS: D Rationale: a. This is correct information but does not assist the women in producing more milk. b. This does not provide her with a plan to increase her milk. c. This does not provide her with a plan. d. The mother should be praised for her efforts to breastfeed and encouraged to continue to pump her milk. A determined schedule for pumping the milk will help the mother keep her milk flow steady and provide enough nutrients for the infant after discharge.

Although remarkable developments have occurred in reproductive medicine, assisted reproductive therapies are associated with numerous legal and ethical issues. Nurses can provide accurate information about the risks and benefits of treatment alternatives to enable couples to make informed decisions about their choice of treatment. Which concern is unnecessary for the nurse to address before treatment A. Risks of multiple gestation B. Whether or how to disclose the facts of conception to offspring C. Freezing embryos for later use D. Financial ability to cover the cost of treatment

ANS: D Rationale: Although the method of payment is important, obtaining this information is not the responsibility of the nurse. Many states have mandated some form of insurance to assist couples with coverage for infertility. Multiple gestation is a risk of treatment of which the couple needs to be aware. To minimize the chance of multiple gestation, generally only three or fewer embryos are transferred. The couple should be informed that multifetal reduction may be needed. Nurses can provide anticipatory guidance on this matter. Depending on the therapy chosen, donor oocytes, sperm, embryos, or a surrogate mother may be needed. Couples who have excess embryos frozen for later transfer must be fully informed before consenting to the procedure. A decision must be made regarding the disposal of embryos in the event of death or divorce or if the couple no longer wants the embryos at a future time.

A client has been diagnosed with an incompetent cervix. What treatment option will be incorporated into the plan of care? a. Bed rest throughout the pregnancy b. Wait and see approach to determine if the client goes into preterm labor c. Preparation for cerclage procedure at 32 weeks' gestation d. More frequent ultrasounds to assess progression of pregnancy

ANS: D Rationale: An incompetent cervix would place the client in a high-risk category, and more frequent ultrasound monitoring would be included. Although bed rest may be ordered, there is conflicting evidence about the merits of this intervention. However, it is unlikely that it would be ordered for the duration of the pregnancy. An incompetent cervix is a clinical abnormality, so the standard of care requires appropriate surgical intervention. A cerclage procedure is typically done much earlier in the pregnancy period.

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

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

A nurse assesses that a 3-day-old neonate who was born at 34 weeks' gestation has abdominal distention and vomiting. These assessment findings are most likely related to: a. Respiratory Distress Syndrome (RDS) b. Bronchopulmonary Dysplasia (BPD) c. Periventricular Hemorrhage (PVH) d. Necrotizing Enterocolitis (NEC)

ANS: D Rationale: Assessment findings related to NEC include abdominal distention, bloody stools, abdominal distention, vomiting, and increased gastric residual. These signs and symptoms are related to the premature neonate's inability to fully digest stomach contents and limitation in absorptive function.

The nurse should be alert to a blood group incompatibility if: a. both mother and infant are O-positive. b. mother is A-positive and infant is A-negative. c. mother is O-positive and infant is B-negative. d. mother is B-positive and infant is O-negative.

ANS: D Rationale: Blood group incompatibilities occur because O-positive mothers have natural antibodies to type A or B blood. When mother and infant both have blood group O or A, no incompatibility exists. The mother with blood group B does not have any antibodies to group O.

The infant of a mother with diabetes is hypoglycemic. What type of feeding should be instituted first? A. Glucose water in a bottle B. D5W intravenously C. Formula via nasogastric tube D. Breast milk

ANS: D Rationale: Breast milk is metabolized more slowly and provides longer normal glucose levels. A- High levels of dextrose correct the hypoglycemia but will stimulate the production of more insulin. B- Oral feedings are tried first; intravenous lines should be a later choice if the hypoglycemia continues. C- Formula does provide longer normal glucose levels but would be administered via bottle, not by tube feeding.

Which condition might premature infants who exhibit 5 to 10 seconds of respiratory pauses, followed by 10 to 15 seconds of compensatory rapid respiration, be experiencing A. Suffering from sleep or wakeful apnea B. Experiencing severe swings in blood pressure C. Trying to maintain a neutral thermal environment D. Breathing in a respiratory pattern common to premature infants

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

A man smokes two packs of cigarettes a day. He wants to know if smoking is contributing to the difficulty he and his wife are having getting pregnant. Which guidance should the nurse provide A. "Your sperm count seems to be okay in the first semen analysis." B. "Only marijuana cigarettes affect sperm count." C. "Although smoking has no effect on sperm count, it can give you lung cancer." D. "Smoking can reduce the quality of your sperm."

ANS: D Rationale: Cigarette smoking has detrimental effects on sperm and has been associated with abnormal sperm, a decreased number of sperm, and chromosomal damage. The nurse may suggest a smoking cessation program to increase the fertility of the male partner. Sperm counts vary from day to day and are dependent on emotional and physical status and sexual activity. Therefore, a single analysis may be inconclusive. A minimum of two analyses must be performed several weeks apart to assess male fertility. Marijuana use may depress the number and motility of sperm. Smoking is indeed a causative agent for lung cancer.

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

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

Which clinical findings would alert the nurse that the neonate is expressing pain A. Low-pitched crying; tachycardia; eyelids open wide B. Cry face; flaccid limbs; closed mouth C. High-pitched, shrill cry; withdrawal; change in heart rate D. Cry face; eyes squeezed; increase in blood pressure

ANS: D Rationale: Crying and an increased heart rate are manifestations indicative of pain in the neonate. Typically, infants tightly close their eyes when in pain, not open them wide. In addition, infants may display a rigid posture with the mouth open and may also withdraw limbs and become tachycardic with pain. A high-pitched, shrill cry is associated with genetic or neurologic anomalies.

Compared to the term infant, the preterm infant has A. Few blood vessels visible through the skin B. More subcutaneous fat C. Well-developed flexor muscles D. Greater surface area in proportion to weight

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

When providing an infant with a gavage feeding, which infant assessment should be documented each time A. Abdominal circumference after the feeding B. Heart rate and respirations before feeding C. Suck and swallow coordination D. Response to the feeding

ANS: D Rationale: Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Abdominal circumference is not measured after a gavage feeding. Although vital signs may be obtained before feeding, the infant's response to the feeding is more important. Similarly, some older infants may be learning to suck; the most important factor to document would still be the infant's response to the feeding, including the attempts to suck.

It is important for the nurse to remember that when performing neonatal resuscitation, the priority action should be to A. Suction the mouth and nose. B. Stimulate the infant by rubbing the back. C. Perform the Apgar test. D. Dry the infant and position the head.

ANS: D Rationale: Drying the infant to prevent heat loss is the first action. It is followed by positioning to open the airway. A- The neonate is not breathing, so drying the neonate to prevent heat loss and positioning the neonate takes priority over the suctioning. B- Stimulating the infant is a step in the process, but not the first action. C- The Apgar can be delayed until steps have been taken to initiate breathing. By assessing the lack of breathing, some of the Apgar has already been completed.

What bacterial infection is definitely decreasing because of effective drug treatment A. Escherichia coli infection B. Tuberculosis C. Candidiasis D. Group B streptococcal infection

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

The infant of a diabetic mother is hypoglycemic. Which type of feeding should be instituted first? a. Glucose water b. D5W intravenously c. Formula via nasogastric tube d. Small amount of glucose water followed by formula or breast milk

ANS: D Rationale: Glucose followed by formula or breast milk is metabolized more slowly and results in longer normal glucose levels. High levels of dextrose correct the hypoglycemia but will stimulate the production of more insulin. Oral feedings are tried first; intravenous lines would be a later choice if the hypoglycemia continues. Formula results in longer normal glucose levels but would be administered via bottle, not by tube feeding.

Which woman is a safe candidate for the use of oral contraceptives? A. 39-year-old with a history of thrombophlebitis B. 16-year-old with a benign liver tumor C. 20-year-old who suspects she may be pregnant D. 43-year-old who does not smoke cigarettes

ANS: D Rationale: Heavy cigarette smoking is a contraindication. A- Oral contraceptives are contraindicated with a history of thrombophlebitis. B- Liver tumors, benign or malignant, preclude the use of oral contraceptives. C- Pregnancy is a contraindication.

Newborns whose mothers are substance abusers frequently have which behaviors? a. Hypothermia, decreased muscle tone, and weak sucking reflex b. Excessive sleep, weak cry, and diminished grasp reflex c. Circumoral cyanosis, hyperactive Babinski reflex, and constipation d. Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding

ANS: D Rationale: Infants exposed to drugs in utero often have poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behaviors. They will have hyperactive muscle tone, a high-pitched cry, and diarrhea, not constipation.

A mother with diabetes has done some reading about the effects of the condition on her newborn. Which statement shows a misunderstanding that should be clarified by the nurse? A. "Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be." B. "My baby will be watched closely for signs of low blood sugar, especially during the early days after birth." C. "The red appearance of my baby's skin is due to an excessive number of red blood cells." D. "My baby's pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy."

ANS: D Rationale: Infants of diabetic mothers may have hypertrophy of the islets of Langerhans, which may cause them to produce more insulin than they need. A- This is a correct statement. B- Neonates of diabetic mothers are prone to hypoglycemia. C- High hematocrits in neonates of diabetic mothers have a ruddy look.

Informed consent concerning contraceptive use is important because some of the methods A. Are invasive procedures that require hospitalization B. Require a surgical procedure to insert C. May not be reliable D. Have potentially dangerous side effects

ANS: D Rationale: It is important for couples to be aware of potential side effects so they can make an informed decision about the use of contraceptives. A- The only contraceptive method that requires hospitalization is sterilization. B- The only surgical procedure used would be for permanent sterilization. C- Some have more effective rates, and this should be included in the teaching.

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

ANS: D Rationale: Low body temperature indicates that additional calories are needed to maintain body temperature. The hematocrit is within the expected range for a newborn. A weight gain of about 20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day.

The nurse is preparing a community education program on preventive health care for women. The nurse plans to tell the women attending the program that a screening test common in women's health care is: A. breast examination by a health professional. B. breast self-examination. C. breast biopsy. D. mammography.

ANS: D Rationale: Mammography is a screening test used to detect breast cancer.

A woman who is undergoing infertility testing states, "My husband won't discuss this with me. I don't think he cares about or wants a baby." The nurse's best response is: a. "You should confront him about this." b. "He probably doesn't understand your concern." c. "Men are sometimes less eager to have children." d. "It may be harder for him to express his feelings."

ANS: D Rationale: Men often internalize their feelings, which may appear to women as lack of concern or interest. Suggesting that the woman confront her husband suggests that the woman is at fault and not communicating with her husband. "He probably doesn't understand your concern" does not explain to the woman why her husband won't discuss the problem; it passes judgment on the husband. "Men are sometimes less eager to have children" does not allow the woman to express her feelings; it offers the nurse's opinion, which is not appropriate.

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

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

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

ANS: D Rationale: Parents should be taught the signs of overstimulation so they will learn to adapt their care to the needs of their infant. Grouping care activities may understimulate the infant during those long periods and overtire the infant during the procedures. Keeping charts on the incubator and giving the report in front of the incubator may cause overstimulation.

Male fertility declines slowly after age 40 years; however, no cessation of sperm production analogous to menopause in women occurs in men. What condition is not associated with advanced paternal age A. Autosomal dominant disorder B. Schizophrenia C. Autism spectrum disorder D. Down syndrome

ANS: D Rationale: Paternal age older than 40 years is associated with an increased risk for autosomal dominant disorder, schizophrenia, and autism spectrum disorder in their offspring. Although Down syndrome can occur in any pregnancy, it is often associated with advanced maternal age.

On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they may hold their infant during his next gavage feeding. Considering that this newborn is physiologically stable, what response should the nurse provide A. "Parents are not allowed to hold their infants who are dependent on oxygen." B. "You may only hold your baby's hand during the feeding." C. "Feedings cause more physiologic stress; therefore, the baby must be closely monitored. I don't think you should hold the baby." D. "You may hold your baby during the feeding."

ANS: D Rationale: Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the caregiving responsive to the needs of both the parents and the infant. Allowing the parents to hold their baby is the most appropriate response by the nurse. Parental interaction by holding should be encouraged during gavage feedings; nasal cannula oxygen therapy allows for easy feedings and psychosocial interactions. The parent can swaddle the infant or provide kangaroo care while gavage feeding their infant. Both swaddling and kangaroo care during feedings provide positive interactions for the infant and help the infant associate feedings with positive interactions.

HIV may be perinatally transmitted A. Only in the third trimester from the maternal circulation B. From the use of unsterile instruments C. Only through the ingestion of amniotic fluid D. Through the ingestion of breast milk from an infected mother

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

When evaluating the preterm infant, the nurse understands that compared with the term infant, what information is important for the nurse to understand A. Few blood vessels visible through the skin B. More subcutaneous fat C. Well-developed flexor muscles D. Greater surface area in proportion to weight

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

In comparison with the term infant, the preterm infant has: A. More subcutaneous fat. B. Well-developed flexor muscles C. Few blood vessels visible through the skin. D. Greater surface area in proportion to weight.

ANS: D Rationale: Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat, well-developed flexor muscles, and few blood vessels visible through the skin are more characteristic of a term infant.

A newly married woman states, "My friend told me I would never have a baby because I had pelvic inflammatory disease when I was younger. I don't understand how that can affect whether or not I get pregnant." The nurse's best response is: a. "Your friend may be right. The disease may affect your ability to conceive." b. "Pelvic inflammatory disease may damage the ovaries and prevent ovulation." c. "Your friend has been misinformed. Fallopian tube damage occurs only following gonorrhea." d. "Infection may cause scarring and obstruction of the fallopian tubes, which can prevent the fertilized egg from reaching the uterus."

ANS: D Rationale: Providing the client with accurate complete information is the best response. Pelvic inflammatory disease produces scarring and obstruction of the fallopian tube if the infection is not treated. It does not occur following gonorrhea.

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

ANS: D Rationale: SGA infants are defined as below the 10th percentile in growth when compared with other infants of the same gestational age. 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.

Which situation best describes secondary infertility in a couple? a. Never conceived b. Had repeated spontaneous abortions c. Not conceived after 1 year of unprotected intercourse d. Has one child but cannot conceive a second time

ANS: D Rationale: Secondary infertility occurs in couples who have conceived before but are unable to conceive again. Primary infertility occurs when a couple has never conceived or who has not conceived after 1 year of unprotected intercourse. Repeated spontaneous abortions are considered primary infertility.

Which statement regarding gamete intrafallopian transfer (GIFT) is most accurate A. Semen is collected after laparoscopy. B. Women must have two normal fallopian tubes. C. Ovulation spontaneously occurs. D. Ova and sperm are transferred to one tube.

ANS: D Rationale: Similar to in vitro fertilization (IVF), GIFT requires the woman to have at least one normal tube. Ovulation is induced, and the oocytes are aspirated during laparoscopy. Semen is collected before laparoscopy. The ova and sperm are then transferred to one uterine tube, permitting natural fertilization and cleavage.

The nurse caring for a family during a loss might notice that survival guilt sometimes is felt at the death of an infant by the child's: A. Siblings. B. Mother. C. Father. D. Grandparents.

ANS: D Rationale: Survival guilt is most often felt by grandparents, not siblings, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not. Survival guilt sometimes is most often felt by grandparents, not the mother, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not. Survival guilt sometimes is most often felt by grandparents, rather than the father, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not. Survival guilt sometimes is felt by grandparents, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not.

When attempting to diagnose and treat developmental dysplasia of the hip (DDH), the nurse should: A. Be able to perform the Ortolani and Barlow tests. B. Teach double or triple diapering for added support. C. Explain to the parents the need for serial casting. D. Carefully monitor infants for DDH at follow-up visits.

ANS: D Rationale: The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. Double or triple diapering is not recommended because it promotes hip extension, thus worsening the problem. Serial casting is done for clubfeet, not DDH. Because DDH often is not detected at birth, infants should be monitored carefully at follow-up visits.

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

ANS: D Rationale: The SGA infant has poor glycogen stores and is subject to hypoglycemia. 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.

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

ANS: D Rationale: The SGA infant has poor glycogen stores and is subject to hypoglycemia. Promoting bonding is a concern for all infants and is not specific for SGA infants. Dehydration is a concern for all infants and is not specific for SGA infants. Respiratory distress syndrome is seen in preterm infants.

A woman currently uses a diaphragm and spermicide for contraception. She asks the nurse what the major differences are between the cervical cap and diaphragm. The nurse's most appropriate response is A. "No spermicide is used with the cervical cap, so it's less messy." B. "The diaphragm can be left in place longer after intercourse." C. "Repeated intercourse with the diaphragm is more convenient." D. "The cervical cap can safely be used for repeated acts of intercourse without adding more spermicide later."

ANS: D Rationale: The cervical cap can be inserted hours before sexual intercourse without the need for additional spermicide later. No additional spermicide is required for repeated acts of intercourse. A- Spermicide should be used inside the cap as an additional chemical barrier. B- The cervical cap should remain in place for 6 hours after the last act of intercourse. C- Repeated intercourse with the cervical cap is more convenient, because no additional spermicide is needed.

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

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

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

ANS: D Rationale: The nurse needs to know that decreased immune functioning increases the 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.

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

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

After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die" The nurse's best response to this woman is: A. "That's an old wives' tale; lots of women are around paint during pregnancy, and this doesn't happen to them." B. "That's not likely. Paint is associated with elevated pediatric lead levels." C. Silence. D. "I can understand your need to find an answer to what caused this. What else are you thinking about"

ANS: D Rationale: The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. In addition, trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feeling does not help the process of grief. Trying to give bereaved parents answers when no clear answers exist does not help the grief process. In addition, this response probably would increase the mother's feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. The nurse should encourage the mother to express her ideas. This statement is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving.

On the second day, the nurse assesses the infant for jaundice. Which factor should alert the nurse to assess for the risk of jaundice? A. Post-mature gestational age. B. Providing formula feedings C. Passage of meconium stools. D. Trauma at birth.

ANS: D Rationale: The presence of a cephalhematoma indicates trauma during birth and bleeding has occurred. As the red blood cells break down, increased amounts of bilirubin are released into the general circulation. A- Post-maturity does not necessarily contribute to jaundice. B- Diminished frequency of feeding may contribute to jaundice, but not formula feeding itself. C- Passage of meconium stools decreases the risk for jaundice.

To promote family bonding, which part of infant care should the nurse delay? A. Giving Vitamin K. B. Securing ID bands. C. Providing cord care. D. Giving eye prophylaxis.

ANS: D Rationale: The presence of eye ointment or drops can interfere with eye-to-eye parent/infant interaction. Giving eye prophylaxis can be delayed for up to 2 hours after birth. A- This injection can be delayed, but another answer is best. B- Although this is a safety measure, it does not interfere with bonding. C- This care is usually delayed until after the first bath, but it does not interfere with bonding.

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

ANS: D Rationale: The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. A- A differential diagnosis can be difficult because signs of sepsis are similar to noninfectious problems such as anemia and hypoglycemia. B- Phrenic nerve injury is usually the result of traction on the neck and arm during birth and is not applicable to this situation. C- The earliest signs of sepsis are characterized by lack of specificity—i.e., lethargy, poor feeding, and irritability—not respiratory distress syndrome.

Which combination of expressing pain could be demonstrated in a neonate? A. Low-pitched crying, tachycardia, eyelids open wide B. Cry face, flaccid limbs, closed mouth C. High-pitched, shrill cry, withdrawal, change in heart rate D. Cry face, eye squeeze, increase in blood pressure

ANS: D Rationale: These manifestations are indicative of pain in the neonate. 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.

The nurse instructs the family about feeding the infant. The mother asks how often the infant should be burped. Which is the best response by the nurse for how often the infant should be burped? A. It is a good time to burp the infant when he stops sucking. B. The infant should be burped before and after each feeding. C. Burping should be done when the infant begins to get sleepy. D. He needs burping at the start of the feeding and after each ounce (30 mL) of formula.

ANS: D Rationale: This gives specific guidelines to the parents.

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

ANS: D Rationale: This infant is macrosomic (over 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. A- Macrosomic infants are at high risk for hypoglycemia after birth and need to be observed closely. This can be achieved in the mother's room with nursing interventions, depending on the condition of the fetus. It may be more appropriate for observation to occur in the nursery. B- Macrosomic infants are at high risk for hypoglycemia after birth and need to be observed closely. Observation may occur in the nursery or in the mother's room, depending on the condition of the fetus. C- Regardless of gestational age, this infant is macrosomic. Macrosomia is defined as fetal weight over 4000 g. Hypoglycemia affects many macrosomic infants. Blood glucose levels should be observed closely.

When Mrs. Ivy finishes feeding the infant, she checks the diaper and it is dry. Mr. Ivy expresses concern that he thinks the infant is becoming dehydrated. In view of Mr. Ivy's concern, how should the nurse respond? A. The infant should have at least 4 to 5 voids per day. B. The infant should have urine that appears dark orange. C. The infant should have pink-tinged urine. D. The infant should have 1 or 2 voids per day.

ANS: D Rationale: To maintain fluid balance, infants in the first 3 to 5 days of life should have 1 or 2 voids per day. A- This is not true for a newborn. B- The urine should be yellow in color. C- The infant should have pink-tinged urine.

In an infant with cyanotic cardiac anomaly, the nurse should expect to see: a. feedings taken eagerly. b. a consistent and rapid weight gain. c. a decrease in the heart rate with activity. d. little to no improvement in color with oxygen administration.

ANS: D Rationale: With a cyanotic cardiac defect, the shunting of blood is right to left, so there is little if any improvement in the oxygenation of the blood with the administration of oxygen. Infants with cardiac anomalies are usually difficult feeders, have difficulty gaining weight, and have an increase in the heart rate with activity.

Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority? A. Start an intravenous line with D5W. B. Notify the clinician stat. C. Document the event in the nurses' notes. D. Test for blood glucose level.

ANS: D Rationale: These symptoms are signs of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain, but it is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer. A- It is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer. B- Test blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results. C- Documentation can wait until the infant has been tested and treated if a problem is present.

Three million unintended pregnancies occur each year in the United States. A Healthy People 2020 goal is to increase the number of intended pregnancies to 70%. Is this statement true or false?

ANS: FALSE Rationale: A Healthy People 2020 goal is to increase the number of pregnancies that are intended to 56% from a baseline of 51%. Unintended pregnancies are those that are unwanted or occur in women who want to become pregnant, but not until a later date. These pregnancies may result in economic hardship, health problems, or interference with educational or career plans. Many of these occur in women who are using contraceptives incorrectly. The nurse plays a vital role as counselor and educator.

The nurse understands that further health teaching is necessary when her young patient who has just had an abortion states, "I guess I'll have to wear a tampon for the next week." Is this statement true or false?

ANS: TRUE Rationale: Bleeding and cramping are normal after the procedure and will last for 1 to 2 weeks. Sanitary pads should be used rather than a tampon for the first week after an abortion to prevent infection. Other necessary health teaching that should be done includes the following: no intercourse for the first week; no douching for the first week, or perhaps not at all; temperature evaluation twice per day to identify infection; follow-up appointment in 2 weeks; and no strenuous work for a few days.

Women in the U.S. are now more likely to die of cardiac disease than all cancers combined. Is this statement true or false?

ANS: TRUE Rationale: Heart disease is now the leading cause of death for women in the United States, killing 26% of women who died in 2006. Almost twice as many American women die of heart disease or stroke than any form of cancer including breast cancer.

Breast milk is best source of food almost all infants and especially for preterm infants. Breast-feeding has numerous benefits for the preterm infant. One of the most important of these benefits is reducing the incidence of necrotizing enterocolitis (NEC). Is this statement true or false?

ANS: TRUE Rationale: Is important for the nurse to explain to parents that the immunologic benefits of breast milk are particularly important to the preterm infant who did not receive passive immunity during fetal life. Human milk may stimulate the immune system and promotes gastrointestinal maturation. Breast milk provides protection against infection and decreases the incidence of NEC in the premature infant.

Conception in the first cycle of treatment for infertility has a success rate of 15% to 25%, falling as subsequent attempts are made. Is this statement true or false?

ANS: TRUE Rationale: Only 3% of couples conceive in the 12th cycle of treatment. Couples are often in a hurry for definitive therapy; however, a thorough assessment of the problem is essential for effective and financially sound treatment.

Persistent pulmonary hypertension of the newborn (PPHN) is a condition in which the vascular resistance of the lungs does not decrease after birth and consequently normal changes to neonatal circulation are impaired. The neonatal nurse knows that there are numerous underlying causes for this condition, one of which is maternal use of nonsteroidal antiinflammatory drugs (NSAIDs). Is this statement true or false?

ANS: TRUE Rationale: Other probable causes of PPHN include abnormal lung development, the use of aspirin, or reasons unknown. PPHN is often associated with meconium aspiration, sepsis, asphyxia, polycythemia, diaphragmatic hernia, diabetes, and respiratory distress syndrome. Nursing care is similar to that of other infants with severe respiratory disease.

A lack of O2 and an increase in CO2 in the blood is known as __________. This condition in the neonate may occur while in utero, at birth, or later.

ANS: asphyxia Rationale: Complications during pregnancy, labor, or birth increase the infant's risk for asphyxia. If the mother receives narcotics shortly before birth, the infant may be too physiologically depressed to breathe spontaneously. Resuscitative measures must be initiated immediately to prevent permanent brain damage or death.

Approximately 30% of preterm infants weighing less than 1500 g develop bleeding around and into the ventricles of the brain. This condition is known as _______________.

ANS: intraventricular hemorrhage Rationale: Rupture of the fragile blood vessels in the germinal matrix, located around the ventricles of the brain results in germinal matrix bleeding or intraventricular hemorrhage. It is associated with increased or decreased blood pressure, asphyxia, mechanical ventilation, and increased or fluctuating cerebral blood flow.

______________, a synthetic opiate, has been the therapy of choice for heroin addiction. It crosses the placenta, leading to significant neonatal abstinence syndrome after birth.

ANS: methadone Rationale: Methadone withdrawal is more severe and prolonged than withdrawal from heroin. Signs of withdrawal include tremors, irritability, hypertonicity, vomiting, nasal stuffiness and disturbed sleep patterns. This infant is also at increased risk for SIDS.

The ____________ is one method used to evaluate the adequacy of coital technique, cervical mucous, sperm quality and penetration.

ANS: postcoital test Rationale: This test is performed within several hours after ejaculation of semen into the vagina and is used to study a number of factors affecting fertility.

The nurse next prepares to administer the erythromycin ointment (Ilotycin ophthalmic ointment). Which approach should the nurse use to administer the ointment? A. Apply ointment across the closed eyelids and rub the eye gently. B. Open the eye using two fingers and apply ointment to the upper lid. C. Apply gentle pressure to the inner canthus after applying ointment to eyes. D. Cover entire lower conjunctiva with ointment after gently retracting the lid.

Rationale: D- To instill medication, the thumb and forefinger are used to open the eye. A ribbon of ointment is applied in the lower conjunctiva from the inner to the outer canthus. A- Typically the infant's eyes are tightly closed and ointment may not reach inside the eyelid as required. B- This is not the correct technique for administering Ilotycin opthalmic ointment. C- This is a technique for eye drops, not ointment.