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A patient asks the nurse why there is corn syrup added to infant formulas. What is the nurse's best response? 1. "To provide sufficient carbohydrates to the baby." 2. "To provide sufficient vitamins to the baby." 3. "To provide sufficient proteins to the baby." 4. "To provide sufficient minerals to the baby."

1. "To provide sufficient carbohydrates to the baby."

While caring for a postpartum client, the nurse finds that she is unable to feed her newborn as often as she needs to because the baby spends most of the time sleeping. What should the nurse suggest to the client in this situation? 1. "You can wake the baby up by gently massaging his back." 2. "Do not allow the baby to suck his thumb because it promotes sleep." 3. "Avoid swaddling the baby with a blanket because it prevents deep sleep in the baby." 4. "Store the expressed breast milk in a bottle and feed the baby when it wakes up."

1. "You can wake the baby up by gently massaging his back."

The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Many regional and ethnic cultures can be found within the United States. One cannot assume generalized observations about any cultural group will hold for all members of the group. Which statement related to cultural practices influencing infant feeding practice is correct? 1. A common practice among Mexican women is known as las dos cosas. 2. Muslim cultures do not encourage breastfeeding due to modesty concerns. 3. Latino women born in the United States are more likely to breastfeed. 4. East Indian and Arab women believe that cold foods are best for a new mother.

1. A common practice among Mexican women is known as las dos cosas.

On reviewing the laboratory reports of a newborn, the nurse finds that the infant has galactosemia. What does the nurse advise the parents to ensure safety? 1. Avoid breastfeeding the infant. 2. Feed the infant with expressed human milk. 3. Avoid giving soy-rich formula to the infant. 4. Start giving fruit juice to the infant.

1. Avoid breastfeeding the infant.

Which nursing intervention helps promote early passage of meconium in the infant? 1. Encouraging the mother to feed the infant colostrum 2. Administering a vitamin K injection (Mephyton) to the infant 3. Providing kangaroo care to the infant immediately after birth 4. Feeding unmodified cow's milk to the infant immediately after birth

1. Encouraging the mother to feed the infant colostrum

A lactating client experiences cramps after breastfeeding. Upon assessing the client, the nurse finds that the lactating mother has after pains. Which medicine does the nurse expect in the standing orders? 1. Ibuprofen (Motrin) 2. Fluoxetine (Prozac) 3. Oxycodone (Oxycontin) 4. Hydrocodone (Reprexain)

1. Ibuprofen (Motrin)

How are the oligosaccharides that are present in breast milk beneficial to the breastfed infant? 1. They prevent bacterial growth. 2. They improve blood circulation. 3. They increase calcium absorption. 4. They promote neurologic development.

1. They prevent bacterial growth.

The nurse is caring for a postpartum client who gave birth to a full-term infant. After delivery, the nurse places the newborn on the client's chest. What is the reason for such an intervention? 1. To help initiate breastfeeding 2. To help the client recognize the infant's hunger cues 3. To promote pulmonary development in the infant 4. To reduce the symptoms of anxiety and restlessness in the mother

1. To help initiate breastfeeding

The nurse taught new parents the guidelines to follow regarding the bottle-feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse's instructions if they did what? 1. Wash the top of the can and can opener with soap and water before opening the can. 2. Adjust the amount of water added according to the weight gain pattern of the newborn. 3. Add some honey to sweeten the formula and make it more appealing to a fussy newborn. 4. Warm formula in a microwave oven for a couple of minutes before feeding.

1. Wash the top of the can and can opener with soap and water before opening the can.

Following a vaginal delivery, the client tells the nurse that she intends to breastfeed her infant but she is very concerned about returning to her prepregnancy weight. Based on this interaction, how would the nurse advise the client? Select all that apply. 1 . She should join Weight Watchers as soon as possible to ensure adequate weight loss. 2 . Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. 3. Weight loss diets are not recommended for women who breastfeed. 4. If breastfeeding, she should regulate her fluid consumption in response to her thirst level. 5. If she decreases her calorie intake by 100 to 200 calories a day she will lose weight more quickly.

2 . Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. 3. Weight loss diets are not recommended for women who breastfeed. 4. If breastfeeding, she should regulate her fluid consumption in response to her thirst level.

With regard to the long-term consequences of infant feeding practices, the nurse should instruct the obese client that the best strategy to decrease the risk for childhood obesity for her infant is what? 1. An on-demand feeding schedule 2. Breastfeeding 3. Lower-calorie infant formula 4. Smaller, more frequent feedings

2. Breastfeeding

The nurse is caring for a postpartum client and instructs the client to make skin-to-skin contact with the infant. Which complication can be prevented in the infant by following this intervention? 1. Jaundice 2. Hypothermia 3. Galactosemia 4. Dehydration

2. Hypothermia

The nurse advises the client to use a hospital-grade electric pump for effective feeding of a preterm infant. What does the nurse tell the client about using this pump? 1. Hospital-grade electric pumps can be used at any time after childbirth. 2. Pumping should be done 8 to 10 times a day to maintain milk supply. 3. Milk obtained by pumping should be microwaved immediately. 4. Honey should be added to the milk obtained by pumping.

2. Pumping should be done 8 to 10 times a day to maintain milk supply.

The nurse finds that an infant has tremors and decreased serum calcium levels. Which finding from the child's medical history may be responsible for these symptoms? 1. The infant's mother gives fluoride supplements to the infant. 2. The infant's mother feeds unmodified cow's milk to the infant. 3. The infant's mother underwent bariatric surgery before the infant was 1 year old. 4. The infant's mother fed the infant concentrated formula before the infant was 15 days old.

2. The infant's mother feeds unmodified cow's milk to the infant.

On interacting with a lactating client, the nurse finds that the patient consumes alcohol. Which advice should the nurse give in order to prevent potential risks to the infant? 1. "Avoid consuming grape juice while breastfeeding." 2. "Pump and discard the first 10 drops of breast milk." 3. "Avoid breastfeeding for 2 hours after consuming alcohol." 4. "Feed the infant cow's milk rather than breast milk."

3. "Avoid breastfeeding for 2 hours after consuming alcohol."

A postpartum client has been advised to give formula to the infant. The client reports that her breasts are firm, hot, and shiny. What treatment does the nurse recommend to reduce the milk supply? 1. Cold compression 2. Breast massage 3. Placing cabbage leaves over the breast 4. Antiinflammatory drugs

3. Placing cabbage leaves over the breast

The nurse tells a postpartum client to gently massage her breasts before performing hand expression. Why the nurse did give such an instruction? 1. Prevent nipple trauma 2. Reduce body temperature 3. Stimulate the let-down reflex 4. Reduce pain during expression

3. Stimulate the let-down reflex

The nurse is assessing a postpartum client who is breastfeeding her infant. Which sign indicates that the infant is latched on to the mother's breast and is receiving the mother's milk? 1. The infant's cheeks are dimpled during sucking. 2. The infant's sucking is not audible. 3. The client feels strong tugging on the nipple. 4. The client feels pinching and pain in the nipple.

3. The client feels strong tugging on the nipple.

While teaching breastfeeding techniques to a postpartum patient, the nurse advises the patient to check whether the infant's cheeks are rounded or dimpled during feeding. What is the reason for giving such advice to the patient? 1. It prevents nipple trauma. 2. Possible prevention of trauma to the infant's jaws. 3. To indicate the effectiveness of breastfeeding. 4. It helps the infant latch onto the nipples.

3. To indicate the effectiveness of breastfeeding.

In helping the breastfeeding mother position the baby, nurses should keep what in mind? 1. The cradle position is usually preferred by mothers who had a cesarean birth. 2. Women with perineal pain and swelling prefer the modified cradle position. 3. Whatever the position used, the infant is "skin to skin" with the mother. 4. While supporting the head, the mother should push gently on the occiput.

3. Whatever the position used, the infant is "skin to skin" with the mother.

After assessing the stools of a newborn, the nurse plans to evaluate the infant's breastfeeding effectiveness. Which possible finding in the stools prompted such an evaluation? 1. Greenish yellow, loose stools on third day. 2. Yellow, soft, and seedy stools on seventh day. 3. Greener, thinner, and less sticky stools on second day. 4. Greenish black, thick, and sticky meconium stools on third day.

4. Greenish black, thick, and sticky meconium stools on third day.

The nurse is assessing a Mexican client one month after delivery. The client tells the nurse that the infant avoids latching on to the breast. Which action by the client could have led to this condition? 1. The client breastfeeds the infant at scheduled times only. 2. The client gave honey to the infant before breastfeeding. 3. The client stopped making skin-to-skin contact with the infant. 4. The client has been feeding the infant both formula and breast milk.

4. The client has been feeding the infant both formula and breast milk.

Why would the nurse suggest that a client tickle her baby's lips with her nipple while breastfeeding? 1. To prevent nipple trauma. 2. As a way to encourage the baby to swallow the milk. 3. To reduce the pain while feeding the infant. 4. To help stimulate mouth opening by her baby.

4. To help stimulate mouth opening by her baby.

The nurse assesses a postpartum client who is breastfeeding her infant. The client states that she does not consume eggs or meat. The nurse is aware that the infant may have which deficiency? 1. Vitamin D deficiency 2. Vitamin E deficiency 3. Vitamin K deficiency 4. Vitamin B12 deficiency

4. Vitamin B12 deficiency

The nurse is caring for a lactating client. On reviewing the client's medical history, the nurse finds that the client has undergone bariatric surgery. Which nutritional supplement would be beneficial to prevent a deficiency state in the mother and the infant? 1. Folic acid supplement 2. Fluoride supplement 3. Vitamin C supplement 4. Vitamin B12 supplement

4. Vitamin B12 supplement

Which statement regarding infant weaning is correct? 1. Weaning should proceed from breast to bottle to cup. 2. The feeding of most interest should be eliminated first. 3. Abrupt weaning is easier than gradual weaning. 4. Weaning can be mother or infant initiated.

4. Weaning can be mother or infant initiated.

The nurse is assisting a client during delivery. What measures does the nurse take to protect the infant from heat loss? A. Ensure the infant is dried immediately after birth. B. Place the naked infant on bare scales for accuracy. C. Place the naked infant on the mother's bare chest and cover with a blanket. D. Ensure the nursery temperature is 27° C (80.6° F). E. Wrap the infant and cover the head with a cap.

A, C, E Heat loss by evaporation is intensified if the newborn is not dried immediately after birth. It is important to dry the infant quickly after birth to prevent hypothermia. The naked infant is placed on the mother's bare chest and covered with a warm blanket to reduce heat loss. The infant must be wrapped in a warm blanket; the head may be covered with a cap to conserve heat. The naked infant is weighed on scales with a protective cover to minimize conductive heat loss. The ambient temperature in the nursery is generally maintained at 24° C (75.2° F) and the infant lies in an open bassinet with a warm blanket and a cap.

The nurse is assessing digestion and elimination in a newborn. Which enzyme helps the newborn convert starch into maltose? A. Amylase in colostrum B. Mammary lipase in breast milk C. Amylase in the salivary glands D. Lactase in the digestive system

A. Amylase in colostrum The enzyme amylase is necessary to convert starch into maltose and occurs in high amounts in colostrum. Mammary lipase in breast milk aids in the digestion of fats. The salivary glands produce amylase starting only at 3 months of age, so the newborn depends on the amylase available in colostrum. The newborn's digestive system produces a high level of lactase, which aids in the digestion of lactose, a carbohydrate present in milk.

With regard to the respiratory development of the newborn, of what should nurses be aware? A. Crying increases the distribution of air in the lungs B. Newborns must expel the fluid in utero from the respiratory system within a few minutes of birth C. Newborns are instinctive mouth breathers D. Seesaw respirations are no cause for concern in the first hour after birth

A. Crying increases the distribution of air in the lungs Respirations in the newborn can be stimulated by mechanical factors such as changes in intrathoracic pressure resulting from the compression of the chest during vaginal birth. With birth, the pressure on the chest is released, which helps draw air into the lungs. The positive pressure created by crying helps to keep the alveoli open and increases distribution of air throughout the lungs. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose breathers; they may not have the mouth breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.

The nurse is assessing a neonate born by vacuum extraction. What assessment does the nurse perform to detect possible subgaleal hemorrhage? A. Measure serial head circumference. B. Monitor the neonate for bradycardia. C. Inspect the frontal aspect of the head. D. Look for backward positioning of the ears.

A. Measure serial head circumference. The nurse should obtain serial head circumference measurements for early detection of possible hemorrhage. Increasing head circumference may be an early sign of a subgaleal hemorrhage. The neonate with subgaleal hemorrhage will have tachycardia, not bradycardia. The nurse must inspect the back of the neck for increasing edema and a firm mass. If hematoma is present, it extends posteriorly, leading to a forward and lateral positioning of the neonate's ears.

The nurse is assessing a neonate immediately after birth. How does the nurse document the presence of bluish-black pigmentation on the neonate's buttocks? A. Mongolian spots B. Nevus simplex C. Nevus flammeus D. Erythema toxicum

A. Mongolian spots Mongolian spots are bluish-black areas of pigmentation on the neonate's back. This information must be documented because they can be mistaken for bruises after discharge, raising the suspicion of physical abuse. Nevi simplex are usually small, flat, pink lesions that are easily blanched. The most common sites are the upper eyelids, nose, upper lip, and nape of the neck. Nevus flammeus, or a port-wine stain, is usually pink and flat at birth, but darkens with time, turning red or purple and becoming pebbly in consistency. Erythema toxicum is a transient rash that first appears in term neonates during the first 24 to 72 hours after birth and can last up to 3 weeks.

The nurse is caring for a full-term neonate born by cesarean. What is the effect of cesarean birth on the respiratory function of the neonate? A. Retention of fluid in the lungs B. Incidence of transient bradypnea C. Exhaustion from the effort of breathing D. Episodes of periodic breathing

A. Retention of fluid in the lungs Before the onset of labor, and during labor, a catecholamine surge promotes fluid clearance from the lungs. This is absent during birth by cesarean when the mother does not go into labor. The full-term neonate born by cesarean is likely to experience some retention of fluid in the lungs, which generally clears without any deleterious effects. The neonate is more likely to develop transient tachypnea of the newborn (TTNB), not bradypnea, due to lower levels of catecholamines. Preterm or sick term infants may experience exhaustion from breathing due to absent or decreased surfactant in the lungs, which causes more pressure on the lungs. It is normal for all infants to experience periodic breathing, with pauses in respirations lasting less than 20 seconds during the active sleep cycle.

The nurse notices that a newborn has difficulty breathing. What infant behavior might have led to the nurse to this conclusion? A. The infant did not cry after birth. B. The infant had improper bowel sounds. C. The infant moved its head from side to side. D. The infant had increased blood pressure (BP).

A. The infant did not cry after birth. The nurse concludes that the newborn has difficulty breathing because the infant did not cry after birth. Crying creates positive intrathoracic pressure, which helps draw air into the alveoli of lungs and promotes respiration. Increased BP is a normal finding after the birth and does not cause any breathing difficulties. Improper bowel sounds may indicate a gastrointestinal disorder, but is not related to respiration. Side to side head movement is common after the birth of an infant and it is not associated with breathing difficulties.

The nurse performs nasal and oral suctioning of a newborn immediately after birth. What is the reason for this nursing intervention? A. To stimulate respiration B. Assist in stimulating cardiac activity C. Removal of fluid from the lungs D. To increase pulmonary blood flow

A. To stimulate respiration Respiration in a newborn is stimulated by several chemical, mechanical, thermal, and sensory factors working together. Suctioning of the mouth and nose of the newborn stimulates the respiratory center. Thoracic squeezing in the newborn helps to remove fluid from the lungs; however, suction helps to remove the secretions from the upper respiratory tract. If cardiac activity is absent in the newborn, it can be stimulated by cardiopulmonary resuscitation. The pulmonary blood flow increases spontaneously once the newborn starts breathing.

What findings might the nurse expect in a neonate within 30 minutes of birth? A. Tremors B. Nasal flaring C. Audible grunting D. Pinkish skin color E. Quick respiration

A. Tremors, B. Nasal flaring, C. Audible grunting The first 30 minutes after birth is referred to as the first period of reactivity. Tremors, nasal flaring, and grunting are the signs seen in this phase. These signs disappear within the first hour of birth. Pinkish skin color and quick, shallow respirations are not observed immediately after the birth; they are observed in the period of decreased responsiveness, which occurs around 60 to 100 minutes after the first period of reactivity.

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is what? A. vision. B. hearing. C. smell. D. taste.

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

3. What is the highest priority nursing intervention for an infant born with myelomeningocele? a. Protect the sac from injury. b. Prepare the parents for the childs paralysis from the waist down. c. Prepare the parents for closure of the sac when the child is approximately 2 years of age. d. Assess for cyanosis.

ANS: A A major preoperative nursing intervention for a neonate with a myelomeningocele is the protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system (CNS) 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 should assess for multiple potential problems in this infant, the major nursing intervention is to protect the sac from injury.

10. The abuse of which substance during pregnancy is a significant cause of mental retardation in the United States? a. Alcohol b. Tobacco c. Marijuana d. Heroin

ANS: A Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. Alcohol is a teratogen; maternal ethanol abuse during gestation can lead to identifiable fetal alcohol spectrum disorders that include alcohol-related neurodevelopmental disorders. Cigarette smoking is linked to adverse pregnancy outcomes. The risk for placenta previa, abruption, and premature rupture of membranes is twice that of nonsmokers. Marijuana is the most common illicit drug used by pregnant women. Marijuana crosses the placenta, and its use during pregnancy can result in shortened gestation and a higher incidence of intrauterine growth restriction (IUGR). Heroin crosses the placenta and often results in IUGR, stillbirth, and congenital anomalies.

9. A nurse is discussing the storage of breast milk with a mother whose infant is preterm and in the special care nursery. Which statement indicates that the mother requires additional teaching? a. I can store my breast milk in the refrigerator for 3 months. b. I can store my breast milk in the freezer for 3 months. c. I can store my breast milk at room temperature for 4 hours. d. I can store my breast milk in the refrigerator for 3 to 5 days.

ANS: A Breast milk for the hospitalized infant can be stored in the refrigerator for only 8 days, not for 3 months. Breast milk can be stored in the freezer for 3 months, in a deep freezer for 6 months, or at room temperature for 4 hours. Human milk for the healthy or preterm hospitalized infant can be kept in the refrigerator for up to 8 days or in the freezer for up to 3 months, but only for 4 hours or less at room temperature.

10. A new mother asks the nurse what the experts say about the best way to feed her infant. Which recommendation of the American Academy of Pediatrics (AAP) regarding infant nutrition should be shared with this client? a. Infants should be given only human milk for the first 6 months of life. b. Infants fed on formula should be started on solid food sooner than breastfed infants. c. If infants are weaned from breast milk before 12 months, then they should receive cows milk, not formula. d. After 6 months, mothers should shift from breast milk to cows milk.

ANS: A Breastfeeding and human milk should also be the sole source of milk for the first 12 months, not for only the first 6 months. Infants should be started on solids when they are ready, usually at 6 months, whether they start on formula or breast milk. If infants are weaned from breast milk before 12 months, then they should receive iron-fortified formula, not cows milk.

11. Which statement is the best rationale for recommending formula over breastfeeding? a. Mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. b. Mother lacks confidence in her ability to breastfeed. c. Other family members or care providers also need to feed the baby. d. Mother sees bottle feeding as more convenient.

ANS: A Breastfeeding is contraindicated when mothers have certain viruses, tuberculosis, are undergoing chemotherapy, or are using or abusing drugs. Some women lack confidence in their ability to produce breast milk of adequate quantity or quality. The key to encouraging these mothers to breastfeed is anticipatory guidance beginning as early as possible during the pregnancy. A major barrier for many women is the influence of family and friends. She may view formula feeding as a way to ensure that the father and other family members can participate. Each encounter with the family is an opportunity for the nurse to educate, dispel myths, and clarify information regarding the benefits of breastfeeding. Many women see bottle feeding as more convenient and less embarrassing than breastfeeding. They may also see breastfeeding as incompatible with an active social life. Although modesty issues related to feeding the infant in public may exist, these concerns are not legitimate reasons to formula-feed an infant. Often, the decision to formula feed rather than breastfeed is made without complete information regarding the benefits of breastfeeding.

29. A new mother asks whether she should feed her newborn colostrum, because it is not real milk. What is the nurses most appropriate answer? a. Colostrum is high in antibodies, protein, vitamins, and minerals. b. Colostrum is lower in calories than milk and should be supplemented by formula. c. Giving colostrum is important in helping the mother learn how to breastfeed before she goes home. d. Colostrum is unnecessary for newborns.

ANS: A Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Supplementation is not necessary and will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge; however, the importance of the colostrum to the infant is the top priority. Colostrum provides immunities and enzymes necessary to cleanse the gastrointestinal system, among other things.

2. A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle feeding. Which statement regarding bottle feeding using commercially prepared infant formulas might influence their choice? a. Bottle feeding using a commercially prepared formula increases the risk that the infant will develop allergies. b. Bottle feeding helps the infant sleep through the night. c. Commercially prepared formula ensures that the infant is getting iron in a form that is easily absorbed. d. Bottle feeding requires that multivitamin supplements be given to the infant.

ANS: A Exposure to cows milk poses a risk of developing allergies, eczema, and asthma. Newborns should be fed during the night, regardless of the feeding method. Iron is better absorbed from breast milk than from formula. Commercial formulas are designed to meet the nutritional needs of the infant and to resemble breast milk. No supplements are necessary.

13. The nurse should be cognizant of which statement regarding the unique qualities of human breast milk? a. Frequent feedings during predictable growth spurts stimulate increased milk production. b. Milk of preterm mothers is the same as the milk of mothers who gave birth at term. c. Milk at the beginning of the feeding is the same as the milk at the end of the feeding. d. Colostrum is an early, less concentrated, less rich version of mature milk.

ANS: A Growth spurts (at 10 days, 3 weeks, 6 weeks, and 3 months) usually last 24 to 48 hours, after which the infants resume normal feeding. The milk of mothers of preterm infants is different from that of mothers of full-term infants to meet the needs of these newborns. Milk changes composition during feeding. The fat content of the milk increases as the infant feeds. Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals (but not fat).

7. Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them regarding pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? a. Premature infants more easily digest breast milk than formula. b. A glass of wine just before pumping will help reduce stress and anxiety. c. The mother should only pump as much milk as the infant can drink. d. The mother should pump every 2 to 3 hours, including during the night.

ANS: A Human milk is the ideal food for preterm infants, with benefits that are unique, in addition to those benefits received by full-term, healthy infants. Greater physiologic stability occurs with breastfeeding, compared with formula feeding. Consumption of alcohol during lactation is approached with caution. Excessive amounts can have serious effects on the infant and can adversely affect the mothers milk ejection reflex. To establish an optimal milk supply, the most appropriate instruction for the mother should be to pump 8 to 10 times a day for 10 to 15 minutes on each breast.

2. Which infant is most likely to express 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 a mother who 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 a mother who is Rh positive

ANS: A If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, then all the offspring of this union will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. Only the Rh-positive offspring of an Rh-negative mother are at risk. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, a 50% chance exists that each infant born of this union will be Rh positive, and a 50% chance exists that each will be born Rh negative. No risk for incompatibility exists if both the mother and the infant are Rh positive. DIF: Cognitive Level: Understand REF: p. 883 TOP: Nursing Process: Planning

10. The condition, hypospadias, encompasses a wide range of penile abnormalities. Which information should the nurse provide to the anxious parents of an affected newborn? a. Mild cases involve a single surgical procedure. b. Infant should be circumcised. c. Repair is performed as soon as possible after birth. d. No correlation exists between hypospadia and testicular cancer.

ANS: A Mild cases of hypospadias are often repaired for cosmetic reasons, and repair involves a single surgical procedure, enabling the male child to urinate in a standing position and to have an adequate sexual organ. These infants are not circumcised; the foreskin will be needed during the surgical repair. Repair is usually performed between 1 and 2 years of age. A correlation between hypospadias and testicular cancer exists; therefore, these children will require long-term follow-up observation. DIF: Cognitive Level: Apply REF: p. 902

14. A nurse providing couplet care should understand the issue of nipple confusion. In which situation might this condition occur? a. Breastfeeding babies receive supplementary bottle feedings. b. Baby is too abruptly weaned. c. Pacifiers are used before breastfeeding is established. d. Twins are breastfed together.

ANS: A Nipple confusion can result when babies go back and forth between bottles and breasts, especially before breastfeeding is established in 3 to 4 weeks; bottle feeding and breastfeeding require different skills. Abrupt weaning can be distressing to the mother and/or baby but should not lead to nipple confusion. Pacifiers used before breastfeeding is established can be disruptive but do not lead to nipple confusion. Breastfeeding twins require some logistical adaptations but should not lead to nipple confusion.

3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: a. Are benign if they disappear within 48 hours of birth b. Result from increased blood volume c. Should always be further investigated d. Usually occur with forceps delivery

ANS: A Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation, the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

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

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

6. Which statement regarding congenital anomalies of the cardiovascular and respiratory systems is correct? a. Cardiac disease may demonstrate signs and symptoms of respiratory illness. b. Screening for congenital anomalies of the respiratory system need only be performed for infants experiencing respiratory distress. c. Choanal atresia can be corrected with the use of a suction catheter to remove the blockage. d. Congenital diaphragmatic hernias are diagnosed and treated after birth.

ANS: A The cardiac and respiratory systems function together; therefore, initial findings will be related to respiratory illness. Screening for congenital respiratory system anomalies is necessary, even for infants who appear normal at birth. All newborns should have critical congenital heart disease (CCHD) screening performed before discharge. Choanal atresia requires emergency surgery. Congenital diaphragmatic hernias are prenatally discovered on ultrasound.

7. 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. Based on 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 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 (IUGR). The infant may have a shrill cry and sleep cycle disturbances and may 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.

During a prenatal examination a 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 questions the nurse as to why, the nurse's best response is: a. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." b. "You and your baby can be exposed to HIV in your cats' feces." c. "It's just gross. You should make your husband clean the litter boxes." d. "Cat feces are known to carry Escherichia coli, which can cause a severe infection in you and your baby."

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

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

ANS: A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of health care-associated infection in nursery units. 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. Separate gowns should be worn in caring for each infant. Soiled linens should be disposed of in an appropriate manner; however, the most important nursing action for preventing neonatal infection is effective handwashing. 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.

OOO The nurse is caring for a woman who experienced a perinatal loss. The nurse finds that the woman is experiencing an intense stage of grieving. What observation did the nurse find in the client? a. The woman weeps when she experiences leakage of breast milk. b. The woman notes the date of birth of the stillborn child. c. The woman cries suddenly and becomes emotional. d. The woman looks at the ultrasound photos of the fetus.

ANS: A Weeping on leakage of breast milk is a sign that the woman is slowly getting through the pain and is adjusting to the life without the expected child. This behavior is observed when the woman is experiencing intense grief. Noting the date of birth of a stillborn child is characteristic of the reorganization phase. Preserving and looking at memorabilia, like the ultrasound pictures of the fetus, show that the woman is cherishing the memories of her pregnancy. This is also a sign of the reorganization phase. If the nurse finds that the woman is emotional and cries spontaneously, the woman is said to be in an acute phase of grief.

3. The nurse is caring for an infant with DDH. Which clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Positive Ortolani click b. Unequal gluteal folds c. Negative Babinski sign d. Trendelenburg sign e. Telescoping of the affected limb

ANS: A, B A positive Ortolani test and unequal gluteal folds are clinical manifestations of DDH observed from birth to 2 to 3 months of age. A negative Babinski sign, Trendelenburg sign, and telescoping of the affected limb are not clinical manifestations of DDH. DIF: Cognitive Level: Apply REF: p. 900 TOP: Nursing Process: Planning

1. 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

3. The Baby Friendly Hospital Initiative endorsed by the World Health Organization (WHO) and the United Nations Childrens Fund (UNICEF) was founded to encourage institutions to offer optimal levels of care for lactating mothers. Which actions are included in the Ten Steps to Successful Breastfeeding for Hospitals? (Select all that apply.) a. Give newborns no food or drink other than breast milk. b. Have a written breastfeeding policy that is communicated to all staff members. c. Help mothers initiate breastfeeding within hour of childbirth. d. Give artificial teats or pacifiers as necessary. e. Return infants to the nursery at night.

ANS: A, B, C No artificial teats or pacifiers (also called dummies or soothers) should be given to breastfeeding infants. Although pacifiers have been linked to a reduction in SIDs, they should not be introduced until the infant is 3 to 4 weeks old and breastfeeding is well established. No other food or drink should be given to the newborn unless medically indicated. The breastfeeding policy should be routinely communicated to all health care staff members. All staff should be trained in the skills necessary to maintain this policy. Breastfeeding should be initiated within hour of childbirth, and all mothers need to be shown how to maintain lactation even if separated from their babies. The facility should practice rooming in and keep mothers and babies together 24 hours a day.

1. Which actions are examples of appropriate techniques to wake a sleepy infant for breastfeeding? (Select all that apply.) a. Unwrapping the infant b. Changing the diaper c. Talking to the infant d. Slapping the infants hands and feet e. Applying a cold towel to the infants abdomen

ANS: A, B, C Unwrapping the infant, changing the diaper, and talking to the infant are appropriate techniques to use when trying to wake a sleepy infant. The parent can rub, never slap, the infants hands or feet to wake the infant. Applying a cold towel to the infants abdomen may lead to cold stress in the infant. The parent may want to apply a cool cloth to the infants face to wake the infant.

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

ANS: A, B, C, D Use of amphetamines, heroin, nicotine, and PDP is contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication often used to treat neonatal abstinence syndrome.

Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage. What are possible causes of early miscarriage? (Select all that apply.) a. Chromosomal abnormalities b. Nausea and vomiting in early pregnancy c. Endocrine imbalance d. Systemic disorders e. Varicella

ANS: A, B, C, D, E Although most N/V in early pregnancy is not likely to relate to miscarriage, severe dehydration can reduce uterine circulation severely enough to impact a pregnancy

2. A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. Which findings should the nurse include in the discussion? (Select all that apply.) a. Breast tenderness b. Warmth in the breast c. Area of redness on the breast often resembling the shape of a pie wedge d. Small white blister on the tip of the nipple e. Fever and flulike symptoms

ANS: A, B, C, E Breast tenderness, warmth in the breast, redness on the breast, and fever and flulike symptoms are commonly associated with mastitis and should be included in the nurses discussion of mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis but is commonly seen in women who have a plugged milk duct.

According to the CDC, which of the following are significant causes of maternal death in the United States? (Select all that apply). a. hemorrhage b. cardio-vascular disease c. non-cardiovascular conditions d. street drug use e. ski accidents f. hypertensive disorders

ANS: A, B, C, F

Yolanda is 6 weeks pregnant by dates and is considering abortion. What options might be appropriate for her at this point? (Select all that apply). a. medical abortion with mifepristone and misopristol b. emergency contraception c. surgical abortion with aspiration d. it is too late for her to have an abortion

ANS: A, C

2. 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.) a. Problems with thermoregulation b. Cardiac distress c. Hyperbilirubinemia d. Sepsis e. Hyperglycemia

ANS: A, C, D

1. Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from the failure of the primary palate to fuse. Multiple genetic and, to a lesser extent, environmental factors may lead to the development of a cleft lip or palate. Which factors are included? (Select all that apply.) a. Alcohol consumption b. Female gender c. Use of some anticonvulsant medications d. Maternal cigarette smoking e. Antibiotic use in pregnancy

ANS: A, C, D Factors associated with the potential development of cleft lip or palate are maternal infections, alcohol consumption, radiation exposure, corticosteroid use, use of some anticonvulsant medications, male gender, Native-American or Asian descent, and maternal smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate. DIF: Cognitive Level: Understand REF: p. 895 TOP: Nursing Process: Planning

4. Which statements concerning the benefits or limitations of breastfeeding are accurate? (Select all that apply.) a. Breast milk changes over time to meet the changing needs as infants grow. b. Breastfeeding increases the risk of childhood obesity. c. Breast milk and breastfeeding may enhance cognitive development. d. Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. e. Benefits to the infant include a reduced incidence of SIDS

ANS: A, C, D, E Breastfeeding actually decreases the risk of childhood obesity. Human milk is the perfect food for human infants. Breast milk changes over time to meet the demands of the growing infant. Scientific evidence is clear that human milk provides the best nutrients for infants with continued benefits long after weaning. Fatty acids in breast milk promote brain growth and development and may lead to enhanced cognition. Infants who are breastfed experience a reduced incidence of SIDS.

What are some causes of perinatal loss? Select all that apply. a. Stillbirth b. Fertility c. Infertility d. Miscarriage e. Intrauterine fetal death (IUFD) f. Death of live-born infant soon after birth

ANS: A, C, D, E, F Some causes of perinatal loss include: stillbirth, infertility, miscarriage, intrauterine fetal death (IUFD), and death of live-born infant soon after birth. Fertility is not a cause of perinatal loss.

5. The AAP recommends pasteurized donor milk for preterm infants if the mothers own milk in not available. Which statements regarding donor milk and milk banking are important for the nurse to understand and communicate to her client? (Select all that apply.) a. All milk bank donors are screened for communicable diseases. b. Internet milk sharing is an acceptable source for donor milk. c. Donor milk may be given to transplant clients. d. Donor milk is used in neonatal intensive care units (NICUs) for severely low-birth-weight infants only. e. Donor milk may be used for children with immunoglobulin A (IgA) deficiencies.

ANS: A, C, E Because of the antiinfective and growth promotion properties for donor milk, donor milk is highly recommended for preterm and sick infants, as well as for term newborns. Human donor milk has also been used for older children with short gut syndrome, immunodeficiencies, metabolic disorders, or congenital anomalies. Human donor milk has also been used in the adult populationposttransplant clients and for those with colitis, ulcers, or cirrhosis of the liver. Some mothers acquire milk through Internet-based or community-based milk sharing. The U.S. Food and Drug Administration (FDA) has issued a warning regarding this practice. Samples of milk from these sources are higher in contaminants and infectious disease. A milk bank that belongs to the Human Milk Banking Association of North America should always be used for donor milk. All donors are scrupulously screened, and the milk is tested to determine its safety for use.

The nurse is caring for a client whose pregnancy ended in stillbirth 2 months ago. The nurse finds that the client experiences feelings of loneliness, emptiness, and yearning. What additional symptoms of grief may the nurse find in the client? Select all that apply. a. Guilt b. Shock c. Numbness d. Resentment e. Disorganization

ANS: A, D, E Pregnancy loss can lead to intense grief and feelings of loneliness, emptiness, and yearning. The client may feel guilty and blame herself for the fetal death, because she may assume that she was responsible for the fetal well-being. The client experiences helplessness because she could not save her fetus and, therefore, has resentment. The client experiences disorganization and depression due to the loss. The client experiences shock and numbness in the acute phase of distress, but not while experiencing intense grief.

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

9. Most congenital anomalies of the CNS result from defects in the closure of the neural tube during fetal development. Which factor has the greatest impact on this process? a. Maternal diabetes b. Maternal folic acid deficiency c. Socioeconomic status d. Maternal use of anticonvulsant

ANS: B All of these environmental influences may affect the development of the CNS. Maternal folic acid deficiency has a direct bearing on the failure of neural tube closure. As a preventative measure, folic acid supplementation (0.4 mg/day) is recommended for all women of childbearing age.

19. The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would provide conflicting information to the client? a. Women who breastfeed have a decreased risk of breast cancer. b. Breastfeeding is an effective method of birth control. c. Breastfeeding increases bone density. d. Breastfeeding may enhance postpartum weight loss.

ANS: B Although breastfeeding delays the return of fertility, it is not an effective birth control method. Women who breastfeed have a decreased risk of breast cancer, an increase in bone density, and a possibility of faster postpartum weight loss.

3. When planning care for an infant with a fractured clavicle, the nurse should recognize that in addition to gentle handling: a. Prone positioning facilitates bone alignment b. No special treatment is necessary c. Parents should be taught range-of-motion exercises d. The shoulder should be immobilized with a splint

ANS: B Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. Movement should be limited, and the infant should be gently handled. It is not necessary to perform range of motion exercises on the infant. A fractured clavicle does not require immobilization with a splint.

1. To explain hemolytic disorders in the newborn to new parents, the nurse who cares for the newborn population must be aware of the physiologic characteristics related to these conditions. What is the most common cause of pathologic hyperbilirubinemia? a. Hepatic disease b. Hemolytic disorders c. Postmaturity d. Congenital heart defect

ANS: B Hemolytic disorders in the newborn are the most common cause of pathologic hyperbilirubinemia (jaundice). Although hepatic damage, prematurity, and congenital heart defects may cause pathologic hyperbilirubinemia, they are not the most common causes. DIF: Cognitive Level: Apply REF: p. 882 TOP: Nursing Process: Diagnosis

28. Which instruction should the nurse provide to reduce the risk of nipple trauma? a. Limit the feeding time to less than 5 minutes. b. Position the infant so the nipple is far back in the mouth. c. Assess the nipples before each feeding. d. Wash the nipples daily with mild soap and water.

ANS: B If the infants mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, thus causing trauma to the area. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need and will also limit access to the higher-fat hindmilk. Assessing the nipples for trauma is important; however, this action alone will not prevent sore nipples. Soap can be drying to the nipples and should be avoided during breastfeeding.

23. The breastfeeding mother should be taught a safe method to remove the breast from the babys mouth. Which suggestion by the nurse is most appropriate? a. Slowly remove the breast from the babys mouth when the infant has fallen asleep and the jaws are relaxed. b. Break the suction by inserting your finger into the corner of the infants mouth. c. A popping sound occurs when the breast is correctly removed from the infants mouth. d. Elicit the Moro reflex to wake the baby and remove the breast when the baby cries.

ANS: B Inserting a finger into the corner of the babys mouth between the gums to break the suction avoids trauma to the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple that makes it sore. A popping sound indicates improper removal of the breast from the babys mouth and may cause cracks or fissures in the breast. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended.

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

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

1. A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until the baby is frantically crying. Which feeding cue would indicate that the baby is ready to eat? a. Waves her arms in the air b. Makes sucking motions c. Has the hiccups d. Stretches out her legs straight

ANS: B Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding readiness cues. Waving her arms in the air, having the hiccups, and stretching out her extremities are not typical feeding readiness cues.

17. A new father is ready to take his wife and newborn son home. He proudly tells the nurse who is discharging them that within the next week he plans to start feeding the infant cereal between breastfeeding sessions. Which information should the nurse provide regarding this feeding plan? a. Feeding solid foods before your son is 4 to 6 months old may decrease your sons intake of sufficient calories. b. Feeding solid foods between breastfeeding sessions before your son is 4 to 6 months old will lead to an early cessation of breastfeeding. c. Your feeding plan will help your son sleep through the night. d. Feeding solid foods before your son is 4 to 6 months old will limit his growth.

ANS: B The introduction of solid foods before the infant is 4 to 6 months of age may result in overfeeding and decreased intake of breast milk. The belief that feeding solid foods helps infants sleep through the night is untrue. The proper balance of carbohydrate, protein, and fat for an infant to grow properly is in the breast milk or formula.

The nurse is caring for a client whose pregnancy ended in a stillbirth. The client has breast engorgement associated with breast milk production. What information will the nurse first provide to the client? a. Various methods of suppressing lactation b. Importance of a visit to the lactation consultant c. Procedures for expressing and donating breast milk d. Explaining that this problem would disappear in due time

ANS: B Clients who have experienced stillbirth may have varied reactions to this traumatic experience. A client whose pregnancy ended in a stillbirth would still be able to produce breast milk. In this situation, the nurse should explain to the client the importance of visiting a lactation counselor. The lactation counselor would listen to the preferences of the client regarding suppressing the production of breast milk or donating breast milk. The nurse needs to find out whether the client wants to suppress lactation or donate breast milk and, accordingly, give suggestions. Breast milk production may take a long time to cease. Thus, breast milk should either be donated or milk production should be suppressed

6. Parents have asked the nurse about organ donation after that infant's death. Which information regarding organ donation is important for the nurse to understand? a. Federal law requires the medical staff to ask the parents about organ donation and then to contact their state's organ procurement organization (OPO) to handle the procedure if the parents agree. b. Organ donation can aid grieving by giving the family an opportunity to see something positive about the experience. c. Most common donation is the infant's kidneys. d. Corneas can be donated if the infant was either stillborn or alive as long as the pregnancy went full term.

ANS: B Evidence indicates that organ donation can promote healing among the surviving family members. The federal Gift of Life Act made state OPOs responsible for deciding whether to request a donation and for making that request. The most common donation is the cornea. For cornea donation, the infant must have been born alive at 36 weeks of gestation or later.

11. Which finding would indicate to the nurse that the grieving parents have progressed to the reorganization phase of grieving? a. The parents say that they "feel no pain." b. The parents are discussing sex and a future pregnancy c. The parents have abandoned those moments of "bittersweet grief." d. The parents' questions have progressed from "Why?" to "Why us?"

ANS: B Many couples have conflicting feelings about sexuality and future pregnancies. A little pain is always present, certainly beyond the first year when recovery begins to peak. Bittersweet grief describes the brief grief response that occurs with reminders of a loss, such as anniversary dates. Most couples never abandon these reminders. Recovery is ongoing. Typically, a couple's search for meaning progresses from "Why?" in the acute phase to "Why me?" in the intense phase to "What does this loss mean to my life?" in the reorganizational phase

13. A client gives birth to a stillborn infant. At first, she appears stunned by the news, cries a little, and then asks the nurse to call her mother. What is the proper term for the phase of bereavement that this client is experiencing? a. Anticipatory grief b. Acute distress c. Intense grief d. Reorganization

ANS: B The immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal. However, a lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Anticipatory grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant's possible death, although he or she clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.

2. A newborn in the neonatal intensive care unit (NICU) is dying of a massive infection. The parents speak to the neonatologist, who informs them of their son's prognosis. When the father sees his son, he says, "He looks just fine to me. I can't understand what all this is about." What is the most appropriate response or reaction by the nurse at this time? a. "Didn't the physician tell you about your son's problems?" b. "This must be a difficult time for you. Tell me how you're doing." c. Quietly stand beside the infant's father. d. "You'll have to face up to the fact that he is going to die sooner or later."

ANS: B The phase of intense grief can be very difficult, especially for fathers. Parents should be encouraged to share their feelings during the initial steps in the grieving process. This father is in a phase of acute distress and is reaching out to the nurse as a source of direction in his grieving process. Shifting the focus is not in the best interest of the parent. Nursing actions may help the parents actualize the loss of their infant through a sharing and verbalization of their feelings of grief. Telling the father that his son is going to die sooner or later is dispassionate and an inappropriate statement on the part of the nurse.

10. During a follow-up home visit, the nurse plans to evaluate whether parents have progressed to the second stage of grieving (phase of intense grief). Which behavior would the nurse not anticipate finding? a. Guilt, particularly in the mother b. Numbness or lack of response c. Bitterness or irritability d. Fear and anxiety, especially about getting pregnant again

ANS: B The second phase of grieving encompasses a wide range of intense emotions, including guilt, anger, bitterness, fear, and anxiety. What the nurse would hope not to see is numbness or unresponsiveness, which indicates that the parents are still in denial or shock.

The nurse is caring for a client who lost her baby immediately after birth. The client blames herself for the loss. Which nursing interventions are designed to promote feelings of self-worth in the client? Select all that apply. a. Attending the memorial services and funeral b. Helping the client identify positive coping mechanisms c. Giving the client the newborn's photograph and footprints d. Encouraging the client to share her feelings with her partner e. Identifying the client's perception and feeling about fetal death

ANS: B, E Clients may experience low self-esteem related to fetal death due to a sense of failure to become a mother. The nurse should help the client identify and follow positive coping skills because it improves the client's self-esteem and self-worth. The nurse should identify the client's perception and feelings about fetal death and should correct any misconceptions and alleviate guilt. This promotes feelings of self-worth. The nurse may attend memorial services and the funeral to support the parents, but this intervention does not promote feelings of self-worth. The nurse would provide photographs and footprints in order to make the client acknowledge the reality of death. The nurse should encourage the client to share her feelings with her partner in order clarify possible effects on the family

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. Provide opportunities for grieving parents and family members to spend time with the baby d. Advise the parents to refrain from discussing the baby's death with their other children.

ANS: C

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

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

20. While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the client accordingly. Which statement as part of this discussion would be incorrect? a. Breastfeeding requires fewer supplies and less cumbersome equipment. b. Breastfeeding saves families money. c. Breastfeeding costs employers in terms of time lost from work. d. Breastfeeding benefits the environment.

ANS: C Actually, less time is lost to work by breastfeeding mothers, in part because infants are healthier. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment. It saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal.

27. As the nurse assists a new mother with breastfeeding, the client asks, If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better? What is the nurses best response? a. More calories b. Essential amino acids c. Important immunoglobulins d. More calcium

ANS: C Breast milk contains immunoglobulins that protect the newborn against infection. The calorie count of formula and breast milk is approximately the same. All the essential amino acids are in both formula and breast milk; however, the concentrations may differ. Calcium levels are higher in formula than in breast milk, which can cause an excessively high renal solute load if the formula is not properly diluted.

25. How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day? a. 50 to 65 b. 75 to 90 c. 95 to 110 d. 150 to 200

ANS: C For the first 3 months, the infant needs 110 kcal/kg/day. At ages 3 to 6 months, the requirement is 100 kcal/kg/day. This level decreases slightly to 95 kcal/kg/day from 6 to 9 months and increases again to 100 kcal/kg/day until the baby reaches 12 months.

12. Which statement regarding the nutrient needs of breastfed infants is correct? a. Breastfed infants need extra water in hot climates. b. During the first 3 months, breastfed infants consume more energy than formula-fed infants. c. Breastfeeding infants should receive oral vitamin D drops daily during at least the first 2 months. d. Vitamin K injections at birth are not necessary for breastfed infants.

ANS: C Human milk contains only small amounts of vitamin D. All infants who are breastfed should receive 400 International Units of vitamin D each day. Neither breastfed nor formula-fed infants need to be fed water, not even in very hot climates. During the first 3 months, formula-fed infants consume more energy than breastfed infants and therefore tend to grow more rapidly. Vitamin K shots are required for all infants because the bacteria that produce it are absent from the babys stomach at birth.

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

ANS: C IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. 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 not at risk for sepsis.

11. The nurse is instructing a family how to care for their infant in a Pavlik harness to treat DDH. What information should be included in the teaching? a. Apply lotion or powder to minimize skin irritation. b. Remove the harness several times a day to prevent contractures. c. Return to the clinic every 1 to 2 weeks. d. Place a diaper over the harness, preferably using an absorbent disposable diaper.

ANS: C Infants have a rapid growth pattern. Therefore, the child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness, and the harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

15. Which information should the nurse provide to a breastfeeding mother regarding optimal self-care? a. She will need an extra 1000 calories a day to maintain energy and produce milk. b. She can return to prepregnancy consumption patterns of any drinks as long as she gets enough calcium. c. She should avoid trying to lose large amounts of weight. d. She must avoid exercising because it is too fatiguing.

ANS: C Large weight loss releases fat-stored contaminants into her breast milk, and it also involves eating too little and/or exercising too much. A breastfeeding mother needs to add only 200 to 500 extra calories to her diet to provide the extra nutrients for her infant. However, this is true only if she does not drink alcohol, limits coffee to no more than two cups (including caffeine in chocolate, tea, and some sodas, too), and carefully reads the herbal tea ingredients. Although she needs her rest, moderate exercise is healthy.

8. A new mother wants to be sure that she is meeting her daughters needs while feeding the baby commercially prepared infant formula. The nurse should evaluate the mothers knowledge about appropriate infant feeding techniques. Which statement by the client reassures the nurse that correct learning has taken place? a. Since reaching 2 weeks of age, I add rice cereal to my daughters formula to ensure adequate nutrition. b. I warm the bottle in my microwave oven. c. I burp my daughter during and after the feeding as needed. d. I refrigerate any leftover formula for the next feeding.

ANS: C Most infants swallow air when fed from a bottle and should be given a chance to burp several times during and after the feeding. Solid food should not be introduced to the infant for at least 4 to 6 months after birth. A microwave should never be used to warm any food to be given to an infant. The heat is not distributed evenly, which may pose a risk of burning the infant. Any formula left in the bottle after the feeding should be discarded because the infants saliva has mixed with it.

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

26. Which action by the mother will initiate the milk ejection reflex (MER)? a. Wearing a firm-fitting bra b. Drinking plenty of fluids c. Placing the infant to the breast d. Applying cool packs to her breast

ANS: C Oxytocin, which causes the MER reflex, increases in response to nipple stimulation. A firm bra is important to support the breast; however, it will not initiate the MER reflex. Drinking plenty of fluids is necessary for adequate milk production, but adequate intake of water alone will not initiate the MER reflex. Cool packs to the breast will decrease the MER reflex.

24. Which type of formula is not diluted with water, before being administered to an infant? a. Powdered b. Concentrated c. Ready-to-use d. Modified cows milk

ANS: C Ready-to-use formula can be poured directly from the can into the babys bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform in consistency. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cows milk is more difficult for the infant to digest and is not recommended, even if it is diluted.

12. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, how should the nurse respond? a. Traction is tried first. b. Surgical intervention is needed. c. Frequent, serial casting is tried first. d. Children outgrow this condition when they learn to walk.

ANS: C Serial casting, the preferred treatment, is begun shortly after birth and before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are frequently repeated (every week) to accommodate the rapid growth of early infancy. Surgical intervention is performed only if serial casting is not successful. Children do not improve without intervention. DIF: Cognitive Level: Understand REF: p. 901 TOP: Nursing Process: Planning

21. In assisting the breastfeeding mother to position the baby, which information regarding positioning is important for the nurse to keep in mind? a. The cradle position is usually preferred by mothers who had a cesarean birth. b. Women with perineal pain and swelling prefer the modified cradle position. c. Whatever the position used, the infant is belly to belly with the mother. d. While supporting the head, the mother should push gently on the occiput.

ANS: C The infant naturally faces the mother, belly to belly. The football position is usually preferred after a cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.

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

5. A breastfeeding woman develops engorged breasts at 3 days postpartum. What action will help this client achieve her goal of reducing the engorgement? a. Skip feedings to enable her sore breasts to rest. b. Avoid using a breast pump. c. Breastfeed her infant every 2 hours. d. Reduce her fluid intake for 24 hours.

ANS: C The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. Skipping feedings may cause further swelling and discomfort. If the infant does not adequately feed and empty the breast, then the mother may pump to extract the milk and relieve some of the discomfort. Dehydration further irritates swollen breast tissue.

6. At a 2-month well-baby examination, it was discovered that an exclusively breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse develop a feeding plan for the infant to increase his weight gain. Which change in dietary management will assist the client in meeting this goal? a. Begin solid foods. b. Have a bottle of formula after every feeding. c. Have one extra breastfeeding session every 24 hours. d. Start iron supplements.

ANS: C Usually the solution to slow weight gain is to improve the feeding technique. Position and the latch-on technique are evaluated, and adjustments are made. Adding a feeding or two within a 24-hour period might help. Solid foods should not be introduced to an infant for at least 4 to 6 months. Bottle feeding may cause nipple confusion and may limit the supply of milk. Iron supplements have no bearing on weight gain.

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

18. According to demographic research, which woman is least likely to breastfeed and therefore most likely to need education regarding the benefits and proper techniques of breastfeeding? a. Between 30 and 35 years of age, Caucasian, and employed part time outside the home b. Younger than 25 years of age, Hispanic, and unemployed c. Younger than 25 years of age, African-American, and employed full time outside the home d. 35 years of age or older, Caucasian, and employed full time at home

ANS: C Women least likely to breastfeed are typically younger than 25 years of age, have a lower income, are less educated, are employed full time outside the home, and are African-American.

A newborn with hypoplastic heart syndrome died after 12 hours of resuscitation. The nurse allows the parents to take the newborn's pictures, and provides a certificate along with the identification band. The nurse also refers the client to memorial services. Which behavior of the parents a month after the loss is an indication of positive outcomes of the above nursing intervention? a. The parents have reduced spiritual distress. b. The parents try not to dwell on the loss. c. The parents do not have intense longing and yearning. d. The parents are trying to have another child

ANS: C Allowing the parents to take the pictures of the newborn and providing a birth certificate to the family helps the parents accept the reality of death and complete their grieving process. Therefore, it helps to prevent the accumulation of grief and symptoms of complicated grief such as intense longing and yearning. The nurse should refer the client to memorial services in order to prevent isolation and risk of complicated grieving. Facilitating spiritual rituals or referral to a religious figure helps to reduce spiritual distress in the parents, but the nurse's actions are not specific to this purpose. If the parents are trying not to dwell on the loss it could be an indication that they are not allowing themselves to grieve, but it is not an indication that the nurse's interventions helped. If the parents are trying to have another child it does not necessarily mean the nurse helped them through their grief.

9. Which options for saying "good-bye" would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? a. The nurse should not discuss any options at this time; plenty of time will be available 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 Mothers and fathers may find it helpful to see their infant after delivery. The parents' wishes should be respected. Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. The initial intervention should be directly related to the parents' wishes concerning seeing or holding their dead infant. Although information about funeral home notification may be relevant, this information is not the most appropriate option at this time. Burial arrangements can be discussed after the infant is born.

When assisting the mother, father, and other family members to actualize the loss of an infant, which action is most helpful? a. Using the words lost or gone rather than dead or died b. Making sure the family understands that naming the baby is important c. Ensuring the baby is clothed or wrapped if the parents choose to visit with the baby d. Setting a firm time for ending the visit with the baby so that the parents know when to let go

ANS: C Presenting the baby as nicely as possible stimulates the parents' senses and provides pleasant memories of their baby. Baby lotion or powder can be applied, and the baby should be wrapped in a soft blanket, clothed, and have a cap placed on his or her head. Nurses must use the words dead and died to assist the bereaved in accepting the reality. Although naming the baby can be helpful, creating the sense that the parents have to name the baby is not important. In fact, some cultural taboos and religious rules prohibit the naming of an infant who has died. Parents need different times with their baby to say "good-bye." Nurses need to be careful not to rush the process.

A pregnant client experiences severe bleeding at 30 weeks of gestation. While performing the ultrasound, the nurse discovers that the fetus is dead. How does the nurse present this information to the client? a. "Your baby has left us." b. "You have lost your baby." c. "The baby has no heartbeat." d. "The baby has passed away."

ANS: C The nurse should be very careful while informing a client about fetal death and should convey this information without any ambiguity. Telling the client that the fetus has no heartbeat clearly indicates that the fetus has died. Telling the client that the baby has left us or that the client has lost her baby may not give a clear indication that the fetus is dead. Saying that the baby has passed away may also be somewhat ambiguous. Therefore, the nurse should not use euphemisms to convey messages about fetal death.

The nurse is caring for a client who lost her newborn 8 hours after the birth. The nurse interacts with the client in an isolated room, identifies the client's perception and feelings about death, and refers the client to counseling. What is the rationale behind these interventions? a. To reduce spiritual distress in the client b. To improve the client's relationship with the family c. To improve and maintain the client's self-esteem d. To reduce the client's risk of complicated grieving

ANS: C The nurse should provide the client private time for expression of feelings through therapeutic communication and active listening. This helps the client express her feelings openly without any judgment, thereby promoting self-esteem. The client will exhibit positive self-comments as evidence of her decreasing sense of failure. In order to reduce spiritual distress, the nurse should assess the client's spiritual preference and facilitate spiritual rituals. In order to improve the client's relationship with family members, the nurse should encourage the partners to talk about their loss. In order to reduce the risk of complicated grieving, the nurse should allow the client to hold and view the infant and refer appropriate support groups.

Which statement is accurate with regard to the emotional state of grief? A. It is a static concept applied to loss. B. Aspects of grief occur simultaneously across family units. C. Time limit for grief experiences is variable among individuals. D. It represents a linear process.

ANS: C There is no prescribed time limit for the expression of grief. Grief is a dynamic concept involving complex emotions. The expression of grief is individualized and may not occur simultaneously across family units. The process of grief represents an iterative process.

Where should a nurse remove a child's lock of hair for the parents' memorabilia in the event of perinatal loss? a. The back of the head b. The forehead c. The nape of the neck d. The top of the head

ANS: C To remove a lock of hair for memorabilia, the nurse should select an area that does not disrupt the appearance of the baby. The nape of the neck is considered the most appropriate area to take a hair lock for the memorabilia. The hair lock should not be taken from the areas such as the back of the head, the forehead, or the top of the head. Taking a hair lock from these areas would make the lack of hair in that area noticeable.

12. Which statement most accurately describes complicated grief? a. Occurs when, in multiple births, one child dies and the other or others live b. Is a state during which the parents are ambivalent, as with an abortion c. Is an extremely intense grief reaction that persists for a long time d. Is felt by the family of adolescent mothers who lose their babies

ANS: C Parents showing signs of complicated grief should be referred for counseling. Multiple births, in which not all of the babies survive, create a complicated parenting situation but not complicated bereavement. Abortion can generate complicated emotional responses, but these responses do not constitute complicated bereavement. Families of lost adolescent pregnancies may have to deal with complicated issues, but these issues are not complicated bereavement.

3. During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. What is the nurse's role at this time? a. To take over as much as possible to relieve the pressure b. To encourage the grandparents to take over c. To ensure that the parents, themselves, approve the final decisions d. To leave them alone to work things out

ANS: C The nurse is always the client's advocate. Nurses can offer support and guidance and yet leave room for the same from grandparents. In the end, however, nurses should let the parents make the final decisions. For the nurse to be able to present options regarding burial and autopsy, among other issues, in a sensitive and respectful manner is essential. The nurse should assist the parents in any way possible; however, taking over all arrangements is not the nurse's role. Grandparents are often called on to help make the difficult decisions regarding funeral arrangements or the disposition of the body because they have more life experiences with taking care of these painful yet required arrangements. Some well-meaning relatives may try to take over all decision-making responsibilities. The nurse must remember that the parents, themselves, should approve all of the final decisions. During this time of acute distress, the nurse should be present to provide quiet support, answer questions, obtain information, and act as a client advocate.

3. A postpartum woman telephones the provider regarding her 5-day-old infant. The client is not scheduled for another weight check until the infant is 14 days old. The new mother is worried about whether breastfeeding is going well. Which statement indicates that breastfeeding is effective for meeting the infants nutritional needs? a. Sleeps for 6 hours at a time between feedings b. Has at least one breast milk stool every 24 hours c. Gains 1 to 2 ounces per week d. Has at least six to eight wet diapers per day

ANS: D After day 4, when the mothers milk comes in, the infant should have six to eight wet diapers every 24 hours. Typically, infants sleep 2 to 4 hours between feedings, depending on whether they are being fed on a 2- to 3-hour schedule or cluster-fed. The infants sleep pattern is not an indication whether the infant is breastfeeding well. The infant should have a minimum of three bowel movements in a 24-hour period. Breastfed infants typically gain 15 to 30 g/day.

13. Which statement regarding hemolytic diseases of the newborn is most accurate? a. Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother. b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. c. Exchange transfusions are frequently 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 An indirect Coombs test may be performed on the mother a few times during pregnancy. Only the Rh-positive child of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers infrequently are needed because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

7. When attempting to screen and educate parents regarding the treatment of developmental dysplasia of the hip (DDH), which intervention should the nurse perform? 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 Because DDH often is not detected at birth, infants should be carefully monitored at follow-up visits. 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 recommended for clubfoot, not DDH. DIF: Cognitive Level: Apply REF: p. 899 TOP: Nursing Process: Planning

4. Which nursing diagnosis is most appropriate for a newborn diagnosed with a diaphragmatic hernia? a. Risk for impaired parent-infant attachment b. Imbalanced nutrition, related to less than body requirements c. Risk for infection d. Impaired gas exchange

ANS: D Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. Although imbalanced nutrition, related to less than body requirements, may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. The nutritional needs of this infant may be a clearly identified need; however, at this time the nurse should be most concerned about impaired gas exchange. This infant is at risk for infection, especially once the surgical repair has been performed. The extent of the herniation may have hindered normal development of the lungs in utero, resulting in respiratory distress.

16. What bacterial infection is definitely decreasing because of effective drug treatment? a. Escherichia coli infection b. Tuberculosis c. Candidiasis d. Group B streptococci (GBS) infection

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

9. Human immunodeficiency virus (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 Postnatal transmission of HIV through breastfeeding may occur. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases. This is highly unlikely because most health care facilities must meet sterility standards for all instrumentation. Transmission of HIV may occur through the placenta from the mother to the fetus or through breast milk postnatally.

22. Nurses should be able to teach breastfeeding mothers the signs that the infant has correctly latched on. Which client statement indicates a poor latch? a. I feel a firm tugging sensation on my nipples but not pinching or pain. b. My baby sucks with cheeks rounded, not dimpled. c. My babys jaw glides smoothly with sucking. d. I hear a clicking or smacking sound.

ANS: D The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. The tugging sensation without pinching is a good sign. Rounded cheeks are a positive indicator of a good latch. A smoothly gliding jaw also is a good sign.

8. The nurse is assigned a home care visit of a 5-day-old infant for the treatment of jaundice. A thorough assessment is completed, and a health history is obtained. Which sign or symptom indicates that the infant may be displaying the initial phase of encephalopathy? a. High-pitched cry b. Severe muscle spasms (opisthotonos) c. Fever and seizures d. Hypotonia, lethargy, and poor suck

ANS: D The early and most subtle symptoms of bilirubin encephalopathy include hypotonia, lethargy, poor suck, and a depressed or absent Moro reflex. Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or an arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase of encephalopathy. Medical attention is immediately necessary. Symptoms may progress from the subtle indications of the first phase to fever and seizures in as few as 24 hours. Only approximately one half of these infants survive, and those that do will have permanent sequelae, including auditory deficiencies, intellectual deficits, and movement abnormalities.

4. A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. How should the client be instructed to position the infant to facilitate correct latch-on? a. The infant should be positioned with his or her arms folded together over the chest. b. The infant should be curled up in a fetal position. c. The woman should cup the infants head in her hand. d. The infants head and body should be in alignment with the mother.

ANS: D The infants head and body should be in correct alignment with the mother and the breast during latch-on and feeding. The infant should be facing the mother with his arms hugging the breast. The babys body should be held in correct alignment (i.e., ears, shoulder, and hips in a straight line) during feedings. The mother should support the babys neck and shoulders with her hand and not push on the occiput.

16. A newly delivered mother who intends to breastfeed tells her nurse, I am so relieved that this pregnancy is over so that I can start smoking again. The nurse encourages the client to refrain from smoking. However, this new mother is insistent that she will resume smoking. How will the nurse adapt her health teaching with this new information? a. Smoking has little-to-no effect on milk production. b. No relationship exists between smoking and the time of feedings. c. The effects of secondhand smoke on infants are less significant than for adults. d. The mother should always smoke in another room.

ANS: D The new mother should be encouraged not to smoke. If she continues to smoke, she should be encouraged to always smoke in another room, removed from the baby. Smoking may impair milk production. When the products of tobacco are broken down, they cross over into the breast milk. Tobacco also results in a reduction of the antiinfective properties of breast milk. Research supports the conclusion that mothers should not smoke within 2 hours before a feeding (AAP Committee on Drugs, 2001). The effects of secondhand smoke on infants include excessive crying, colic, upper respiratory infections, and an increased risk of sudden infant death syndrome (SIDS).

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

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 lb, 6 oz). 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 This infant is macrosomic (more than 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. Macrosomic infants need to be observed closely. This can be achieved in the mother's room with nursing interventions, depending on the condition of the infant. It may be more appropriate for observation to occur in the nursery. Observation of the macrosomic infant may occur in the nursery or in the mother's room, depending on the condition of the infant. 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.

The nurse is caring for clients in a maternity unit. Which client is most likely to experience isolation during the grieving period? a. A client who is on bed rest for a high risk pregnancy b. A client whose newborn was born with a cleft palate c. A client who lost her newborn 6 hours after birth d. A client who had a miscarriage at 6 weeks of gestation

ANS: D A client who miscarries during early pregnancy may experience loss and suffer from isolation, because it may be difficult to discuss the loss with friends and family who may not have known about the pregnancy yet. A client who is on bed rest for a high-risk pregnancy may experience fear and boredom, but it is not experiencing a loss. A client whose newborn has a cleft palate may be depressed, but she does not necessarily experience isolation and loss. A client who lost her newborn 6 hours after birth may have the support of family and friends who were ready for the birth. Therefore, the client may be less likely to experience isolation.

7. Which statement is the most appropriate for the nurse to make when caring for bereaved parents? a. "This happened for the best." b. "You have an angel in heaven." c. "I know how you feel." d. "What can I do for you?"

ANS: D Acknowledging the loss and being open to listening is the best action that the nurse can do. No bereaved parent would find the statement "This has happened for the best" to be comforting in any way, and it may sound judgmental. Nurses must resist the impulse to speak about the afterlife to people in pain. They should also resist the temptation to give advice or to use clichés. Unless the nurse has lost a child, he or she does not understand how the parents feel.

1. A family is visiting two surviving triplets. The third triplet died 2 days ago. What action indicates that the family has begun to grieve for the dead infant? a. Refers to the two live infants as twins b. Asks about the dead triplet's current status c. Brings in play clothes for all three infants d. Refers to the dead infant in the past tense

ANS: D Accepting that the infant is dead (in the past tense of the word) demonstrates an acceptance of the reality and that the family has begun to grieve. Parents of multiples are challenged with the task of parenting and grieving at the same time. Referring to the two live infants as twins does not acknowledge an acceptance of the existence of their third child. Bringing in play clothes for all three infants indicates that the parents are still in denial regarding the death of the third triplet. The death of the third infant has imposed a confusing and ambivalent induction into parenthood for this couple. If the two live infants are referred to as twins and/or if play clothes for all three infants are still considered, then the family is clearly still in denial regarding the death of one of the triplets

5. Parents are often asked if they would like to have an autopsy performed on their infant. Nurses who are assisting parents with this decision should be aware of which information? a. Autopsies are usually covered by insurance. b. Autopsies must be performed within a few hours after the infant's death. c. In the current litigious society, more autopsies are performed than in the past. d. Some religions prohibit autopsy.

ANS: D Some religions prohibit autopsies or limit the choice to the times when it may help prevent further loss. The cost of the autopsy must be considered; it is not covered by insurance and can be very expensive. There is no rush to perform an autopsy unless evidence of a contagious disease or maternal infection is present at the time of death. The rate of autopsies is declining, in part because of a fear by medical facilities that errors by the staff might be revealed, resulting in litigation.

4. A nurse caring for a family during a loss might notice that a family member is experiencing survivor guilt. Which family member is most likely to exhibit this guilt? a. Siblings b. Mother c. Father d. Grandparents

ANS: D Survivor guilt is sometimes felt by grandparents because they feel that the death is out of order; they are still alive, while their grandchild has died. They may express anger that they are alive and their grandchild is not. The siblings of the expired infant may also experience a profound loss. A young child will respond to the reactions of the parents and may act out. Older children have a more complete understanding of the loss. School-age children are likely to be frightened, whereas teenagers are at a loss on how to react. The mother of the infant is experiencing intense grief at this time. She may be dealing with questions such as, "Why me?" or "Why my baby?" and is unlikely to be experiencing survival guilt. Realizing that fathers can be experiencing deep pain beneath their calm and quiet appearance and may need help acknowledging these feelings is important. This need, however, is not the same as survivor guilt.

8. 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?" What is the nurse's most appropriate response? 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 The statement "I can understand your need to find an answer to what caused this. What else are you thinking about?" 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. 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 grieving. Silence would probably 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 then listening with care. The nurse should encourage the mother to express her thoughts.

Which findings would lead to increased bilirubin levels in the newborn? A. Cord clamped immediately following delivery of newborn B. Meconium passed after 24 hours C. Initiation of newborn feedings were delayed following birth D. Hyperglycemia E. Twin to twin transfusion syndrome

B, C, E Delay in passage of meconium and delay in newborn feedings could lead to increased bilirubin levels due to increased enterohepatic circulation. Twin to twin transfusion syndrome could lead to increased bilirubin levels due to increased amount of hemoglobin. An increase in bilirubin levels would be seen if cord clamping was delayed following birth. Hypoglycemia could lead to increased bilirubin levels due to alterations in hepatic function and perfusion

The nurse is caring for an infant with breathing difficulty. Upon auscultating, the infant the nurse finds that the infant has a murmur. What suggestion does the nurse give to the parents about infant care? A. "Use formula milk." B. "Additional cardiac testing is necessary." C. "The infant should be wrapped in a thick blanket." D. "Maintain skin-to-skin contact with the mother."

B. "Additional cardiac testing is necessary." Typically, the presence of cardiac murmurs in infants has no pathologic significance. However, when murmurs are associated with other conditions, such as breathing difficulty, which may cause apnea and cyanosis, they are considered abnormal. In this case the primary health care provider will send the child for cardiac testing to diagnose any more serious condition. While skin-to-skin contact is useful in enhancing thermoregulation in infants, it will not have any effect on heart murmurs. Wrapping the infant in a thick blanket prevents cold distress in the infant, but does not affect the cardiac murmur. Feeding the infant with formula milk is unrelated to cardiac murmurs.

A client tells the nurse, "While crying, my baby often moves its hand towards its mouth and also gets startled by the sound of the rattle." What statement given by the nurse best explains this behavior? "The baby: A. "Is hungry." B. "Is consoling itself." C. "Wants to interact with you." D. "Is frightened by some noise."

B. "Is consoling itself." Newborns adopt one of several ways to console themselves to diminish their anguish. Making hand-to-mouth movements and becoming alert to voices, noise, and visual stimuli are common observations and indications of consoling. Hunger, grabbing attention, and phonophobia are the reasons for why the infant cries.

The nurse is caring for a neonate immediately after delivery. What does the nurse expect to find while assessing the neonate during the first 30 minutes after birth? A. Heart rate increases from 100 to 120 beats/minute. B. Fine crackles may be present on auscultation. C. Peristaltic waves may benoted over the abdomen. D. Respirations are shallow and may reach up to 60 breaths/minute.

B. Fine crackles may be present on auscultation. The first stage of the transition period lasts for up to 30 minutes after birth. During this period, fine crackles may be noted on auscultation. The newborn's heart rate increases rapidly from 160 to 180 beats/minute. After the first stage of the transition period, the neonate may maintain a baseline rate of 100 to 120 beats/minute. Though bowel sounds are audible in the first 30 minutes, peristaltic waves may be noted over the abdomen only after the first 30 minutes. An irregular respiratory rate between 60 to 80 breaths/minute may be noted during the first 30 minutes. After 30 minutes, respirations usually become rapid and shallow and reach up to 60 breaths/minute.

The nurse is caring for an infant experiencing cold stress. Which complication does the nurse suspect in the infant? A. Hyperglycemia B. Hyperbilirubinemia C. Respiratory alkalosis D. Decreased metabolic rate

B. Hyperbilirubinemia As a result, excessive fatty acids may be produced displacing the bilirubin from the albumin binding sites, leading to hyperbilirubinemia. In addition, cold stress may also result in excessive glycolysis. This in turn reduces the blood glucose levels and causes hypoglycemia instead of hyperglycemia. Due to the increased production of acids during cold stress, infants have respiratory acidosis rather than respiratory alkalosis. During cold stress, the metabolic rate usually increases rather than decreasing, to cause thermogenesis.

The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as what? A. Tonic neck reflex. B. Moro reflex. C. Cremasteric reflex. D. Babinski reflex.

B. Moro reflex. These actions show the Moro reflex. Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the head to the side. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.

What is the basic mechanism for conserving internal heat within infants? A. Shivering B. Vasoconstriction C. Metabolism of brown fat D. Decrease in muscle activity

B. Vasoconstriction The posterior hypothalamus stimulates the sympathetic nervous system and initiates powerful vasoconstriction throughout the body. This results in decreased conduction of heat from the internal core to the skin. Production of heat through shivering mechanism is rarely operable in infants unless there is prolonged cold exposure. Newborns generate heat by metabolism of brown fat, which is a unique feature and is not possible in infants. Brown fat has a richer vascular and nerve supply than ordinary fat. Heat produced by intense lipid metabolic activity in brown fat can warm the newborn by increasing heat production as much as 100%. Reserves of brown fat, usually present for several weeks after birth, are rapidly depleted with cold stress. In response to cold the neonate attempts to generate heat (thermogenesis) by increasing muscle activity, but not by decreasing muscle activity.

An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver: A. tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. B. alerts the physician that the infant may have a dislocated hip. C. informs the parents and physician that molding has not taken place. D. suggests that if the condition does not change, surgery to correct vision problems might be needed.

B. alerts the physician that the infant may have a dislocated hip. The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified. Telling the parents that one of the infant's legs might be longer than the other is an inappropriate statement that may result in unnecessary anxiety for the new parents. Molding refers to movement of the cranial bones and has nothing to do with the infant's hips. The Ortolani maneuver is not a technique used to evaluate visual acuity in the newborn. This maneuver checks hip integrity.

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by: A. telling the mother not to worry because breastfed babies have this type of stool. B. explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. C. asking the mother what she ate at her last meal. D. suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.

B. explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. At this early age this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. This type of stool is the first stool that all newborns have, not just breastfed babies. The mother's nutritional intake is not responsible for the appearance of meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

When caring for a newborn, the nurse must be alert for signs of cold stress, including: A. decreased activity level. B. increased respiratory rate. C. hyperglycemia. D. shivering.

B. increased respiratory rate. An increased respiratory rate is a sign of cold stress in the newborn. Infants experiencing cold stress have an increased activity level. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.

15. 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 (HSV) infection c. Congenital syphilis d. Human immunodeficiency virus (HIV)

C This rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. 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. Infants affected with HSV display growth restriction, skin lesions, microcephaly, hypertonicity, and seizures. Typically the HIV-infected neonate is asymptomatic at birth. Most often the infant develops an opportunistic infection and rapid progression of immunodeficiency.

In most healthy newborns, blood glucose levels stabilize at _________ mg/dl during the first hours after birth. A. 30 to 40 B. 40 to 50 C. 50 to 60 D. 60 to 70

C. 50 to 60 In most healthy term newborns, blood glucose levels stabilize at 50 to 60 mg/dl during the first several hours after birth. A blood sugar level less than 40 mg/dl in the newborn is considered abnormal and warrants intervention. This infant can display classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. By the third day of life, the blood glucose levels should be approximately 60 to 70 mg/dl.

Upon assessment, the nurse finds that the infant has a sunken abdomen, bowel sounds heard in the chest, nasal flaring, and grunting. What clinical condition does the nurse suspect the infant has based on these findings? A. Epispadias. B. A ruptured viscus. C. A diaphragmatic hernia. D. Hirschsprung's disease.

C. A diaphragmatic hernia. The infant has a sunken abdomen (scaphoid) with bowel sounds heard in the chest. Nasal flaring and grunting indicate respiratory distress. All these symptoms indicate a diaphragmatic hernia. Epispadias, ruptured viscus, and Hirschsprung's disease are not associated with these symptoms. Epispadias is the condition where the urethral opening is located in an abnormal position. Ruptured viscus is due to abdominal distentionat birth, caused by abdominal wall defects. Hirschsprung's disease is a congenital disorder that involves an imperforate anus.

While assessing a 1-week-old infant, the nurse observes that the newborn has apnea, lethargy, jitteriness, and feeding problems. What could be the possible reason for the infant's symptoms? A. Heart rate of 120 beats/min. B. Body temperature of 99.5° F. C. Blood glucose level of 38 mg/dl. D. Blood pressure (BP) of 80/40 mm Hg

C. Blood glucose level of 38 mg/dl. Apnea, lethargy, jitteriness, and feeding problems are the symptoms of hypoglycemia (less than 40 mg/dl of blood glucose levels). Therefore the infant with a blood glucose level of 38 mg/dl (hypoglycemia) would have these symptoms. A body temperature of 99.5° F, heart rate of 120beats/min and BP of 80/40 mm Hg are normal values for a newborn, and are not associated with the infant's manifestations.

The nurse observes that the lips, feet, and palms of a newborn are pale blue even 48 hours after birth. What can the nurse suspect from this observation about the newborn's clinical condition? A. Acrocyanosis. B. Polycythemia. C. Central cyanosis. D. Transient tachypnea.

C. Central cyanosis. When pale blue discoloration of the lips, feet, and palms of the newborn persists for more than 24 hours after birth, it is referred to as central cyanosis. Central cyanosis can be the result of an inadequate supply of oxygen to the alveoli, poor perfusion of the lungs that inhibits gas exchange, or cardiac dysfunction. Because central cyanosis is a late sign of distress, newborns usually have significant hypoxemia when cyanosis appears. Transient tachypnea is a condition in which the newborn has difficulty breathing due to the obstruction of the nasal passage. If the newborn has polycythemia, the newborn's face would have a dark red complexion, but the newborn would not have pale blue lips, feet, and palms. Acrocyanosis is a condition in which the infant shows bluish discoloration of the hands and feet for about 24 hours after birth. Since the newborn in this scenario shows bluish discoloration 48 hours after birth, it indicates that the infant has central cyanosis and not acrocyanosis.

The nurse is caring for a neonate in the nursery. What behavior in the neonate does the nurse recognize as thermogenesis? A. Starts shivering incessantly B. Assumes position of extension C. Cries and appears restless D. Develops pallor and seizures

C. Cries and appears restless Thermogenesis is the process by which the neonate tries to generate heat in response to cold. The neonate increases muscle activity by crying and being restless in a quest to stay warm.The shivering mechanism is used to produce heat in adults; however, this mechanism is rarely operable in the newborn unless there is prolonged exposure to cold. The neonate assumes a position of flexion, not extension, to conserve heat. This position reduces the amount of body surface exposed to the environment. The neonate with hyperthermia may develop pallor and seizures due to neurologic injury.

The nurse is caring for an infant after a forceps-assisted birth. Which feature does the nurse attribute to a forceps-assisted birth? A. Erythematous skin B. Blotchy or mottled skin C. Edema and ecchymosis D. Cyanotic discoloration

C. Edema and ecchymosis An infant who had a forceps-assisted birth is likely to have edema of the face and ecchymosis, or bruising. It is normal for the term infant to have erythematous, or red skin, for a few hours after birth. The skin gradually fades to its normal color. The skin often appears blotchy or mottled, especially over the extremities in aterm infant. It is normal for the infant to have acrocyanosis, or cyanotic discoloration of the hands and feet.The discoloration is caused by vasomotor instability and capillary stasis and may appear intermittently over the first 7 to 10 days, especially with exposure to cold.

The nurse is caring for a baby who is 4 weeks old. The nurse finds that the newborn is breathing through the mouth. What does the nurse expect to be the most likely clinical condition for this observation? A. Hypoxemia. B. Cardiac disorder. C. Nasal obstruction. D. Laryngeal obstruction.

C. Nasal obstruction. Newborns are generally nose breathers. After 3 weeks of age, newborns develop a reflex response that allows them to use their mouths for breathing at times of nasal obstruction. If the newborn has hypoxemia, the infant would breathe deeply through nose and not through the mouth. Mouth breathing in infants is a normal finding and does not indicate a cardiac problem. If the infant has laryngeal obstruction, the infant would be unable to breathe. This is a life-threatening condition.

The nurse clamps the umbilical cord of a preterm infant after 3 minutes of birth. What would be the possible effect in the newborn associated with this action? A. Epispadias B. Polydactyly C. Polycythemia D. Hyperbilirubinemia

C. Polycythemia Clamping the umbilical cord after 2 minutes of birth refers to delayed clamping. Delayed clamping of the cord results in polycythemia (greater plasma volume) and improves hematocrit and iron status. Polycythemia is more commonly observed in preterm infants than in term infants. Epispadias is an abnormal position of the urethral opening and is a congenital abnormality that is not associated with the umbilical cord. Polydactyly is the presence of extra digits on the extremities and is a congenital abnormality. Hyperbilirubinemia (increased bilirubin) is not related to delayed clamping of the umbilical cord, though it may lead to jaundice in the infant.

The nurse is caring for a healthy caucasian neonate who was born at 37 weeks of gestation. What does the nurse find while performing the skin assessment of the newborn immediately after the birth? A. Bluish-black areas on the body B. Desquamation of the epidermis C. Vernix caseosa covering the body D. Dark red-colored swellings on the body

C. Vernix caseosa covering the body After 35 weeks of gestation the newborn's body gets covered with vernix caseosa, which resembles a cheesy white substance and is fused with the epidermis of the skin. It is formed to protect the fetus' skin from the contents of the uterus. Postdate fetuses lose the vernix caseosa and the epidermis may become desquamated. Desquamation (peeling) of the skin occurs a few days after birth. Mongolian spots are characterized by bluish-black pigmentation of the skin, and are generally observed in Mediterranean, Latin American, Asian, or African newborns. They are not usually observed in European newborns. A nevus vascularis is a common type of capillary hemangioma, in which the infant develops dark red-colored swellings. Because the child is healthy, the nurse will not find dark red-colored lesions on the body.

While caring for an infant, which method should the nurse adapt to prevent heat loss due to evaporation? A. Wrap the infant in a cloth. B. Place the infant in a warm crib. C. Place the crib away from the windows. D. Dry the infant immediately after the bath.

D. Dry the infant immediately after the bath. The infant loses heat due to the evaporation of moisture from the body. To prevent heat loss in the infant, the nurse should immediately dry the infant after the bath. Vasoconstriction of the skin may lead to acrocyanosis. Wrapping the infant in a cloth protects the infant from exposure to cold and prevents pneumonia. The newborn is placed in the warm crib to minimize heat loss caused by conduction. Placing the crib away from the windows helps prevent heat loss due to radiation.

The nurse is examining the external genitalia of a female infant. What finding must the nurse report? A. Slight bloody spotting B. Presence of hymenal tag C. Mucoid vaginal discharge D. Fecal discharge from vagina

D. Fecal discharge from vagina Fecal discharge from the vagina indicates a rectovaginal fistula. This finding should be reported to the neonatal nurse practitioner for further evaluation. Slight bloody spotting, or pseudomenstruation, is normal and need not be reported. Nearly all female infants are born with hymenal tags. The nurse must report the absence of such tags, which can indicate vaginal agenesis. The presence of mucoid vaginal discharge is a normal finding. The discharge occurs due to an increase in estrogen during pregnancy followed by a drop after birth.

A mother reports that her baby's skin always appears flushed. What does the nurse suspect to be the reason for this condition in the infant? A. Loss of water and fluids B. Increased acid production C. Increased heat production D. Loss of heat from the body

D. Loss of heat from the body Loss of heat from the infant's body dilates the skin vessels, therefore causing the skin to appear flushed. Loss of water and fluids from the body occurs to prevent overheating complications, such as cerebral damage from dehydration or even heat stroke and death. Increased production of acids result in increased bilirubin levels which leads to jaundice. If the infant has increased heat production in the body because of sepsis, vessels in the skin are constricted and the skin appears pale.

The nurse is caring for a patient who is breastfeeding a term newborn. What does the nurse teach the patient about how normal stool should appear on the fourth day after birth? A. Greenish-black stool B. Greenish-brown stool C. Pale yellow to brown stool D. Pasty yellow to golden stool

D. Pasty yellow to golden stool The breastfed newborn passes pale yellow to golden stool on the fourth day. The stool is pasty in consistency with an odor similar to sour milk. The newborn's first stool is meconium, which is viscous in its consistency and greenish-black in color. It contains amniotic fluid, and its constituents include intestinal secretions, shed mucosal cells, and blood. The newborn passes transitional stools by the third day after initiation of feeding. Transitional stools appear greenish-brown to yellowish-brown in color. They are thinner and less viscous than meconium and may contain milk curds. By the fourth day, the newborn fed on formula milk passes pale yellow to light brown stool with a foul odor.

5. What is the clinical finding most likely to be exhibited in an infant diagnosed with erythroblastosis fetalis? a. Edema b. Immature red blood cells c. Enlargement of the heart d. Ascites

Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. Edema occurs with hydrops fetalis, a more severe form of erythroblastosis fetalis. The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces, as well as demonstrate signs of ascites.

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

Methadone 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 sudden infant death syndrome (SIDS).

2. The most widespread use of postnatal testing for genetic disease is the routine screening of newborns for inborn errors of metabolism (IEM). Which conditions are considered metabolic disorders? (Select all that apply.) a. Phenylketonuria (PKU) b. Galactosemia c. Hemoglobinopathy d. Cytomegalovirus (CMV) e. Rubella

NS: A, B, C PKU is an IEM that can be diagnosed with newborn screening. Galactosemia is a metabolic defect that falls under the category of an IEM. Sickle cell disease and thalassemia are hemoglobinopathies that can be detected by newborn screening. CMV and rubella cannot be detected by newborn screening and are not metabolic disorders; rather, they are viruses contracted by the fetus. DIF: Cognitive Level: Understand REF: p. 904 TOP: Nursing Process: Planning

Pain should be regularly assessed in all newborns. If the infant is displaying physiologic or behavioral cues that indicate pain, then measures should be taken to manage the pain. Which interventions are examples of nonpharmacologic pain management techniques? (Select all that apply.) a. Swaddling b. Nonnutritive sucking c. Skin-to-skin contact with the mother d. Sucrose e. Acetaminophen

a, b, c, d Swaddling, nonnutritive sucking, skin-to-skin contact with the mother, and sucrose are all appropriate nonpharmacologic techniques used to manage pain in neonates. Acetaminophen is a pharmacologic method of treating pain.

The "Period of Purple Crying" is a program developed to educate new parents about infant crying and the dangers of shaking a baby. Each letter in the acronym "PURPLE" represents a key concept of this program. Which concepts are accurate? (Select all that apply.) a. P: peak of crying and painful expression b. U: unexpected c. R: baby is resting at last d. L: extremely loud e. E: evening

a, b, e P: peak of crying; U: unexpected—comes and goes; R: resists soothing; P: pain—line face; L: long—lasting up to 5 hours a day; E: evening or late afternoon. Many hospitals now provide parents with an educational DVD and provide education before discharge.

As recently as 2005, the AAP revised safe sleep practices to assist in the prevention of SIDS. The nurse should model these practices in the hospital and incorporate this information into the teaching plan for new parents. Which practices are ideal for role modeling? (Select all that apply.) a. Fully supine position for all sleep b. Side-sleeping position as an acceptable alternative c. "Tummy time" for play d. Infant sleep sacks or buntings e. Soft mattress

a, c, d The "back to sleep" position is now recommended as the only position for every sleep period. To prevent positional plagiocephaly (flattening of the head) the infant should spend time on his or her abdomen while awake and for play. Loose sheets and blankets may be dangerous because they could easily cover the baby's head. The parents should be instructed to tuck any bedding securely around the mattress or use sleep sacks or bunting bags instead. The side-sleeping position is no longer an acceptable alternative position, according to the AAP. Infants should always sleep on a firm surface, ideally a firm crib mattress covered by a sheet only. Quilts and sheepskins, among other bedding, should not be placed under the infant.

Hearing loss is one of the genetic disorders included in the universal screening program. Auditory screening of all newborns within the first month of life is recommended by the AAP. What is the rationale for having this testing performed? (Select all that apply.) a. Prevents or reduces developmental delays b. Reassures concerned new parents c. Provides early identification and treatment d. Helps the child communicate better e. Is recommended by the Joint Committee on Infant Hearing

a, c, d, e New parents are often anxious regarding auditory screening and its impending results; however, parental anxiety is not the reason for performing the screening test. Auditory screening is usually performed before hospital discharge. Importantly, the nurse ensures the parents that the infant is receiving appropriate testing and fully explains the test to the parents. For infants who are referred for further testing and follow-up, providing further explanation and emotional support to the parents is an important responsibility for the nurse. All other responses are appropriate reasons for auditory screening of the newborn. Infants who do not pass the screening test should have it repeated. If the infant still does not pass the test, then he or she should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in an early intervention program by 6 months of age.

A mother is changing the diaper of her newborn son and notices that his scrotum appears large and swollen. The client is concerned. What is the best response from the nurse? a. "A large scrotum and swelling indicate a hydrocele, which is a common finding in male newborns." b. "I don't know, but I'm sure it is nothing." c. "Your baby might have testicular cancer." d. "Your baby's urine is backing up into his scrotum."

a. "A large scrotum and swelling indicate a hydrocele, which is a common finding in male newborns." Explaining what a hydrocele is and its characteristics is the most appropriate response by the nurse. The swelling usually decreases without intervention. Telling the mother that the condition is nothing important is inappropriate and does not address the mother's concern. Furthermore, if the nurse is unaware of any abnormal-appearing condition, then she should seek assistance from additional resources. Telling the mother that her newborn might have testicular cancer is inaccurate, inappropriate, and could cause the new mother undue worry. Urine will not back up into the scrotum if the infant has a hydrocele. Any nurse caring for the normal newborn should understand basic anatomy.

3. 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."

a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide."

The nurse is using the New Ballard Scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? a. Flexed posture b. Abundant lanugo c. Smooth, pink skin with visible veins d. Faint red marks on the soles of the feet

a. Flexed posture Term infants typically have a flexed posture. Abundant lanugo; smooth, pink skin with visible veins; and faint red marks are usually observed on preterm infants.

25. 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

a. Good handwashing

10. 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

a. Hypovolemia and/or shock

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

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

The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. What approach should the nurse take when performing the test to prevent this complication? a. Lancet should penetrate at the outer aspect of the heel. b. Lancet should penetrate the walking surface of the heel. c. Lancet should penetrate the ball of the foot. d. Lancet should penetrate the area just below the fifth toe.

a. Lancet should penetrate at the outer aspect of the heel. The stick should be made at the outer aspect of the heel and should penetrate no deeper than 2.4 mm. Repeated trauma to the walking surface of the heel can cause fibrosis and scarring that can lead to problems with walking later in life. The ball of the foot and the area below the fifth toe are inappropriate sites for a heelstick.

18. 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

a. Listening to breath sounds, and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician

9. 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

a. Meconium aspiration, hypoglycemia, and dry, cracked skin

The nurse is preparing to administer a hepatitis B virus (HBV) vaccine to a newborn. Which intervention by the nurse is correct? a. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration b. Confirming that the newborn's mother has been infected with the HBV c. Assessing the dorsogluteal muscle as the preferred site for injection d. Confirming that the newborn is at least 24 hours old

a. Obtaining a syringe with a 25-gauge, 5/8-inch needle for medication administration The HBV vaccine should be administered in the vastus lateralis muscle at childbirth with a 25-gauge, 5/8-inch needle and is recommended for all infants. If the infant is born to an infected mother who is a chronic HBV carrier, then the hepatitis vaccine and HBV immunoglobulin should be administered within 12 hours of childbirth.

A 3.8-kg infant was vaginally delivered at 39 weeks of gestation after a 30-minute second stage. A nuchal cord occurred. After the birth, the infant is noted to have petechiae over the face and upper back. Based on the nurse's knowledge, which information regarding petechiae should be shared with the parents? a. Petechiae (pinpoint hemorrhagic areas) are benign if they disappear within 48 hours of childbirth. b. These hemorrhagic areas may result from increased blood volume. c. Petechiae should always be further investigated. d. Petechiae usually occur with a forceps delivery.

a. Petechiae (pinpoint hemorrhagic areas) are benign if they disappear within 48 hours of childbirth. Petechiae that are acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this infant, the presence of petechiae is more likely a soft-tissue injury resulting from the nuchal cord at birth. Unless the lesions do not dissipate in 2 days, no reason exists to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

Which explanation will assist the parents in their decision on whether they should circumcise their son? a. The circumcision procedure has pros and cons during the prenatal period. b. American Academy of Pediatrics (AAP) recommends that all male newborns be routinely circumcised. c. Circumcision is rarely painful, and any discomfort can be managed without medication. d. The infant will likely be alert and hungry shortly after the procedure.

a. The circumcision procedure has pros and cons during the prenatal period. Parents need to make an informed choice regarding newborn circumcision, based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families should provide factual, unbiased information regarding circumcision and give parents opportunities to discuss the risks and benefits of the procedure. The AAP and other professional organizations note the benefits but stop short of recommending routine circumcision. Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures. After the procedure, the infant may be fussy for several hours, or he may be sleepy and difficult to awaken for feeding.

The nurse should be cognizant of which important statement regarding care of the umbilical cord? a. The stump can become easily infected. b. If bleeding occurs from the vessels of the cord, then the nurse should immediately call for assistance. c. The cord clamp is removed at cord separation. d. The average cord separation time is 5 to 7 days.

a. The stump can become easily infected. The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If bleeding occurs and does not stop, then the nurse should call for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

At 1 minute after birth a nurse assesses an infant and notes a heart rate of 80 beats per minute, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. Which Apgar score does the nurse calculate based upon these observations and signs? a. 4 b. 5 c. 6 d. 7

b. 5 Each of the five signs the nurse notes scores a 1 on the Apgar scale, for a total of 5. A score of 4 is too low for this infant. A score of 6 is too high for this infant. A score of 7 is too high for an infant with this presentation.

19. 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

b. Abdominal distention, temperature instability, and grossly bloody stools

Which intervention by the nurse would reduce the risk of abduction of the newborn from the hospital? a. Instructing the mother not to give her infant to anyone except the one nurse assigned to her that day b. Applying an electronic and identification bracelet to the mother and the infant c. Carrying the infant when transporting him or her in the halls d. Restricting the amount of time infants are out of the nursery

b. Applying an electronic and identification bracelet to the mother and the infant A measure taken by many facilities is to band both the mother and the baby with matching identification bracelets and band the infant with an electronic device that will sound an alarm if the infant is removed from the maternity unit. It is impossible for one nurse to be on call for one mother and baby for the entire shift; therefore, parents need to be able to identify the nurses who are working on the unit. Infants should always be transported in their bassinette for both safety and security reasons. All maternity unit nursing staff should have unique identification bracelets in comparison with the rest of the hospital. Infants should remain with their parents and spend as little time in the nursery as possible.

23. NEC is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. Which intervention has the greatest effect on lowering the risk of NEC? a. Early enteral feedings b. Breastfeeding c. Exchange transfusion d. Prophylactic probiotics

b. Breastfeeding

11. 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.

b. Correct for milestones, such as motor competencies and vocalizations, until the child is approximately 2 years of age.

5. 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

b. Environmental stress

7. 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.

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.

22. 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.

b. Infants with asymmetric IUGR have the potential for normal growth and development.

What is the nurse's initial action while caring for an infant with a slightly decreased temperature? a. Immediately notify the physician. b. Place a cap on the infant's head, and have the mother perform kangaroo care. c. Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d. Change the formula; a decreased body temperature is a sign of formula intolerance.

b. Place a cap on the infant's head, and have the mother perform kangaroo care. Keeping the head well covered with a cap prevents further heat loss from the head, and placing the infant skin-to-skin against the mother should increase the infant's temperature. Nursing actions are needed first to correct the problem. If the problem persists after the interventions, physician notification may then be necessary. A slightly decreased temperature can be treated in the mother's room, offering an excellent time for parent teaching on the prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days after childbirth as the infant adapts to external life.

20. 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)

b. ROP

The nurse is completing a physical examination of the newborn 24 hours after birth. Which component of the evaluation is correct? a. The parents are excused to reduce their normal anxiety. b. The nurse can gauge the neonate's maturity level by assessing his or her general appearance. c. Once often neglected, blood pressure is now routinely checked. d. When the nurse listens to the neonate's heart, the S1 and S2 sounds can be heard; the S1sound is somewhat higher in pitch and sharper than the S2 sound.

b. The nurse can gauge the neonate's maturity level by assessing his or her general appearance. The nurse is looking at skin color, alertness, cry, head size, and other features. The parents' presence actively involves them in child care and gives the nurse the chance to observe their interactions. Blood pressure is not usually taken unless cardiac problems are suspected. The S2 sound is higher and sharper than the S1 sound.

A new father wants to know what medication was put into his infant's eyes and why it is needed. How does the nurse explain the purpose of the erythromycin (Ilotycin) ophthalmic ointment? a. Erythromycin (Ilotycin) ophthalmic ointment destroys an infectious exudate caused byStaphylococcus that could make the infant blind. b. This ophthalmic ointment prevents gonorrheal and chlamydial infection of the infant's eyes, potentially acquired from the birth canal. c. Erythromycin (Ilotycin) prevents potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. d. This ointment prevents the infant's eyelids from sticking together and helps the infant see.

b. This ophthalmic ointment prevents gonorrheal and chlamydial infection of the infant's eyes, potentially acquired from the birth canal. The nurse should explain that prophylactic erythromycin ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal and chlamydial infection that potentially could have been acquired from the birth canal. This prophylactic ophthalmic ointment is not instilled to prevent dry eyes and has no bearing on vision other than to protect against infection that may lead to vision problems.

8. 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."

c. "Your baby will need to be corrected for prematurity."

1. An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths per minute with significant substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure (CPAP). What level of partial pressure of arterial oxygen (PaO2) indicates hypoxia? a. 67 mm Hg b. 89 mm Hg c. 45 mm Hg d. 73 mm Hg

c. 45 mm Hg

Which statement accurately describes an appropriate-for-gestational age (AGA) weight assessment? a. AGA weight assessment falls between the 25th and 75th percentiles for the infant's age. b. AGA weight assessment depends on the infant's length and the size of the newborn's head. c. AGA weight assessment falls between the 10th and 90th percentiles for the infant's age. d. AGA weight assessment is modified to consider intrauterine growth restriction (IUGR).

c. AGA weight assessment falls between the 10th and 90th percentiles for the infant's age. An AGA weight falls between the 10th and 90th percentiles for the infant's age. The AGA range is larger than the 25th and 75th percentiles. The infant's length and head size are measured, but these measurements do not affect the normal weight designation. IUGR applies to the fetus, not to the newborn's weight.

An infant boy was delivered minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. When should the Apgar assessment be performed? a. Only if the newborn is in obvious distress b. Once by the obstetrician, just after the birth c. At least twice, 1 minute and 5 minutes after birth d. Every 15 minutes during the newborn's first hour after birth

c. At least twice, 1 minute and 5 minutes after birth Apgar scoring is performed at 1 minute and at 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts. The Apgar score is performed on all newborns. Apgar score can be completed by the nurse or the birth attendant. The Apgar score permits a rapid assessment of the newborn's transition to extrauterine life. An interval of every 15 minutes is too long to wait to complete this assessment.

What is the rationale for the administration of vitamin K to the healthy full-term newborn? a. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be administered by injection. c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. d. The supply of vitamin K in the healthy full-term newborn is inadequate for at least 3 to 4 months and must be supplemented.

c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week. The maternal diet has no bearing on the amount of vitamin K found in the newborn. Vitamin K promotes the formation of clotting factors in the liver and is used for the prevention and treatment of hemorrhagic disease in the newborn. Vitamin K is not produced in the intestinal tract of the newborn until after microorganisms are introduced. By day 8, normal newborns are able to produce their own vitamin K.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the client need to be taught to care for her newborn son? a. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. b. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. c. Gently cleanse the penis with water and apply petroleum jelly around the glans after each diaper change. d. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.

c. Gently cleanse the penis with water and apply petroleum jelly around the glans after each diaper change. Gently cleansing the penis with water and applying petroleum jelly around the glans after each diaper change are appropriate techniques when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed with warm water to remove any urine or feces. If bleeding occurs, then the mother should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates are part of normal healing and cover the glans penis 24 hours after the circumcision; yellow exudates are not an infective process and should not be removed.

The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients? a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b. Federal law prohibits newborn genetic testing without parental consent. c. If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks. d. Hearing screening is now mandated by federal law.

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

The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. This clinical finding may be indicative of what? a. Excessive saliva is a normal finding in the newborn. b. Excessive saliva in a neonate indicates that the infant is hungry. c. It may indicate that the infant has a tracheoesophageal fistula or esophageal atresia. d. Excessive saliva may indicate that the infant has a diaphragmatic hernia.

c. It may indicate that the infant has a tracheoesophageal fistula or esophageal atresia. The presence of excessive saliva in a neonate should alert the nurse to the possibility of a tracheoesophageal fistula or esophageal atresia. Excessive salivation may not be a normal finding and should be further assessed for the possibility that the infant has an esophageal abnormality. The hungry infant reacts by making sucking motions, rooting, or making hand-to-mouth movements. The infant with a diaphragmatic hernia exhibits severe respiratory distress.

12. 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.

c. Kangaroo care helps infants interact directly with their parents and enhances their temperature regulation.

A nurse is assessing a newborn girl who is 2 hours old. Which finding warrants a call to the health care provider? a. Blood glucose of 45 mg/dl using a Dextrostix screening method b. Heart rate of 160 beats per minute after vigorously crying c. Laceration of the cheek d. Passage of a dark black-green substance from the rectum

c. Laceration of the cheek Accidental lacerations can be inflicted by a scalpel during a cesarean birth. They are most often found on the scalp or buttocks and may require an adhesive strip for closure. Parents would be overly concerned about a laceration on the cheek. A blood glucose level of 45 mg/dl and a heart rate of 160 beats per minute after crying are both normal findings that do not warrant a call to the physician. The passage of meconium from the rectum is an expected finding in the newborn.

15. 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

c. Mottled skin with acrocyanosis

14. 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.

c. Parents of high-risk infants need special support and detailed contact information.

A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. What is the most appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy? a. Applying an oil-based lotion to the newborn's skin to prevent dying and cracking b. Limiting the newborn's intake of milk to prevent nausea, vomiting, and diarrhea c. Placing eye shields over the newborn's closed eyes d. Changing the newborn's position every 4 hours

c. Placing eye shields over the newborn's closed eyes The infant's eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should completely cover the eyes but not occlude the nares. Lotions and ointments should not be applied to the infant because they absorb heat and can cause burns. The lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration. Therefore, adequate hydration is important for the infant. The infant should be turned every 2 hours to expose all body surfaces to the light.

13. 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

c. Preterm: Before 37 weeks of gestation and postterm beyond 42 weeks of gestation; no matter the size for gestational age at birth

4. 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

c. Slow, small, warm bolus feedings over 30 minutes

If the newborn has excess secretions, the mouth and nasal passages can be easily cleared with a bulb syringe. How should the nurse instruct the parents on the use of this instrument? a. Avoid suctioning the nares. b. Insert the compressed bulb into the center of the mouth. c. Suction the mouth first. d. Remove the bulb syringe from the crib when finished.

c. Suction the mouth first. The mouth should always be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. After compressing the bulb, the syringe should be inserted into one side of the mouth. If it is inserted into the center of the mouth, then the gag reflex is likely to be initiated. When the infant's cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The nasal passages should be suctioned one nostril at a time. The bulb syringe should remain in the crib so that it is easily accessible if needed again.

What is the primary rationale for nurses wearing gloves when handling the newborn? a. To protect the baby from infection b. As part of the Apgar protocol c. To protect the nurse from contamination by the newborn d. Because the nurse has the primary responsibility for the baby during the first 2 hours

c. To protect the nurse from contamination by the newborn With the possibility of transmission of viruses such as HBV and the human immunodeficiency virus (HIV) through maternal blood and amniotic fluid, the newborn must be considered a potential contamination source until proven otherwise. As part of Standard Precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing. Proper hand hygiene is all that is necessary to protect the infant from infection. Wearing gloves is not necessary to complete the Apgar score assessment. The nurse assigned to the mother-baby couplet has primary responsibility for the newborn, regardless of whether or not she wears gloves.

2. 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."

d. "You may hold your baby during the feeding."

Screening for critical congenital heart disease (CCHD) was added to the uniform screening panel in 2011. The nurse has explained this testing to the new mother. Which action by the nurse related to this test is correct? a. Screening is performed when the infant is 12 hours of age. b. Testing is performed with an electrocardiogram. c. Oxygen (O2) is measured in both hands and in the right foot. d. A passing result is an O2 saturation of ≥95%.

d. A passing result is an O2 saturation of ≥95%. Screening is performed when the infant is between 24 and 48 hours of age. The test is performed using pulse oximetry technology. O2 is measured in the right hand and one foot. A passing result is an O2 saturation of ≥95% with a ≤3% absolute difference between upper and lower extremity readings.

21. 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

d. Breathing in a respiratory pattern common to premature infants

A nurse is responsible for teaching new parents regarding the hygienic care of their newborn. Which instruction should the nurse provide regarding bathing? a. Avoid washing the head for at least 1 week to prevent heat loss. b. Sponge bathe the newborn for the first month of life. c. Cleanse the ears and nose with cotton-tipped swabs, such as Q-tips. d. Create a draft-free environment of at least 24° C (75° F) when bathing the infant.

d. Create a draft-free environment of at least 24° C (75° F) when bathing the infant. The temperature of the room should be 24° C (75° F), and the bathing area should be free of drafts. To prevent heat loss, the infant's head should be bathed before unwrapping and undressing. Tub baths may be initiated from birth. Ensure that the infant is fully immersed. Q-tips should not be used; they may cause injury. A corner of a moistened washcloth should be twisted into shape so that it can be used to cleanse the ears and nose.

6. 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

d. Cry face; eyes squeezed; increase in blood pressure

16. 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

d. Greater surface area in proportion to weight

As part of the infant discharge instructions, the nurse is reviewing the use of the infant car safety seat. Which information is the highest priority for the nurse to share? a. Infant carriers are okay to use until an infant car safety seat can be purchased. b. For traveling on airplanes, buses, and trains, infant carriers are satisfactory. c. Infant car safety seats are used for infants only from birth to 15 pounds. d. Infant car seats should be rear facing and placed in the back seat of the car.

d. Infant car seats should be rear facing and placed in the back seat of the car. An infant placed in the front seat could be severely injured by an air bag that deploys during an automobile accident. Infants should travel only in federally approved, rear-facing safety seats secured in the rear seat and only in federally approved safety seats even when traveling on a commercial vehicle. Infants should use a rear-facing car seat from birth to 20 pounds and to age 1 year.

As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Based on the most recent evidence, which information is incorrect and should be discussed with parents? a. Prevent exposure to people with upper respiratory tract infections. b. Keep the infant away from secondhand smoke. c. Avoid loose bedding, water beds, and beanbag chairs. d. Place the infant on his or her abdomen to sleep.

d. Place the infant on his or her abdomen to sleep. The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome (SIDS). Grandmothers may encourage the new parents to place the infant on the abdomen; however, evidence shows "back to sleep" reduces SIDS. Infants are vulnerable to respiratory infections; therefore, infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding and in furniture that can trap them. Per AAP guidelines, infants should always be placed "back to sleep" and allowed tummy time to play to prevent plagiocephaly.

17. 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

d. Response to the feeding

24. 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

d. Risk for infection

How should the nurse interpret an Apgar score of 10 at 1 minute after birth? a. The infant is having no difficulty adjusting to extrauterine life and needs no further testing. b. The infant is in severe distress and needs resuscitation. c. The nurse predicts a future free of neurologic problems. d. The infant is having no difficulty adjusting to extrauterine life but should be assessed again at 5 minutes after birth.

d. The infant is having no difficulty adjusting to extrauterine life but should be assessed again at 5 minutes after birth. An initial Apgar score of 10 is a good sign of healthy adaptation; however, the test must be repeated at the 5-minute mark.

Early this morning, an infant boy was circumcised using the PlastiBell method. Based on the nurse's evaluation, when will the infant be ready for discharge? a. When the bleeding completely stops b. When yellow exudate forms over the glans c. When the PlastiBell plastic rim (bell) falls off d. When the infant voids

d. When the infant voids The infant should be observed for urination after the circumcision. Bleeding is a common complication after circumcision, and the nurse will check the penis for 12 hours after a circumcision to assess and provide appropriate interventions for the prevention and treatment of bleeding. Yellow exudate covers the glans penis in 24 hours after the circumcision and is part of normal healing; yellow exudate is not an infective process. The PlastiBell plastic rim (bell) remains in place for approximately a week and falls off when healing has taken place.