PrepU: Chapter 24: Nursing Management of the Newborn at Risk: Acquired and Congenital Newborn Conditions, PrepU: Chapter 23: Nursing Care of the Newborn with Special Needs, Chapter 22: Nursing Management of the Postpartum Woman at Risk (Prep U), Chap...

The nurse is preparing to assess an infant who is diagnosed with a ventricular septal defect. Which assessment finding should the nurse be prepared to document?

Loud, harsh murmur

A preterm newborn is noted to be cyanotic. Which laboratory test will the nurse prepare the infant for to determine if the cyanosis is due to respiratory or circulatory problems?

arterial blood gases

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

asymmetrical movement

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? an immature autoregulation of blood flow concentration of immature blood vessels bruising from the birth process an allergic reaction to the soap used for the first bath

concentration of immature blood vessels A concentration of immature blood vessels causes salmon patches. Bruising does not look like salmon patches but would be more bluish-purple in appearance. Harlequin sign is a result of immature autoregulation of blood flow and is commonly seen in low birth weight newborns. An allergic reaction would be more generalized and would not be salmon colored.

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

meconium stained fluids followed by tachypnea

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

on the back with the head slightly extended.

It would be best to place an infant with a myelomeningocele in which position prior to surgery?

on the stomach (prone)

The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding? three arteries and no veins two arteries and two veins one artery and two veins two arteries and one vein

two arteries and one vein The normal umbilical cord contains three vessels: two arteries and one vein.

During a clinical conference, a group of nursing students are discussing a newborn that is large for gestational age. The instructor determines the students have successfully differentiated the potential cause after choosing which contributing maternal factor?

Being 30 pounds overweight before getting pregnant

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

Intubation and suctioning of the trachea

The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth?

Retinopathy

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

within 24 hours after birth The healthy newborn should pass meconium within 24 hours of life.

If a delivering mother weighed 140 pounds at the time of delivery, how much weight should she have lost when she goes home 2 days later, based upon the average pattern? 5-10 pounds 17-29 pounds 10-15 pounds 15-22 pounds

17-29 pounds Normal expected weight loss is approximately 12-14 pounds with the delivery of the fetus, placenta and amniotic fluid then an additional 5-15 pounds in the early postpartum period from fluid loss.

The nurse is teaching a prenatal class emphasizing factors that pregnant mothers can implement to ensure a healthy newborn. Which nursing recommendations would be important to discuss? Select all that apply.

-Keep all prenatal checkups. -Have good blood sugar control. -Avoid the use of any types drugs and alcohol. -Visit the dentist regularly.

A new mother is learning how to change the diaper on her newborn and becomes concerned after observing a rash on the trunk of the infant. Which response should the nurse prioritize? Explain this is normal. Check all of the baby's vital signs before calling the doctor. Immediately call the RN or health care provider. Change and bathe the infant.

Explain this is normal. Erythema toxicum is otherwise known as normal newborn rash. The rash will resolve without intervention. There is no need to call the RN or health care provider, change and bathe the infant, or check the vital signs.

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status? "What time did you last change your pad?" "When did you last void?" "Are you in any pain with your bleeding?" "How much blood was on the two pads?"

"How much blood was on the two pads?" The nurse needs to determine the amount of bleeding the client is experiencing; therefore, the best question to ask the mother is the amount of blood noted on her perineal pads when she changes them. If she had an epidural, she may not feel any pain or discomfort with the bleeding. Although a full bladder can prevent the uterus from contracting, the nurse's main concern is the amount of lochia the mother is having.

A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be: "Often, when a postpartum woman perspires like you are reporting, it means that they have an infection." "Many women sweat after delivery but you seem to be perspiring far more than normal. I'll call the doctor." "Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy." "I need to get your vital signs and check your fundus to be sure you are not going into shock."

"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy." Diaphoresis often occurs in postpartum women as a way to get rid of both excess water and waste through the skin. It is not uncommon for a woman to wake up drenched in sweat during the first few days following delivery. This is a normal finding and is not a cause for concern.

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

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

The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client? "You need to avoid medications which contain acetylsalicylic acid." "It is appropriate for you to sit with your legs crossed over each other." "You can breastfeed your newborn while taking any anticoagulation medication." "It is expected for you to have minimal blood in your urine during therapy."

"You need to avoid medications which contain acetylsalicylic acid." The nurse should caution the client to avoid products containing acetylsalicylic acid, or aspirin, and other nonsteroidal anti-inflammatory medications while on anticoagulation therapy. These medications inhibit the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. Hematuria is not expected and indicates internal bleeding. The client would be instructed to notify the primary health care provider for any prolonged bleeding. The client may not be able to breastfeed while taking anticoagulation medications. Warfarin is not thought to be excreted in breastmilk; however, most medications are excreted in breast milk. Therefore, breastfeeding is generally not recommended for the client on anticoagulation therapy.

A postpartum mother is recovering from a cesarean delivery and is reporting incisional and abdominal pain at a level of 8. Morphine sulfate is ordered as follows: Morphine Sulfate 8 mg IV q 4 hours prn for pain greater than 6. Morphine Sulfate comes in 10 mg/mL. How many milliliters of morphine would the nurse administer to this client using slow push over 5 minutes? Record your answer using one decimal place.

0.8 mL The on-hand medication is morphine sulfate 10 mg/mL. The ordered dose is 8 mg, so the nurse would calculate the dose as follows: 10 mg/1 mL = 8 mg/X mL Cross multiply, 10X = 8 mL Divide 8 by 10 to get 0.8 mL

The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? At the symphysis pubis 1 cm above the umbilicus At level of umbilicus 1 cm below the umbilicus

1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. Suction equipment Glucose water Identification bands Warmer bed Ophthalmoscope

Suction equipment Identification bands Warmer bed In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn.

The nurse is developing a plan of care for a neonate experiencing symptoms of drug withdrawal. What should be included in this plan?

Swaddle the infant between feedings.

A mother tells the nurse that she has been reading a book that says that newborns need stimulation to develop properly and asks what she can do to help her infant. Which tip would not be helpful to the mother? Rocking and singing to her infant. Swaddling the infant Holding and cuddling the infant Use of mobiles above the crib.

Swaddling the infant Stimulation of an infant allows the infant to experience the 5 senses. Holding and cuddling the infant addresses the sense of touch. Singing to the infant provides auditory stimulation. A mobile above the crib provides visual stimulation. Swaddling the infant may be comforting but provides no stimulation for the infant.

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? 750 ml 500 ml 250 ml 1000 ml

1000 ml Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth.

The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse? Teach that adequate hydration helps clear the infection quicker. Advise her to take acetaminophen to ease symptoms. Ask primary care provider to prescribe an analgesic. Instruct to use a sitz bath while voiding.

Teach that adequate hydration helps clear the infection quicker. Adequate hydration is necessary to dilute the bacterial concentration in the urine and aid in clearing the organisms from the urinary tract. Encourage the woman to drink at least 3000 mL of fluid a day, suggesting she drink one glass per hour. Drinking fluid will make the urine acidic, deterring organism growth. The other choices are also options but address the symptoms and not the root cause. The goal should be to rid the body of the infection, not concentrate on counteracting the results of the infection.

A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification?

Term, small for gestational age, and low-birth-weight infant

The nurses at a local free clinic are concerned there may be an increase in small-for-gestational age infants in the community. When collecting data to research the situation, the nurses will exclude infants above which category?

The 10th percentile for gestational age

The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding? There is an infection inside the uterus. The uterine placement is normal. The uterus is filling up with blood. The bladder is distended.

The bladder is distended. If a postpartum client's bladder becomes full, the client's uterus is displaced to the side. The client should be taught to void on demand to prevent the uterus from becoming soft and increasing the flow of lochia.

A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding? The breakdown of RBCs release bilirubin, which the liver cannot excrete. The newborn's Vitamin K levels are low. The GI tract is immature, so the bilirubin remains in the intestines. Feedings are not adequate to eliminate the build-up of bilirubin.

The breakdown of RBCs release bilirubin, which the liver cannot excrete. After birth, the newborn's hematocrit is about 45% to 65%, which is not needed after birth for oxygenation. The cells then die and are broken down, releasing bilirubin. The liver normally breaks down the bilirubin and eliminates it but since the liver is immature, it becomes overwhelmed and the bilirubin builds up in the bloodstream. Vitamin K levels have no effect on bilirubin levels. The immaturity of the GI tract does not cause the bilirubin to increase and feedings do not directly affect bilirubin levels.

A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? The color of the flow is red. Her uterus is soft to your touch. The flow is over 500 mL. The flow contains large clots.

The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? 24 hours after the newborn's first protein feeding 36 hours before the infant is discharged home with its parents When the infant is 48 hours old Just before discharge home

24 hours after the newborn's first protein feeding The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

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

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

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

The infant is attempting self-consoling maneuvers. The hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. The other options are states of behavior of a newborn but are not applicable to this situation.

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

The infant is attempting self-consoling maneuvers. The hand-to-mouth movement of the baby indicates the self-quieting and consoling ability of a newborn. The other options are states of behavior of a newborn but are not applicable to this situation.

The client brings her infant daughter to the pediatrician's office for her first visit since hospital discharge. At birth, the newborn was at the 8th percentile with a weight of 2,350 g. She was born at 36 weeks' gestation. Which documentation is most accurate?

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

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

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

What should the nurse expect for a full-term newborn's weight during the first few days of life? A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%. There is an increase in 3% to 5% of birth weight by day 3 in formula-fed babies. There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. There is a loss of 5% to 10% of the birth weight in the first few days in breastfed infants only.

There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns. The nurse should expect the newborn who is breastfed or formula-fed to lose 5% to 10% of birth weight in the first few days of life.

What is the expected range for respirations in a newborn? 20 to 40 breaths per minute 40 to 80 breaths per minute 10 to 30 breaths per minute 30 to 60 breaths per minute

30 to 60 breaths per minute Although episodic breathing is normal and short periods of apnea can occur, the normal respiratory rate for a newborn is 30 to 60 breaths per minute. For adults, it is typically 8 to 20 breaths per minute.

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

40 mg/100 mL whole blood

The new mother has decided to feed her infant formula. When teaching her about the different types of formula, the nurse should stress the infant should receive how many calories each day? 800 calories 650 calories 500 calories 950 calories

650 calories Newborns need about 108 cal/kg or approximately 650 cal/day. Therefore, they will need 2 to 4 ounces at each feeding to feel satisfied. Until about 6 months, most bottle-fed infants need six feedings a day.

A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner? A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn. A birth weight between 2200 and 3000 g is considered small for gestational age. Normal birth length is usually 52 cm or above for a full-term newborn. A length between 48 and 50 cm plots out at the 95th percentile for length.

A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn. Average birth weight for a newborn is between 5 lb, 8 oz (2500 g) and 8 lb, 13 oz. (4000 g). Average length at birth for a newborn is between 19 and 21 inches (48 to 53 cm).

The nurse is caring for an infant diagnosed with a ventricular septal defect. Which assessment findings does the nurse anticipate?

A harsh murmur

The nurse is reviewing the medical record of the antepartum client with an abnormal alpha-fetoprotein test. The mother is distraught and states, "How bad can it be?" The nurse is correct to describe which?

A type of spina bifida

The nurse is caring for a patient who has gone into labor 6 weeks early and whose amniocentesis has shown a lack of lecithin. Of the following interventions, which would the nurse most likely do first?

Administer a glucocorticosteroid to the mother

A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed? 1 day after birth After the newborn has completed the antibiotic therapy Before discharge from the hospital 1 month after discharge

After the newborn has completed the antibiotic therapy It is recommended that all newborns undergo a hearing screening before they are discharged from the hospital. If the newborn is treated with an ototoxic medication such as gentamycin, the hearing screen must be conducted after completion of the antibiotic therapy.

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? Fewer complications than if done later in life Anesthetic may not be effective during the procedure Lower rate of urinary tract infections Reduced risk of penile cancer

Anesthetic may not be effective during the procedure The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure.

Immediately after birth, the nurse is caring for a newborn with a myelomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage?

Apply a sterile dressing moistened in a warm sterile saline solution.

A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." What is the nurse's most appropriate response? Ask the client why she does not want to go home. Inform the primary care provider that the client does not want to go home. Tell the client that she must go home as per hospital policy. Ask the client if she has any support in the home.

Ask the client why she does not want to go home. It is important for the nurse to identify the client's concerns and reasons for wanting to stay in the hospital. Open-ended questioning facilitates both effective and therapeutic communication and allows the nurse to address concerns appropriately. Asking about supports at home implies that the nurse has made assumptions about why the client may not want to go home. Informing the care provider or telling the client that discharge is hospital policy is not appropriate at this time because the nurse has not addressed the underlying reason for the client's comment. The client may have safety-related concerns, undisclosed fears, or a need for increased support before discharge. It is imperative that the nurse not make assumptions but further explore concerns.

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? Blanch a toe, and count the seconds it takes to color again. Assess for pedal edema. Ask her to raise her foot and draw a circle. Bend her knee, and palpate her calf for pain.

Assess for pedal edema. Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? Call the woman's health care provider. Initiate Ringer's lactate infusion. Assess the woman's vital signs. Assess the woman's fundus.

Assess the woman's fundus. The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding. Assessing the vital signs would be the next step, especially if the massage is ineffective, to determine if the client is becoming unstable. The nurse would then alert the RN or health care provider about the increased bleeding and/or unstable vital signs. The LPN would not initiate an IV infusion without an order from the health care provider but should be prepared to do so, if it is ordered.

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority? Ensure that the newborn's daily bath is performed by the nurses. Allow time for the numerous visitors who come to see the woman and newborn. Provide time for prayers to be performed at the bedside. Assign a female nurse to care for her.

Assign a female nurse to care for her. Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Nurses give the daily bath for newborns of some Japanese-American women. Numerous visitors can be expected to visit some women of the Filipino-American culture because families are very closely knit. Bedside prayer is common due to the strong religious beliefs of the Filipino-American culture.

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching? Wear knee-high stockings when possible. Avoid over-the-counter (OTC) salicylates. Avoid iron replacement therapy. Shortness of breath is a common adverse effect of the medication.

Avoid over-the-counter (OTC) salicylates. Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism.

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma?

Cephalhematoma

Which assessment findings are most prominent in the infant with Tetralogy of Fallot and significant pulmonary stenosis?

Dyspnea on limited exertion, fatigue, cyanosis

A nursing student has read that cleft lip is diagnosed at birth based on inspection of physical appearance and that cleft palate is diagnosed in which way?

Feeling the palate with a gloved finger or using a tongue blade

Parents are taking home their second child. They also hve a 2-year-old at home. The nurse would anticipate which behavior by these parents? General questions about different aspects of newborn care Only questions specific to breast-feeding No questions of the nurse Confidence since they have another child already

General questions about different aspects of newborn care Just because parents have had a previous child does not mean that they will not have questions about their newborn infant. Each newborn is different and parents my not feel comfortable this time caring for the newborn.

A nurse is changing a newborn's diaper and realizes that the bassinet is out of diapers. What would be the best choice of action to alleviate the problem? Go get another pack of diapers for the bassinet from the supply closet. Go to the next bassinet and take a diaper from that newborn's drawer. Tell the parents that their newborn needs more diapers. Go from bed to bed and locate some more diapers for the infant.

Go get another pack of diapers for the bassinet from the supply closet. Infection control measures dictate that there is no sharing of supplies between newborns, so the best choice would be to get another package of diapers for the newborn. Also, the parents are not responsible for diapers until after the newborn is discharged.

The nurse is caring for a pregnant woman who is struggling with controlling her gestational diabetes mellitus. What effect does the nurse predict this situation may have on the fetus?

Grow to an unusually large size

The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition?

Hemolytic disease

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

Hypoglycemia

The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize? Ineffective airway clearance related to mucus and secretions Altered nutrition less than body requirement related to limited formula intake Altered urinary elimination related to postcircumcision status Ineffective thermoregulation related to heat loss to the environment

Ineffective airway clearance related to mucus and secretions Any airway clearance or obstruction issue is the highest priority for nursing interventions, whether the infant is born via vaginal or cesarean delivery. The other options are valid nursing diagnoses for some newborns; however, they would not take precedence over an airway problem.

The nurse is evaluating the morning blood glucose results from the laboratory of several 1-day-old infants. Which result should the nurse prioritize for further action? Infant C - 48 mg/dL Infant D - 60 mg/dL Infant B - 56 mg/dL Infant A - 52 mg/dL

Infant C - 48 mg/dL Blood glucose levels between 50 and 60 mg/dL during the 24 hours of life are considered normal. Levels less than 50 are indicative of hypoglycemia in the newborn. Infant C is showing potential hypoglycemia. Infants A, B, and D have values within the normal range.

The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation? Normal vital signs Shock Dehydration Infection

Infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration.

The nurse caring for a newborn notes a distended abdomen approximately 24 hours after birth. Which action should the nurse prioritize after review of the medical record reveals an apparent healthy newborn at birth but no documentation of a bowel movement

Inform the RN and/or primary care provider immediately

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

Initiate early oral feedings.

In the infant born with a cleft lip and a cleft palate, the highest priority of the nurse is related to which intervention?

Maintaining the nutritional needs if the infant

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder? Plugged milk duct Breast yeast Mastitis Engorgement

Mastitis Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Assessment should reveal a localized reddened area that is warm and painful to palpation. The scenario described is not indicative of a plugged milk duct or engorgement. Yeast is not recognized to cause mastitis.

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

Meconium aspiration in utero or at birth

When assessing infant reflexes, the nurse documents a startled response and extension of the arms and legs as which reflex? Moro tonic neck rooting fencing

Moro The Moro reflex is also known as the startle reflex. When the infant is startled they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.

A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. Observe respiratory status frequently. Massage the newborn's back. Provide warm water to drink. Ensure the newborn's warmth. Provide oxygen supplementation.

Observe respiratory status frequently. Ensure the newborn's warmth. Provide oxygen supplementation. The nurse should give the newborn oxygen, ensure the newborn's warmth, and observe the newborn's respiratory status frequently. The nurse need not give the newborn warm water to drink or massage the newborn's back.

In which position should the nurse place a newborn to administer oxygen by bag and mask?

On the back with the head slightly extended

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

Peeling and wrinkling of the neonate's epidermis

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? Percussion reveals dullness. Bladder is nonpalpable. Lochia is less than usual. Uterus is firm.

Percussion reveals dullness. A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.

The nurse is monitoring a new mother changing her newborn's diaper and notices a musty smell to the infant's urine. Which condition should the nurse prioritize in further assessments to rule out?

Phenylketonuria

The nurse is conducting a postparum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize? Place an ice pack. Notify a primary care provider. Apply a warm washcloth. Put on a witch hazel pad.

Place an ice pack. The labia and perineum may be edematous after birth and bruised; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the primary care provider. Notifying a care provider is not necessary at this time as this is considered a normal finding.

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

Retinopathy of prematurity

The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex? Rooting Sucking Moro Tonic neck

Rooting This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle) reflex are total body reflexes and assess neurologic function in the newborn.

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted? Provide phone numbers for call centers for questions. Schedule home visits for high-risk families. Ask family members to monitor the parents' progress. Encourage frequent clinic visits for high-risk families.

Schedule home visits for high-risk families. To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents' coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system.

A nursing student is caring for a newborn with a defect in the neural arch where the posterior laminae of the vertebrae have failed to close. The nurse knows that this infant is suffering from which disorder?

Spina bifida

When providing care to a newborn with necrotizing enterocolitis (NEC), the nurse would need to report which finding immediately?

abdomen appearing red and shiny

When examining a newborn for developmental hip dysplasia, which motion would the newborn's hip be unable to accomplish?

abduction

The nurse suspects that a mother who delivered her infant 2 weeks ago is experiencing postpartum depression. What is the first line of treatment for this client? scheduling electroconvulsive therapy administrating a selective serotonin reuptake inhibitor talking to the client and reassuring her that she will feel better soon telling the client that she has no need to be depressed

administrating a selective serotonin reuptake inhibitor Selective serotonin reuptake inhibitors are the first-line drugs for postpartum depression and will help the new mother cope with the stresses of motherhood. They are also safe for breastfeeding mothers. Electroconvulsive therapy is used on women who are not responsive to medications. Minimizing the importance of the depression is counterproductive and not supportive of the mother.

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? Apgar score heart rate blood sugar temperature

blood sugar Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dL).

The nurse suspects a preterm newborn receiving enteral feedings of having necrotizing enterocolitis (NEC). What assessment finding best correlates with this diagnosis?

bloody stools

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

chest rises with each bag compression.

Following birth, the newborn's independent circulatory system is established. If there is an abnormal opening between the chambers in the heart, which cardiac defect may occur?

Ventricular septal defect

A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction after making which statement?

All congenital disorders can be diagnosed at birth.

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

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

A client who gave birth 2 hours ago expresses concern about her baby developing jaundice. Which response from the nurse would be best?

"I understand your concern because as many as 50% of babies can develop jaundice."

The nurse is caring for a newborn client newly diagnosed with dysplasia of the hip. Which response by the nurse educates the parents on the correct plan of treatment for this diagnosis?

"Treatment will begin immediately."

A newborn is scheduled for casting to correct a talipes disorder. You would advise her parents that the cast will extend

Above the knee

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

Alveolar collapse on expiration

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

Alveolar collapse on expiration

Which clinical manifestation is seen in the child with hydrocephalus?

An extremely large and rapidly growing head

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

Apnea

A postpartum woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartum? Ask her if she feels any warmth in her legs. Palpate her feet for tingling or numbness. Assess for calf redness and edema. Take her temperature every 4 hours.

Assess for calf redness and edema. Calf redness and edema, especially at the ankle and along the tibia, suggest thrombophlebitis.

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

Assess for decrease in urinary output.

A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate? Assist the woman into the shower, and have her run cold water over her breasts. Assist the woman in placing ice packs on her breasts. Explain to the woman that she should breastfeed because she is producing so much milk. Ask if she wants a breast pump to empty her breasts.

Assist the woman in placing ice packs on her breasts. If the breasts are engorged and the woman is bottle-feeding her newborn, instruct her to keep a support bra on 24 hours per day. Cool compresses or an ice pack wrapped in a towel will usually be soothing and help to suppress milk production.

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

Begin early feedings either by the breast or bottle.

A newborn at 33 weeks' gestation has an Apgar score of 5 at 10 minutes of life. Which nursing action is a priority?

Begin resuscitation measures.

The nurse is questioning the effective bonding of a client and her 2-day-old infant after noting signs of impaired bonding and attachment. Which actions does the nurse find concerning? Asking for assistance changing a diaper Making eye contact with the baby Calling the baby "it" or "they" Breastfeeding the infant on demand

Calling the baby "it" or "they" Many new parents will need assistance with diaper changes; this is not a flag for concern. Making eye contact and breastfeeding are positive interaction behaviors. If the mother calls the baby "it" and does not use the child's name, this is a sign that further information needs to be gathered and assessments should be completed.

New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents? Crying indicates that the newborn has a need, so changing the diaper and feeding the infant should help. Rocking the newborn may soothe her but the time needs to be limited to 30 minutes per session. Try walking with the newborn around the house then place her back in the crib to let her cry for a while. Holding and comforting the newborn will not cause the infant to become spoiled.

Holding and comforting the newborn will not cause the infant to become spoiled. Newborns often have periods of crying; the parents should first check for a physical reason for crying such as hunger or a soiled diaper. If this is not the cause, then the parents need to try to soothe the newborn by holding, walking, rocking the newborn or even taking the infant for a ride in the car. Reassure the parents that they will not spoil the newborn by meeting its needs.

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

Intercostal and substernal retractions

A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanelle, cyanosis, and increased head circumference. These signs indicate the newborn has which complication?

Intraventricular hemorrhage (IVH)

When planning preoperative care for a newborn with a cleft lip and palate, a major need for which the nurse would plan interventions is:

Nutrition

The nurse is preparing a nursing care plan for an infant who was born with spina bifida with myelomeningocele. Which nursing goal should the nurse prioritize for this child?

Preventing infection

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

Provide a mobile the child can see no matter how the child is turned.

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

aging placenta.

What is a consequence of hypothermia in a newborn?

holds breath 25 seconds

When evaluating a newborn with congenital clubfoot, the nurse recognizes this condition usually involves:

internal rotation of leg.

A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production? estrogen oxytocin progesterone prolactin

prolactin Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum.

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? mastitis normal findings in breastfeeding mothers an improperly positioned baby during feedings too much milk being retained

mastitis Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly.

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition?

expiratory grunting

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

expiratory grunting.

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

-Avoid coming to work when ill. -Use sterile gloves for an invasive procedure. -Initiate universal precautions when caring for the infant.

A nurse is caring for a large-for-gestational-age newborn. Which signs would lead the nurse to suspect that the newborn is experiencing hypoglycemia? Select all that apply.

-Lethargy and stupor -Respiratory difficulty -Appearance of central cyanosis

When instructing a new mom on providing skin care to her newborn, which statement should not be included in the teaching? "Change diapers frequently." "Give the newborn sponge baths until the umbilical cord falls off." "Daily tub baths are not necessary." "Use talc powders to prevent diaper rash."

"Use talc powders to prevent diaper rash." Talc powders can be a respiratory hazard and should not be used with a newborn.

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

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

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

30 mg/dL

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

RDS is caused by a lack of alveolar surfactant.

The parents are upset their newborn has a cleft lip. When describing the treatment, the nurse should mention that surgical repair can be done:

between the age of 6 to 12 weeks.

A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching?

"We can probably start feeding him with the bottle about a day after the surgery."

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding." "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." "Your newborn should finish a bottle in less than 15 minutes." "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed."

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." A sign of adequate formula intake is when the newborn seems satisfied and is gaining weight regularly. The formula fed newborn should take 30 minutes or less to finish a bottle, not less than 15 minutes. The newborn does normally produce several stools per day, but should wet 6 to 10 diapers rather than 3 to 4 per day. The newborn should consume approximately 2 oz of formula per pound of body weight per day, not per feeding.

A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request? "Your baby is so vulnerable to infections right now that it would be better to wait until you are at home to introduce her to her siblings." "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" "That's a great idea! They can also take the baby out into the hall and walk with it for a while to give you a break." "I recommend that you introduce the new baby to her siblings once you are back at home. Right now you need to rest and recover."

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.

A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? "Talk to your 2-year-old about the baby when you're driving him to day care." "Ask your 2-year-old to pick out a special toy for his sister." "Have your 2-year-old stay at home while you're here in the hospital." "Expect to see your 2-year-old become more independent when the baby gets home."

"Ask your 2-year-old to pick out a special toy for his sister." The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn.

A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement? "My episiotomy should begin to heal and feel better over the next few weeks" "If I develop chills or my fever goes above 100.4℉ (38℃), I need to let someone know." "I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." "I need to let the doctor know if my lochia begins to have a foul smell."

"I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." Breast engorgement may be uncomfortable but there should never be reddened, painful areas on either breast and, if this occurs, the doctor needs to be called. This is not normal and the mother needs further teaching. Development of a fever or the lochia becoming foul smelling both indicate a possible infection and the doctor needs to be notified. The mother is correct in stating that the episiotomy should heal over the next few weeks.

When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage? "It'll be fun to have a baby in the house, but things shouldn't change too much." "I didn't realize all that went into being a dad. I wasn't prepared for this." "I may not be a pro at helping out with the baby, but I enjoy being involved." "I've learned how to diaper and bathe the baby so I can be a really involved dad."

"I didn't realize all that went into being a dad. I wasn't prepared for this." The statement about not feeling prepared reflects the realization that the man's expectations were not realistic. Many wish to be more involved but do not feel prepared to do so, and this is characteristic of the second stage, reality. The statement that it will be fun to have a baby around but life will not change too much indicates a preconceived idea about what home life will be like with a newborn; this is characteristic of the first stage, expectations. The statement about things not changing reflects the first stage of expectations, where the partner is unaware of the changes that may occur after the birth of the newborn. The statement about learning new skills and enjoying being involved indicate a conscious decision to be at the center of the newborn's life; this is characteristic of the third stage, transition to mastery.

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant? "I will make handprints and footprints of the baby for you to keep." "Many mothers who have lost an infant want pictures of the baby. Can I make some for you?" "I know you are hurting, but you can have another baby in the future." "Have you named your baby yet? I would like to know your baby's name."

"I know you are hurting, but you can have another baby in the future." Parents who have experienced a stillborn need support from the nursing staff. Statements by the nurses need to be therapeutic for the grieving parents. Statements that offer false hope or diminish the value of the stillborn child cause the parents pain. Telling them that they can have another child is both thoughtless and hurtful.

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? "Sitz baths worked the last time." "My mom always used dibucaine." "I already have some pads with witch hazel at home." "I only eat a low-fiber diet."

"I only eat a low-fiber diet." Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching? "I need to avoid using any aspirin-containing products." "If my lochia increases, I need to call my health care provider." "If I get a cut, I need to apply direct pressure for about 5 minutes or more." "I should brush my teeth vigorously to stimulate the gums."

"I should brush my teeth vigorously to stimulate the gums." The client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury. An increase in lochia warrants notification of the health care provider. Aspirin and aspirin-containing products should be avoided. If the client experiences a cut that bleeds, she should apply direct pressure to the site for 5 to 10 minutes.

A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be: "If you are breast-feeding, that will help make your uterus contract and get smaller." "There is really nothing you can do to speed along the progress, so just be patient." "Eating a large amount of protein and carbohydrates will help make the uterus contract." "I would recommend that you rest for a few days to allow your body to heal and get back to normal."

"If you are breast-feeding, that will help make your uterus contract and get smaller." There are several things that a new mother can do to assist in uterine involution. The most well known one is breast-feeding the infant. Whenever a new mother breast-feeds her infant, it stimulates the release of oxytocin, which stimulates the uterus to contract. The mother is also advised to eat a well-balanced diet and ambulate early in the postpartum period.

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? "Let me call your health care provider about this problem." "It might take up to a week for your bowels to return to their normal pattern." "I'll get a laxative prescribed so that you can move your bowels." "That's unusual. Are you making sure to eat enough?"

"It might take up to a week for your bowels to return to their normal pattern." Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the health care provider is not necessary, and this statement could add to the client's current concern.

A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase? "It sounded like you had quite a time getting here. Would you like to continue your story?" "If you plan to breast-feed, you need to calm down." "You have a beautiful baby, why worry about that now?" "I need to assess your fundus now."

"It sounded like you had quite a time getting here. Would you like to continue your story?" The mother is going through the taking-in phase of relating events during her pregnancy and birth. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation.

A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." "Tell me, are you seeing things that aren't there, or hearing voices?" "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to."

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? "If you don't attempt to void, I'll need to catheterize you." "I'll contact your health care provider." "I'll check on you in a few hours." "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the care provider at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? "I'll contact your primary care provider." "I'll check on you in a few hours." "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." "If you don't attempt to void, I'll need to catheterize you."

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the primary care provider at this time, because the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?" "Let me show you how to calm him down. I've been doing this for many years." "You would probably be more successful if you wrapped him in on a warm blanket." "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." Parents need support when trying to care for their newborn infants. By offering positive phrases and encouraging the mother in her caretaking, the nurse conveys acceptance and confirms the mother's abilities.

The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best? "No, it is the blink reflex. It is meant to protect the eyes." "Yes, she is afraid you will drop her." "No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." "No, it is the tonic neck reflex. It signifies handedness."

"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker." The Moro reflex is known as the startle reflex. A startled newborn will extend the arms and legs away from the body and to the side. Then the arms come back toward each other with the fingers spread in a "C" shape. The arms look as if the newborn is trying to embrace something. The Moro reflex should be symmetrical.

After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? "Postpartum psychosis usually appears soon after the woman comes home." "Postpartum blues usually resolves by the 4th or 5th postpartum day." "Postpartum depression develops gradually, appearing within the first 6 weeks." "Postpartum psychosis usually involves psychotropic drugs but not hospitalization."

"Postpartum depression develops gradually, appearing within the first 6 weeks." Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy.

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response? "Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." "The teeth will fall out within the first month, so don't worry about them." "The teeth will fall out when the newborn's baby teeth come in so this is a blessing." "This is most unusual! Let me get the lactation specialist to assist you in breastfeeding. It should not be a problem though."

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." Precocious or natal teeth occur infrequently but need to be addressed when they are present. They may cause the mother discomfort when nursing and pumping may be needed initially until the mother can condition the newborn not to bite. Precocious teeth are often loose and need to be removed to prevent aspiration. Even if they are not loose, they are often removed due to them causing ulcerations on the newborn's tongue from irritation. They will not just fall out and are not the newborn's actual baby teeth that are just coming in early.

New parents are getting ready to go home and have received information to help them learn how best to care for the new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? "We'll turn the mobile on that's hanging above his head in his crib." "We'll lightly rub his back as we talk to him softly." "We'll swaddle him snuggly to make him feel secure." "We'll hold off on feeding him for a while because he might be too full."

"We'll hold off on feeding him for a while because he might be too full." The parents need more teaching that feeding or burping can be helpful in relieving air or stomach gas. Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn provides security and comfort.

A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching? "Breastfeeding takes time and practice." "Some women just can't breastfeed. Maybe I'm one of these women." "Some babies latch on and catch on quickly; others take a little more time." "Maybe a lactation specialist can help me work through this."

"Some women just can't breastfeed. Maybe I'm one of these women." The statement about some women not being able to breastfeed is incorrect and displays a negative attitude, indicating that the woman is at fault for the current situation. Breastfeeding takes time and practice and is a learned response. Support and practical suggestions can be helpful. Understanding that some babies need more time helps to reduce any frustration and uncertainty about her ability to breastfeed. A lactation consultant can provide the woman with additional support and teaching to foster empowerment in this situation.

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

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

A mother is concerned because her 2-day-old newborn's birth weight was 8 lb (3584 g) and his current weight is 7 lb 8 oz (3360 g). What would be the nurse's response to the mother's concern? "The weight loss may be indicative of some underlying health problem. I need to notify the doctor." "The weight loss is a normal finding, since newborns lose 5% to10% of their birth weight in the first few days after birth." "Although newborns lose some weight after birth due to poor nutrition, this amount is concerning." "The newborn needs to be fed more frequently to stop this weight loss pattern."

"The weight loss is a normal finding, since newborns lose 5% to10% of their birth weight in the first few days after birth." The normal weight loss of a newborn is 5% to10% of their birth weight, which means an average of 6 to 10 oz (168 to 280 g). This newborn's weight loss falls within the normal range. There is no need to increase the feeding frequency or notify the doctor and there is no indication of any underlying health problem.

The parents of a newborn baby boy ask the nurse about circumcising their son. They are undecided as to what to do. Which response by the nurse is best? "There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." "Circumcision is best in order to protect the baby from diseases like cancer." "If you do not circumcise your baby, he will always have difficulty maintaining adequate hygiene." "It is best not to circumcise your baby because the procedure is very painful."

"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." If the parents decide to have their male newborn circumcised, informed consent is necessary. It is the primary care provider's responsibility to obtain informed consent, although the nurse may be responsible for witnessing the parents' signatures to a written documentation of that consent. If the parents have unanswered questions, the nurse should notify the care provider before the procedure is done.

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse? "The baby may have a problem; let's schedule an appointment." "If this continues, call us back; for now, just watch her." "This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." "This can be related to cleaning her perineal area; be more careful."

"This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." The mother is describing pseudomenstruation and is usually the result of the infant no longer having the mother's hormones in the body. This is not a cause for alarm. It is always appropriate to offer to schedule an appointment if the mother continues to be upset. The nurse should know that the infant's "bleeding" is not indicative of a pathologic process and should be careful to not upset the mother further. The statement of it being related to the way the mother is cleaning the perineum is incorrect for it places the blame on the mother for the infant's problem. The instruction to call back if it continues does not meet the mother's need to know why this is happening to her baby, and it negates her concern for her infant.

A nurse teaches new parents about how to soothe their crying newborn. Which statement by the parents indicates that they understand how to soothe their newborn if he becomes upset? "We'll turn the mobile on that's hanging above his head in his crib." "We'll place him on his belly on a blanket on the floor." "We'll hold off on feeding him for a while because he might be too full." "We'll vigorously rub his back as we play some music."

"We'll turn the mobile on that's hanging above his head in his crib." Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn rather than having him lie on a blanket on the floor provides security and comfort. Feeding or burping can be helpful in relieving air or stomach gas.

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate? "It takes a while to get your body back to its normal function after having a baby." "This is entirely normal, and many women go through it. It just takes time." "You might try using a water-soluble lubricant to ease the discomfort." "Try doing Kegel exercises to get your pelvic muscles back in shape."

"You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client? "Anesthesia causes decreased bladder tone, which causes you to urinate more frequently." "Larger than normal amounts of urine frequently occurs due to swelling of tissues surrounding the urinary meatus." "Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." "Bruising and swelling of the perineum often causes excessive urination."

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." Postpartum diuresis is due to the buildup and retention of extra fluids during pregnancy. Bruising and swelling of the perineum, swelling of tissues surrounding the urinary meatus, and decreased bladder tone due to anesthesia cause urinary retention.

The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply

- swaddling the newborn closely -offering a pacifier prior to a procedure -encouraging kangaroo care during procedures

A set of newborn twins have been admitted to the neonatal intensive care unit with the diagnosis of fetal growth restriction (FGR). Which maternal factors would predispose the newborn to this diagnosis? Select all that apply.

- A1C levels of 8% - heroin use -blood pressure baseline of -170/90 mm Hg -maternal age 39 -multiple gestation

The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply.

-swaddling the newborn closely -offering a pacifier prior to a procedure -encouraging kangaroo care during procedures

A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. The nurse integrates understanding of this measure, administering the feedings at which rate?

0.5 to 1 mL/kg/h

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? 3 weeks 1 week 4 weeks 2 weeks

2 weeks Postpartum blues is a phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders. Symptoms usually arise within the first few days after childbirth, reaching a peak at 3 to 5 days and spontaneously disappearing within 10 days. Although postpartum blues is usually benign and self-limited, these mood changes can be frightening to the woman. Women should also be counseled to seek further evaluation if these moods do not resolve within 2 weeks as postpartum depression may be developing.

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? 1,000 additional calories per day 250 additional calories per day 750 additional calories per day 500 additional calories per day

500 additional calories per day The breastfeeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.

A newborn is born and, at 1 minute of life, is acrocyanotic, HR is 110, is floppy with some flexion, has a weak cry and grimaces. What Apgar score would the nurse assign this infant? 9 7 6 8

6 According to the Apgar criteria, acrocyanosis is scored as 1, HR over 100 is scored as 2, grimace is scored as 1, some flexion is scored as 1, and a weak cry is scored as 1. This totals 6 for the 1-minute Apgar score.

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: 5 to 9. 12 to 15. 7 to 10. 1 to 2.

7 to 10. An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.

The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she is most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women? 40% 85% 25% 100%

85% Postpartum blues, or mild depression during the first 10 days after giving birth, affects up to 85% of women who give birth. More intense depression during this period is referred to as postpartum depression, which affects approximately 10% to 15% of postpartum clients. Postpartum depression can be severe with negative implications for maternal and neonatal well-being.

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)?

Sternal retraction

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? milia stork bites Epstein's pearls Mongolian spots

Epstein's pearls Unopened sebaceous glands are generally called milia. When they are in the mouth and gums, they are called Epstein's pearls.

A nurse is providing care to a postpartum woman who gave birth vaginally 6 hours ago. The client is reporting perineal pain secondary to an episiotomy. Which intervention would be most appropriate for the nurse to implement at this time? Apply a glycerin-based ointment to the area. Encourage use of a sitz bath. Instruct in the use of witch hazel compresses. Apply an ice pack to the perineal area.

Apply an ice pack to the perineal area. Commonly, an ice pack is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration. An ice pack seems to minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to the site. It is applied during the fourth stage of labor and can be used for the first 24 hours to reduce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing. After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids. Witch hazel compresses are used for hemorrhoidal discomfort. Glycerin-based ointments can be used to address nipple pain.

The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client? Bend the knee and palpate the calf for pain. Assess for warmth, erythema, and pedal edema. Ask the client to raise the foot and draw a circle. Blanch a toe, and count the seconds it takes to color again.

Assess for warmth, erythema, and pedal edema. This client is demonstrating potential symptoms of DVT, but is avoiding putting pressure on the leg and limping when ambulating. DVT manifestations are caused by inflammation and obstruction of venous return and can be assessed by the presence of calf swelling, warmth, erythema, tenderness, and pedal edema. The client would not need to bend the knee to assess for pain in the calf. Asking the client to raise her toe and draw a circle is assessing reflexes, and blanching a toe is assessing capillary refill (which may be affected by the DVT but is not indicative of a DVT).

A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply. Monitor the client's vital signs. Assess the client's uterine tone. Assess the client's skin turgor. Assess deep tendon reflexes. Get a pad count.

Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count. A nurse should evaluate the efficacy of IV oxytocin therapy by assessing the uterine tone, monitoring vital signs, and getting a pad count. Assessing the skin turgor and assessing deep tendon reflexes are not interventions applicable to administration of oxytocin.

A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant?

The neonate is small for its gestational age.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? Postpone breastfeeding until after the initial bath. Bathe the baby under a radiant warmer. Limit the bathing time to 5 minutes. Bathe the baby in water between 90 and 93 degrees.

Bathe the baby under a radiant warmer. Bathing a newborn under a radiant warmer helps to prevent heat loss. To minimize the effects of cold stress during the bath, the nurse should also prewarm blankets, dry the child completely to prevent heat loss from evaporation, encourage skin-to-skin contact with the mother, promote early breastfeeding, used heated and humidified oxygen, and defer bathing until the newborn is medically stable. Limiting the length of time spent bathing the baby is secondary to maintaining the baby's body temperature. Having warm water is also important but is irrelevant if the baby is not kept warm under a warmer.

How can new parents aid their newborn to develop trust so the infant can become more organized in the responses to his or her environment? Allow the newborn opportunities to self-soothe by crying himself to sleep. Place the infant in an open crib to allow freedom of movement. Be attentive to the basic needs of the infant and be consistent. Have the parents place the infant on a schedule as soon as possible.

Be attentive to the basic needs of the infant and be consistent. To enhance an infant's organization and develop a sense of trust, parents need to consistently meet the infant's needs through feedings, holding him and keeping him dry. Swaddling, not allowing freedom of movement, also helps the infant feel secure. Self-soothing at this age is discouraged because the infant needs to feel that someone is always there and attentive to his needs.

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

Blood Pressure The blood pressure of a newborn should be quite low—around 60-70 over 35 to 50. The heart rate and respiratory rate are both high, which are normal findings. The temperature falls within a normal range of 97.7℉ to 99.5℉ (36.5℃ to 37.5℃).

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? Degree of responsiveness, respiratory rate, fundus location Attachment, lochia color, complete blood cell count Blood pressure, pulse, reports of dizziness Height, level of orientation, support systems

Blood pressure, pulse, reports of dizziness Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day. Recommend that the mother pump her breast milk and measure it before feeding. Add cereal to the newborn's feedings twice a day. Breastfeed the infant every 2 to 4 hours on demand.

Breastfeed the infant every 2 to 4 hours on demand. Breastfeeding the newborn every 2 to 4 hours on demand is the best way to help the infant gain weight the fastest. Normal weight gain for this age infant is .66 to 1 ounce (19 to 28 grams) per day, not 1.5 to 2 ounces (42.5 to 57 grams). Cereal is never given to infants this young. The mother does not need to pump her breast milk to measure it. As long as the newborn is feeding well and has 6+ wet diapers and 3+ stools, the infant is receiving adequate nutrition.

The nurse notes that a client's uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next? Offer analgesics prescribed by health care provider. Perform vigorous fundal massage for the client. Check for bladder distention, while encouraging the client to void. Use semi-Fowler position to encourage uterine drainage.

Check for bladder distention, while encouraging the client to void. If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distention and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the health care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? Assess the temperature. Monitor the pain level. Assess the fundal height. Check the lochia.

Check the lochia. The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4° F (38° C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus.

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? Location, shape, and content Content, lochia, place Consistency, shape, and location Consistency, location, and place

Consistency, shape, and location Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day.

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? Radiation Conduction Convection Evaporation

Convection There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. The cold air blowing on the infant's skin will cause heat loss.

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize? Cover the glans generously with petroleum jelly. Notify the primary care provider if it appears red and sore. Cleanse the glans daily with alcohol. Soak the penis daily in warm water.

Cover the glans generously with petroleum jelly. Covering the surgical site with an ointment such as petroleum jelly prevents it from adhering to the diaper and being continually irritated. Normal appearance is red and raw. Soaking the penis daily in warm water is not recommended. Washing the penis with warm water, dribbled gently from a washcloth at each diaper change, is the recommended way of keeping the penis clean. The nurse would not tell the parents to use alcohol on the glans.

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

Dehydration

A client is Rh-negative and has given birth to her newborn. What should the nurse do next? Administer Rh immunoglobulins intramuscularly. Ask if the client received rH immunoglobulins during the pregnancy. Determine if this is the client's first baby. Determine the newborn's blood type and rhesus.

Determine the newborn's blood type and rhesus. The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.

The nurse is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents? Select all that apply. Do not remove the identification bands until the newborn is discharged from the hospital. Don't leave the newborn unattended unless the mother is going to the bathroom. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. It is ok to release your newborn to hospital personnel when they come into your room to transport the newborn back to the nursery. Know when the newborn is scheduled for any tests and how long the procedure will last.

Do not remove the identification bands until the newborn is discharged from the hospital. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Know when the newborn is scheduled for any tests and how long the procedure will last. To ensure the safety of their newborn, parents must understand how to keep their infant safe. They are to never leave their newborn unattended at any time, be sure to ask to see identification of anyone who comes into the room to remove the infant, don't remove the newborn's identification bands until leaving the hospital at discharge, and know when any test or procedures are scheduled for their newborn. Parents are instructed to question anyone who does not have proper identification or acts suspiciously.

The nurse is preparing a client for discharge and notes an order for rubella vaccine. Which teaching should the nurse prioritize? May experience rash, sore throat, headache, or general malaise within 2 to 4 weeks of the injection Advise the client that the vaccine is excreted in breast milk. Will prevent hemolytic disease of the infant in next pregnancy Do not to attempt another pregnancy for at least 3 months.

Do not to attempt another pregnancy for at least 3 months. The nurse should prioritize the fact that after the immunization, she needs to wait for at least 3 months before attempting to get pregnant again, if desired, so the fetus will not be exposed to the rubella vaccination. The rubella vaccine is a live virus and is considered teratogenic. The other choices are not priorities. Inform the breastfeeding woman that the rubella vaccine crosses over into the breast milk. The newborn benefits from short-term immunity but may become flushed, fussy, or develop a slight rash. Suggest that the woman speak to the pediatrician if she has concerns. The client may also experience a rash, sore throat, headache, and general malaise within 2 to 4 weeks after the injection. The nurse would not advise the new mother that the immunization will prevent hemolytic disease of the infant in her next pregnancy; this is incorrect information.

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Document the data. Call the primary care provider. Inform the charge nurse. Stimulate the neonate.

Document the data. The nurse should document the findings as this neonate's assessment is within the normal range. The normal respiratory rate is 30 to 60 breaths/min and should be counted for a full minute when the neonate is quiet. A neonate starts with a low blood pressure (60/40 mm Hg) and a high pulse (120 to 160 beats/min). Normal temperature range is between 97.7°F (36.5°C) and 99.5°F (37.5°C).

The nurse is assisting new parents adjust to the birth of their first child. The parents appear hesitant to pick up the baby, stating they are afraid they will make the baby cry. What is the best response if the nurse discovers the infant is lying relatively still with eyes wide open, looking at the parents? Suggest they rock the baby to sleep Commend the parents for making the right choice Encourage the parents to pick up the baby Encourage the mother to breastfeed

Encourage the parents to pick up the baby Dr. T. Berry Brazelton's Neonatal Behavioral Scale is often used to note the state of reactivity in newborns. This infant is in the quiet alert state with the eyes open and attentive to people. There is movement, but limited. This is a good time for the parents to interact with the infant, such as picking up the infant, touching, talking, and bonding with the infant. Other states of reactivity include: Active alert: eyes are open and active body movements are present, newborn responds to stimuli with activity; Deep sleep: quiet, nonrestless sleep state, newborn is hard to awaken; Light sleep: eyes are closed but more activity is noted, newborn moves actively and may show sucking behavior; Drowsy: eyes open and close and the eyelids look heavy, body activity is present with intermittent periods of fussiness; and Crying: eyes may be tightly closed, thrashing movements are made in conjunction with active crying. This would not be the time for the parents to avoid interacting with the infant. There is also no indication the infant is hungry or tired, so feeding or trying to get the infant to go to sleep would also be inappropriate at this time.

The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration? Excessive oxytocin Mastitis Engorgement Blocked milk duct

Engorgement The client is only 72 hours postbirth and is reporting bilateral breast tenderness. Milk typically comes in at 72 hours after birth, and with the production of the milk comes engorgement. Mastitis or blocked milk ducts do not typically develop until there is fully established breastfeeding. Oxytocin would not be responsible for this.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? Use ice packs for a week after birth. Ensure ice pack is changed frequently. Apply ice packs for 40 minutes continuously. Apply ice packs directly to the perineal area.

Ensure ice pack is changed frequently. The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as: thrush. milia. vernix caseosa. Epstein's pearls.

Epstein's pearls. Epstein's pearls are small, white epidermal cysts on the gums and hard palate that disappear in weeks. Thrush is white plaque inside the mouth caused by exposure to Candida albicans during birth, which cannot be wiped away with a cotton-tipped applicator. Milia are multiple pearly-white or pale yellow unopened sebaceous glands frequently found on a newborn's nose. Vernix caseosa is a thick white substance that protects the skin of the fetus. It is formed by secretions from the fetus's oil glands and is found during the first 2 or 3 days after birth in body creases and the hair.

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal? Escherichia coli Staphylococcus aureus Gardnerella vaginalis Klebsiella pneumoniae

Escherichia coli E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of endometritis, but some species of Klebsiella may cause urinary tract infections.

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? Evaporative Conductive Convective Radiating

Evaporative Evaporative heat loss occurs with the evaporation of fluid from the infant.

A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response? Encourage the mother to breast-feed to help relax the uterus. Tell her that you will notify the doctor of the unusual pain and see what he wants to do. Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Recommend that the client ambulate more to help relieve the pain.

Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Afterpains occur most commonly in multipara mothers and occur when the uterus contracts and relaxes at intervals. Breast-feeding also can cause afterpains, increasing both the duration and the intensity of the pains. Ambulation will not affect the incidence of afterpains; afterpains are a very common postpartum event so there is no need to call the doctor.

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? Place the newborn's buttocks in warm water after each void or stool. Expose the newborn's bottom to air several times a day. Use products such as talcum powder with each diaper change. Use only baby wipes to cleanse the perianal area.

Expose the newborn's bottom to air several times a day. The nurse should instruct the parent to expose the newborn's bottom to air several times per day to treat and prevent diaper rashes. Use of baby wipes and products such as powder should be avoided. The parent should be instructed to place the newborn's buttocks in warm water after having had a diaper on all night but not with every diaper change.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? Feed the baby at least every two or three hours. Apply cold compresses to the breasts. Provide the infant oral nystatin. Dry the nipples following feedings.

Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendations would the nurse not make to this mother? Swaddling the infant before returning to the crib Rocking and talking to the infant Gently patting or stroking the infant's back Feeding the infant more formula whenever she begins to fuss

Feeding the infant more formula whenever she begins to fuss Crying by a young infant is frustrating for parents, so it is suggested that the parents first be sure that the infant's physical needs are met, then soothing measures are implemented. Feeding the infant every time he cries is not needed nor suggested. Swaddling, a soothing touch and gentle pats on the back all help calm a fussy infant.

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

Focus on decreasing blood viscosity by increasing fluid volume.

The client, G5 P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago? Put on the call button to summon help Administer oxytocics to prevent uterine atony Teach the woman to perform periodic self-fundal massage Gently massage the fundus until it tones up

Gently massage the fundus until it tones up After delivery, the fundus should be firm and at the umbilicus or lower. The more pregnancies and the larger the infant, the more at risk for complications secondary to atony of the uterus for the patient. The first action is to massage the uterus until firm. The scenario described does not indicate any need to summon help. The administration of oxytocics to prevent uterine atony can only be done by order of the health care provider. Teaching the woman to perform self-fundal massage is not appropriate at this time. It would be appropriate after the atony of the uterus is corrected.

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex? Turn the head to one side without moving the rest of the body. Place a gloved finger in the newborn's mouth. Gently stroke the newborn's cheek. Startle the newborn by letting the head drop back slightly.

Gently stroke the newborn's cheek. Stroking the newborn's cheek and observing for the newborn to turn toward the touch with the mouth open elicit the rooting reflex. Placing a gloved finger in the newborn's mouth elicits the suck reflex. Startling the newborn elicits the Moro reflex. Turning the newborn's head to one side elicits the tonic neck reflex.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? Notify the primary care provider, and document the findings. Have the client void, and then massage the fundus until it is firm. Assess a full set of vital signs. Check and inspect the lochia, and document all findings.

Have the client void, and then massage the fundus until it is firm. The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. Help the mother initiate breastfeeding within 30 minutes of birth. Give newborns water and other foods to balance nutritional needs. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. Provide breastfeeding newborns with pacifiers.

Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.

The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 gm/dL and hematocrit of 42%. Which result should the nurse prioritize? Hemoglobin 11 gm/dL and hematocrit 34 percent in a woman who has given birth by cesarean Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean Hemoglobin 13 gm/dL and hematocrit 40 percent in a woman who has given birth vaginally Hemoglobin 12 gm/dL and hematocrit 38 percent in a woman who has given birth vaginally

Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean First, the nurse needs to determine the amount of blood loss during the delivery. For every 250 mL of blood lost during the delivery process, the hemoglobin should decrease by 1 gm/dL and the hematocrit by 2 percent. The acceptable amount of blood loss during a normal vaginal delivery is approximately 300 mL to 500 mL and for a cesarean delivery approximately 500 mL to 1000 mL. The loss of hemoglobin from 14 gm/dL to 9 gm/dL is 5 and for the hematocrit from 42% to 32% is 10. This would indicate the client lost approximately 1250 mL of blood during the cesarean delivery (5 x 250 = 1250); this is too much and should be reported to the health care provider immediately. The other choices would be considered to be within normal range.

The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? Vitamin K HiB Hep B HBV immunoglobin

Hep B Hep B is the vaccination against hepatitis B and recommended by the CDC. It has been found to help prevent cirrhosis and liver cancer later in life. The HBV immunoglobin may be given in conjunction with the hep B if the mother is found to be HBV positive. The HiB is given later, usually at the 2-month visit.

A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client? The size of her infant Her bladder for distension Her hematocrit Her episiotomy

Her bladder for distension Bladder distension can cause the uterus to not contract effectively following delivery and displace to the side. This is easily checked and should be the first assessment done for a client whose uterus is not contracting as expected.

The nurse administers methylergonovine 0.2 mg to a postpartum woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication? Her hematocrit level is over 45%. Her blood pressure is below 140/90 mm Hg. She can walk without experiencing dizziness. Her urine output is over 50 ml/h.

Her blood pressure is below 140/90 mm Hg. Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

What is the best rationale for trying to decrease the incidence of cold stress in the neonate? The neonate will stabilize his or her temperature by 8 hours after birth if kept warm and dry. Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. If the neonate becomes cold stressed, he or she will eventually develop respiratory distress. It takes energy to keep warm, so the neonate has to remain in an extended position.

If the neonate becomes cold stressed, he or she will eventually develop respiratory distress. If cold stressed, the infant eventually will develop respiratory distress; oxygen requirements rise (even before noting a change in temperature), glucose use increases, acids are released into the bloodstream, and surfactant production decreases bringing on metabolic acidosis. A flexed position, not an extended position, keeps the neonate warm.

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? Injecting the medication into the vastus lateralis Injecting 1cc of medication Using a 21-gauge needle Injecting at a 45-degree angle

Injecting the medication into the vastus lateralis Use of the vastus lateralis is the preferred site for administration of the medication. The nurse would use a 22- to 25-gauge needle and inject 0.5 cc's of medication at a 90-degree angle.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? Instill 0.5% ophthalmic erythromycin. Watch for signs of eye irritation. Instill 0.5% ophthalmic silver nitrate. Instill 0.5% ophthalmic tetracycline.

Instill 0.5% ophthalmic erythromycin. The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.

A nurse is assessing a postpartum client. Which measure is appropriate? Instruct the client to empty her bladder before the examination. Perform the examination as quickly as possible. Wear sterile gloves when assessing the pad and perineum. Place the client in a supine position with her arms overhead for the examination of her breasts and fundus.

Instruct the client to empty her bladder before the examination. An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate? Instruct the client to empty her bladder before the examination. Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. Perform the examination as quickly as possible. Wear sterile gloves when assessing the pad and perineum.

Instruct the client to empty her bladder before the examination. An empty bladder facilitates the examination of the fundus. The client should be in a supine position with her arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.

When teaching a postpartum client about possible complications following the birth, which would be the best information to include? Ineffectiveness of breastfeeding Alteration in normal maternal hormonal function Interference with the maternal-newborn attachment process Delayed development of the newborn

Interference with the maternal-newborn attachment process The nurse would include information that maternal postpartum complications affect not only the health status of the woman, but also that of the newborn by potentially interfering with the maternal-newborn attachment process. Furthermore, they can disrupt the dynamics of the entire family, with health-related, fiscal, and emotional effects and costs. Maternal postpartum complications are not known to result in ineffective breastfeeding, delayed development of the newborn, or altered maternal hormonal function.

The nursing instructor is leading a discussion on the physical changes to a woman's body after delivery of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs? Evolution Involution Decrement Progression

Involution Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding? It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel. This is an abnormal finding and needs to be reported immediately. If the fontanel feels full, then this is normal. This finding is normal if the pulsation can also be palpated in the posterior fontanel.

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel. Feeling a pulsation over the fontanel (fontanelle) correlating to the newborn's heart rate is normal. The pulsation should not be felt in the posterior fontanel. The fontanel should not be bulging under any circumstance in a newborn.

The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function? It removes fluid from the lungs. It expands the lungs with breaths. It keeps alveoli from collapsing with breaths. It allows oxygen to move in the lungs.

It keeps alveoli from collapsing with breaths. The role of surfactant is to act on surface tension and assist in keeping the alveoli open in the lungs so the lungs do not collapse with the respiratory effort of the newborn. Surfactant does not expand the lungs, remove fluid from the lungs, or allow oxygen to move in the lungs.

Upon examination of the skin, which assessment findings would the nurse recognize as normal findings for a full-term newborn at 3 hours of age? Select all that apply. Lanugo on the back Acrocyanosis Jaundice Milia Vernix caseosa over the abdomen and lower extremities

Lanugo on the back Milia Acrocyanosis A full-term newborn may have thin patches of lanugo over his back, shoulders or arms. He may also have milia, which appear as white papules on the face. Acrocyanosis at 3 hours of age is also a normal finding. However, this should resolve by 24 to 48 hours of age. A newborn at 3 hours of age should never have jaundice. Vernix on the abdomen and lower extremities is seen in preterm infants, not full-term ones.

The nurse is assessing the newborn male of a teen mother who was afraid to seek appropriate prenatal care. Which assessment finding should lead the nurse to question if this infant is preterm?

Lanugo on the back and shoulders

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

Less than 1,000 g.

The nurse cares for preterm infants and assesses them for potential complications to provide adequate countermeasures to prevent futher complications. Which complication should the nurse prioritize and initiate proper measures to protect the newborn?

Loss of body heat

A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints? Try to avoid carrying the baby for a few days. Maintain correct posture and positioning. Apply ice to the sore joints. Soak in a warm bath several times a day.

Maintain correct posture and positioning. The nurse should recommend that clients maintain correct position and good body mechanics to prevent pain in the lower back, hips, and joints. Avoiding carrying her baby and soaking several times per day is unrealistic. Application of ice is suggested to help relieve breast engorgement in nonbreastfeeding clients.

Which nursing measure is most effective in reducing newborn infections?

Maintain medical asepsis while providing care.

The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response? Fencing Moro Tonic neck Rooting

Moro The Moro reflex is also known as the startle reflex. When the infant is startled, they extend their arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.

A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation? Newborns cannot focus on any objects. Newborns have the ability to focus on objects in midline. Newborns have the ability to focus only on objects far away. Newborns have the ability to focus only on objects in close proximity.

Newborns have the ability to focus only on objects in close proximity. In regards to vision the newborn has the ability to focus on objects only in close proximity (8 to 30 cm away) and tracks objects in midline or beyond. Vision is the least mature sense at birth.

The parents of a 2-day-old newborn are preparing for discharge from the hospital. They question the nurse concerning sleeping patterns for the newborn once they get home. What advice can the nurse provide for them? Place the infant on his abdomen or side to encourage sleep. If the infant continues to wake up at night after a few months, offer rice cereal before going to bed. Expect the infant to sleep through the night by 2 months of age. Newborns usually sleep for 16 or more hours each day, broken into periods of 3 to 4 hours per session.

Newborns usually sleep for 16 or more hours each day, broken into periods of 3 to 4 hours per session. Normally, newborns sleep 16 to 20 hours per day. Timing for sleeping through the night varies from infant to infant and should not be predicted to parents. Infants are always placed on their backs to sleep to reduce the risk of SIDS. Giving an infant solids earlier than 6 months is not helpful in encouraging them to sleep through the night and may upset their digestive tract.

A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy?

Oxygen saturation levels are at 98%.

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize? Assess her blood pressure. Palpate her fundus. Have her turn to her left side. Assess her perineum.

Palpate her fundus. The nurse should assess the status of the uterus by palpating the fundus and determining its condition. If it is boggy, the nurse would then initiate fundal massage to help it contract and encourage the passage of the lochia and any potential clots that may be in the uterus. Assessing the blood pressure and assessing her perineum would follow if indicated. It would be best if the woman is in the semi-Fowler position to allow gravity to help the lochia to drain from the uterus. The nurse would also ensure the bladder was not distended.

A postpartum client who was discharged home returns to the primary health care facility after 2 weeks with reports of fever and pain in the breast. The client is diagnosed with mastitis. What education should the nurse give to the client for managing and preventing mastitis? Discontinue breastfeeding to allow time for healing. Avoid hot or cold compresses on the breast. Discourage manual compression of breast for expressing milk. Perform handwashing before and after breastfeeding.

Perform handwashing before and after breastfeeding. The nurse should educate the client to perform handwashing before and after breastfeeding to prevent mastitis. Discontinuing breastfeeding to allow time for healing, avoiding hot or cold compresses on the breast, and discouraging manual compression of the breast for expressing milk are inappropriate interventions. The nurse should educate the client to continue breastfeeding, because it reverses milk stasis, and to manually compress the breast to express excess milk. Hot and cold compresses can be applied for comfort.

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? Avoid massaging the breast area. Perform handwashing before breastfeeding. Avoid frequent breastfeeding. Apply cold compresses to the breast.

Perform handwashing before breastfeeding. As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold (not warm) moist heat to the breast. Gently massaging the affected area of the breast also helps.

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention would the nurse perform next? Notify the healthcare provider. Perform urinary catheterization. Administer oxytocin IV. Insert a 20 gauge IV.

Perform urinary catheterization. Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone. An IV and oxytocin are indicated if the client experiences hemorrhage due to uterine atony from being displaced. The healthcare provider would be notified if no other interventions help the client.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. How should the nurse respond? Complete emptying of the breast Frequent feeding Pierced nipple Use of breast pumps

Pierced nipple Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads.

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature? Tape electronic thermistor probe to the abdominal skin. Obtain the temperature rectally. Obtain the temperature orally. Place electronic temperature probe in the midaxillary area.

Place electronic temperature probe in the midaxillary area. The nurse should obtain a newborn's temperature by placing an electronic temperature probe in the midaxillary area. The nurse should not tape an electronic thermistor probe to the abdominal skin, as this method is applied only when the newborn is placed under a radiant heat source. Rectal temperatures are no longer taken because of the risk of perforation. Oral temperature readings are not taken for newborns.

A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take? Begin the newborn on oxygen with BNC at 2L. Place a pillow under the newborn to raise the head of the bed. Feed the newborn to provide more glucose. Place the newborn away from drafts and under a blanket.

Place the newborn away from drafts and under a blanket. When a newborn becomes cold stressed, they often develop respiratory distress. The newborn's temperature is low, so the first nursing action is to place the newborn in a warmer environment and cover with a blanket to warm the newborn up. The serum glucose is normal so the newborn does not need additional nutrition. The newborn does not have documented hypoxia, so oxygen is not appropriate. Pillows are never used in newborn's beds due to the risk of suffocation.

A nurse is caring for a newborn client after birth who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury?

Place the newborn in a prone or lateral position.

A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration?

Position the child on the side

A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning?

Positive end-expiratory pressure to increase oxygenation

The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder? Postpartum psychosis Postpartum blues Postpartum depression Maladjustment

Postpartum psychosis Postpartum psychosis in a client can present with extreme mood changes and odd behavior. Her sudden change in behavior from normal, along with a lack of self-care and care for the infant, are signs of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum women.

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? Pressure changes occur and result in closure of the ductus arteriosus. Fluid is removed from the alveoli and replaced with air. Oxygen is exchanged in the lungs. The oxygen in the blood decreases.

Pressure changes occur and result in closure of the ductus arteriosus. The ductus arteriosus is one of the openings through which there was fetal circulation. At birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. The exchange of oxygen in the lungs and increasing oxygen content in the blood are respiratory functions. The removal of the fluid from the alveoli occurs mainly during the birthing process and is completed by the lungs after birth.

The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment? Protect the urethra from fecal material Prevent infection of the umbilical cord Protect tear ducts from vaginal bacteria Prevent infection of the eyes from vaginal bacteria

Prevent infection of the eyes from vaginal bacteria Antibiotic ointment is used in the infant's eyes at birth to prevent ophthalmia neonatorum, an infection which can lead to blindness. It is not an acceptable practice to apply antibiotic ointment to the tear ducts, the umbilical cord, or the perineum and urethra.

An infant is suspected of having persistent pulmonary hypertension of the newborn (PPHM). What intervention implemented by the nurse would be most beneficial in treating this client?

Provide oxygen by oxygen hood or ventilator.

Under which circumstances should gloves be worn in the newborn nursery? Select all that apply. Providing the first bath Taking the newborn's crib to the mother's room Feeding the newborn a bottle Performing a heel stick Accucheck Changing a diaper

Providing the first bath Performing a heel stick Accucheck Changing a diaper Universal precautions, such as wearing gloves, is necessary whenever the nurse is likely to come in contact with bodily fluids, such as when changing a diaper, performing the initial bath after birth, and drawing blood for testing. Gloves are not needed with formula feedings or when transporting the newborn in its crib to the mother's room.

According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and the newborn has minimal activity or body movement? Quiet alert Drowsy Active attentive Active alert

Quiet alert A newborn that has its eyes open but is quiet and observing people and things around him is in the quiet alert state. The active alert state is characterized by the newborn having the eyes open but is moving about. The drowsy state shows the newborn whose eyes are open and closing with heavy eyelids and is intermittently fussy. There is no "active attentive" state according the Neonatal Behavioral Assessment Scale.

During which state of Brazelton's Neonatal Behavioral Assessment Scale would be the best time for new parents to interact with their newborn? Quiet alert state Drowsy state Active alert state Light drowsy state

Quiet alert state In the quiet alert state, the newborn's eyes are open and the infant is attentive to people and things occurring in close proximity to them. This is an ideal time for parents to interact with the infant.

The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take? Since it looks like a milk curd, no action is needed. Rinse the tongue off with sterile water and a cotton swab. Wipe the tongue off vigorously to remove the white patches. Report the finding to the pediatrician.

Report the finding to the pediatrician. Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patches.

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate? She should supplement feeding with formula until the infection resolves. She should stop breastfeeding until completing the antibiotic. She should continue to breastfeed; mastitis will not infect the neonate. She should not use analgesics because they are not compatible with breastfeeding.

She should continue to breastfeed; mastitis will not infect the neonate. The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? Showing increased confidence when caring for the newborn Pointing out specific features in the newborn Having feelings of grief or guilt Talking about her labor experience to others around her

Showing increased confidence when caring for the newborn Independence with self-care is an important aspect of the taking-hold phase. During the letting-go phase, the woman assumes responsibility and care for the newborn with increased confidence. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? Streptococcus pyogenes (group A strep) group B streptococcus (GBS) Escherichia coli Staphylococcus aureus

Staphylococcus aureus The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis is not harmful to the neonate. E. coli, GBS, and S. pyogenes are not associated with mastitis. GBS infection is associated with neonatal sepsis and death.

The nurse manager at a family clinic is identifying ways to address the 2020 National Health Goals for the prevention of birth defects. Which action should the manager encourage all staff to perform when caring for pregnant patients?

Stress the importance of taking prenatal folic acid as prescribed.

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? The most common pathogen is group A streptococcus (GAS). A breast abscess is a common complication of mastitis. Mastitis usually develops in both breasts of a breastfeeding client. Symptoms include fever, chills, malaise, and localized breast tenderness.

Symptoms include fever, chills, malaise, and localized breast tenderness. Mastitis is an infection of the breast characterized by flu-like symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement? Recommend rooming-in to foster attachment and confidence by the mother. Recommend that she talk to the unit social worker to get the mother some counseling prior to discharge. Dismiss the mother's concerns by telling her that you are sure she doesn't really mean it. Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.

Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Negative comments are often made by mothers who lack confidence in their mothering abilities and are experiencing hormonal fluctuations. The best response by the nurse is to acknowledge the mother's concerns and be accepting and supportive to her. Trying to force attachment will only make the situation worse. The mother does not need psychological counseling nor should the nurse dismiss the mother's concerns.

Which situation should concern the nurse treating a postpartum client within a few days of birth? The client would like the nurse to take her baby to the nursery so she can sleep. The client is nervous about taking the baby home. The client feels empty since she gave birth to the neonate. The client would like to watch the nurse give the baby her first bath.

The client feels empty since she gave birth to the neonate. A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.

Upon examination of a postpartal client's perineum, the nurse notes a large hematoma. The client does not report any pain, and lochia is dark red and moderate in amount. Which factor would most likely contribute to the nurse not discovering the perineal hematoma prior to the examination? The client has a distended bladder. The client has a history of epidural anesthesia. The client had an episiotomy. The client is receiving oral pain medications.

The client has a history of epidural anesthesia. If a client has an epidural, her sensation of pain is decreased, so nurses cannot rely on client reports of pain as a symptom of a perineal hematoma. The nurse should always inspect the perineum to determine if there is a hematoma present. Having an episiotomy, having a distended bladder, or taking oral pain medications would have no effect on a perineal hematoma.

The nursing instructor is leading a discussion with a group of nursing students who are analyzing the preterm infant's physiologic immaturity and the associated difficulties the newborn and familty must deal with. The instructor determines the session is successful when the students correctly choose which body system that presents with the most critical concerns related to this immaturity?

The respiratory system

A nurse is providing information for a pregnant woman who has just discovered that the fetus she's carrying is likely to have Down syndrome. Which statement by the nurse is most accurate regarding the possible concerns for a child with Down syndrome?

They have a higher risk of developing leukemia than those in the general population.

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery? To monitor the mother's blood pressure to note any elevations To check for postpartum hemorrhage To determine if the mother's milk is coming in To answer questions the new parents may have

To check for postpartum hemorrhage If a new mother is going to hemorrhage, it will usually occur within the first hour following delivery. Therefore, the nurse checks on the client every 15 minutes, noting fundal firmness and position, amount and character of lochia and checking for bladder distension. There are no anticipated elevations in the mother's blood pressure, nor should the mother's milk come in this early.

Which statement is false regarding bathing the newborn? Bathing should not be done until the newborn is thermally stable. Mild soap should be used on the body and hair but not on the face. To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. While bathing the newborn, the nurse should wear gloves.

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. Bathing the newborn is not necessary for thermal stability. It can be postponed until the parents are able to do it.

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski reflex. Which response would the nurse interpret as normal for the newborn? Infant throws arms outward and flexes knees. Infant's toes curl over the nurse's finger. Infant makes stepping motion. Toes fan out when sole of foot is stroked.

Toes fan out when sole of foot is stroked. The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The toes should fan out. The Moro reflex occurs when the infant is startled and will respond by throwing the arms outward and flexing the knees. The stepping reflex should elicit a stepping motion or walking when held upright. The plantar grasp will occur when a finger is placed just below the newborn's toes and the toes typically curl over the finger.

Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding? At the pubic bone One fingerbreadth below the umbilicus Two fingerbreadths below the umbilicus Level with the umbilicus

Two fingerbreadths below the umbilicus Immediately after delivery, the uterine fundus should be at the level of the umbilicus. One day postpartum, the height is one fingerbreadth below the umbilicus and by Day 2, the fundal height is two fingerbreadths below the umbilicus.

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? Use any frozen milk within 6 months of obtaining it. Use the sealed and chilled milk within 24 hours. Use microwave ovens to warm the chilled milk. Refreeze any unused milk for later use if it has not been out more that 2 hours.

Use the sealed and chilled milk within 24 hours. The nurse should instruct the woman to use the sealed and chilled milk within 24 hours. The nurse should not instruct the woman to use frozen milk within 6 months of obtaining it, to use microwave ovens to warm chilled milk, or to refreeze the used milk and reuse it. Instead, the nurse should instruct the woman to use frozen milk within 3 months of obtaining it, to avoid using microwave ovens to warm chilled milk, and to discard any used milk and never refreeze it.

The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage? Uterine atony Hematoma Perineal lacerations Disseminated intravascular coagulation

Uterine atony Early postpartum hemorrhage usually results from one of the following conditions: uterine atony, lacerations, or hematoma. Most cases of early postpartum hemorrhage result from uterine atony, which is due to the uterine muscles remaining relaxed and not contracting as they should. Disseminated intravascular coagulation is a complication which can occur with excessive postpartum hemorrhage.

A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention? Percussion reveals tympany. Bladder is nonpalpable. Lochia is less than usual. Uterus is boggy.

Uterus is boggy. A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual.

A nurse is assisting a postpartum client out of bed to the bathroom for the first time. Which interventions would be most appropriate? Select all that apply. Walk alongside the client to the bathroom. Frequently ask the client how her head feels. Elevate the head of the bed for several minutes before getting her up. Check her blood pressure after she stands up. Sit her in a chair after getting out of bed before going to the bathroom.

Walk alongside the client to the bathroom. Elevate the head of the bed for several minutes before getting her up. Frequently ask the client how her head feels. One of the safety concerns during the postpartum period is orthostatic hypotension. When the woman rapidly moves from a lying or sitting position to a standing one, her blood pressure can suddenly drop, causing her pulse rate to increase. She may become dizzy and faint. Appropriate interventions include: checking blood pressure first before ambulating the client; elevating the head of the bed for a few minutes before ambulating the client; having the client sit on the side of the bed for a few moments before getting up; helping the client to stand up, and staying with her; ambulating alongside the client and providing support if needed; and frequently asking the client how her head feels. Having her sit in the chair after getting out of bed would be inappropriate because the client's blood pressure may already have dropped.

A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action? Avoid elevating her feet when she rests in a chair. Avoid getting out of bed for another 2 days. Walk the length of the hallway to regain her strength. Walk with the nurse the length of her room.

Walk with the nurse the length of her room. Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.

The parents of a 1-day-old newborn are concerned the infant is cold and shivering. Which action should the nurse prioritize to best prevent heat loss? Cover the newborn with several blankets while under the warmer. Warm all surfaces and objects that come in contact with the newborn. Keep the newborn under the radiant heater when not with mom. Bathe and wash the newborn when temperature is 97.5° F (36.4° C)

Warm all surfaces and objects that come in contact with the newborn. The 1-day-old infant will have regulated body temperature at this point in life and the radiant heater is no longer used. Interventions are the best way to prevent heat loss for this newborn; these would include making sure surfaces such as scales, examination tables and instruments are warm. Keeping the newborn under a radiant heater and covering the newborn with several blankets while under the warmer could lead to hyperthermia, which can be just as detrimental to the newborn as hypothermia. Infants are bathed when their temperatures are stable.

Since newborns are at risk to contract infections, what is the best measure the nurse can teach parents to implement to prevent the newborn from getting ill? Keeping the infant's cord clean and dry Washing their hands before handling the infant Rooming-in with their infant Using gloves when handling their infant

Washing their hands before handling the infant Hand washing is the best way to prevent infections in newborn infants. Even the nursery personnel are required to perform a hand scrub before beginning their work in most nurseries. Rooming-in reduces the risk of cross-contamination but is not nearly as important as good hand washing.

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider? Weak and rapid pulse Elevated blood pressure Warm and flushed skin Decreased respiratory rate

Weak and rapid pulse Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted.

The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching? Massage the breasts when they are painful. Express small amounts of milk when they are too full. Run warm water over the breast in the shower. Wear a tight, supportive bra.

Wear a tight, supportive bra. The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.

A nurse is caring for a nonbreast-feeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? Wear a well-fitting bra. Express milk frequently. Apply hydrogel dressing. Apply warm compresses.

Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize? Clean hands with a betadine scrub. Perform a 3-minute surgical-type scrub. Use infection transmission precautions. Wear clean gloves.

Wear clean gloves. Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature? Wrap the infant in a warm, dry blanket. Turn the temperature up in the birth room. Place the infant on the mother's abdomen after birth. Bathe the infant immediately after birth.

Wrap the infant in a warm, dry blanket. Evaporation is one of the four ways a newborn can lose heat. As moisture evaporates from the body surface of the infant, the newborn loses heat. Wrapping the infant in a warm, dry blanket will allow the moisture to be absorbed, limiting heat loss from evaporation. Bathing the infant will only add to the evaporative heat loss. The newborn's skin is wet, so placing him on the mother' abdomen will not prevent evaporation and heat loss. Increasing the ambient temperature in the birth room does not address the evaporation problem.

The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartal blues? a 29-year-old mother who has lots of family visiting and offering to help her with meals and cleaning for the next few months a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding an 18-year-old mother who is currently holding her baby and looking face-to-face at the baby without saying a word a 38-year-old G1 P1 who is constantly holding the baby and touching the baby's hands and fingers

a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding During the postpartal period many women experience some feelings of overwhelming sadness or "baby blues." They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. The teenage mom is holding the baby in en face position, which is normal. The 29-year-old woman has a supportive, close family and there is no indication she is experiencing postpartal blues. The 38-year old-mother is in a normal phase after birth and is exploring the infant's body, a part of the taking-in phase that occurs 1 to 3 days after birth.

Which postpartum client will the nurse assess first? an 18-year-old who wants to sleep until 10:00 before the nurse brings the infant for a visit. a 35-year-old who had estimated blood loss of 700 ml and has a supine BP of 130/80 mm Hg and BP of 100/65 mm Hg when head of the bed is elevated a 22-year-old who has been up, showered, and packing for discharge later today a 30-year-old postpartum client who had a cesarean birth and is sleeping following pain medication administration

a 35-year-old who had estimated blood loss of 700 ml and has a supine BP of 130/80 mm Hg and BP of 100/65 mm Hg when head of the bed is elevated A major complication in women who have lost an appreciable amount of blood with birth is orthostatic hypotension, or dizziness that occurs on standing because of the lack of adequate blood volume to maintain nourishment of brain cells. If blood pressure is 15 to 20 mm Hg lower after raising the head of the bed upright compared with the supine reading, the woman might be susceptible to dizziness and fainting when she ambulates. Developmentally, 18-year-old teenagers may stay up late and sleep late as a normal sleep cycle. The young 22-year-old packing for discharge is not the priority. A client who had a cesarean birth with minimal blood loss should be allowed to sleep after receiving pain medication and is not the priority.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? a scant amount of lochia alba a moderate amount of lochia rubra a scant amount of lochia serosa a moderate amount of lochia alba

a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?

a sudden drop in hemoglobin

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

above 90th percentile

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply. abdominal pain active bowel sounds nondistended abdomen passing gas tender abdomen

active bowel sounds nondistended abdomen passing gas Finding active bowel sounds, verification of passing gas, and a nondistended abdomen are normal assessment results. The abdomen should be nontender and soft. Abdominal pain is not a normal assessment finding and should be immediately looked into.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have: slightly increased. acutely decreased. acutely increased. slightly decreased.

acutely decreased. Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first? avoiding administration of oxytocics administration of platelet transfusions as prescribed continual firm massage of the uterus administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs)

administration of platelet transfusions as prescribed When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho(D) are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? lochia appearing pinkish-brown on the fourth day lochia that is the color of menstrual blood an absence of lochia red-colored lochia for the first 24 hours

an absence of lochia Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client? opioid pain medication a sitz bath a heating pad applied to the perineum an ice pack applied to the perineum

an ice pack applied to the perineum Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Opioid pain medication would not be the first choice.

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts? restricting fluids applying warm compresses applying ice administering bromocriptine

applying ice Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? administering bromocriptine applying ice restricting fluids applying warm compresses

applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: increase the flow of an IV. assess and massage the fundus. inspect the perineum for lacerations. call the primary care provider or the nurse-midwife.

assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? respiratory rate of 50 breaths/minute short periods of apnea (less than 15 seconds) acrocyanosis asymmetrical chest movement

asymmetrical chest movement Chest movements should be symmetrical. Typical newborn respirations range from 30 to 60 breaths per minute. Acrocyanosis is a common finding in newborns and does not indicate respiratory distress. Periods of apnea of less than 15 seconds are considered normal in a newborn. However, if these periods last more than 15 seconds and are accompanied by cyanosis and heart rate changes, additional evaluation is needed.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? hemorrhage infection atony normal involution

atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior? engorgement involution attachment engrossment

attachment When a woman has successfully linked with her newborn it is termed attachment or bonding. Although a woman carried the child inside her for 9 months, she often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smoothes the baby's hair, brushes a cheek, plays with toes, and lets the baby's fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby's or kiss the infant's nose; she has successfully bonded or become a mother tending to her child. Engrossment describes the action of new fathers when they stare at their newborn for long intervals. Involution is the process whereby the reproductive organs return to their nonpregnant state. Engorgement is the tension in the breasts as they begin to fill with milk.

A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding? bleeding postpartal gestational hypertension infection diabetes

bleeding Blood pressure should also be monitored carefully during the postpartal period because a decrease in this can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.

A preterm newborn is being monitored for potential necrotizing enterocolitis. The nurse recognizes which factors as major pathologic mechanisms that could lead to this complication? Select all that apply.

bowel ischemia perinatal stressors formula feeding

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn? bringing the newborn into the room allowing the mother to pick the best time to hold her newborn talking about how the nurse held her own newborn while on the birthing table showing a video of parents feeding their babies

bringing the newborn into the room Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold the infant. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.

A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism? sudden chest pain difficulty in breathing sudden change in mental status calf swelling

calf swelling The nurse should monitor the client for swelling in the calf. Swelling in the calf, erythema, and pedal edema are early manifestations of deep vein thrombosis, which may lead to pulmonary embolism if not prevented at an early stage. Sudden change in the mental status, difficulty in breathing, and sudden chest pain are manifestations of pulmonary embolism, beyond the stage of prevention.

A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client? fluid overload hypotension decreased level of consciousness tachycardia

fluid overload The possibility of fluid overload is increased and must be considered by a nurse when administering IV therapy to a newborn. IV therapy does not significantly increase heart rate or change blood pressure, as well as the level of consciousness, unless fluid overload occurs.

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change? increased progesterone levels use of anesthesia during birth decreased bladder pressure decreased intra-abdominal pressure

decreased intra-abdominal pressure The nurse should identify decreased intra-abdominal pressure as the cause of the respiratory system functioning normally. Progesterone levels do not influence the respiratory system. Decreased bladder pressure does not affect breathing. Anesthesia used during birth causes the respiratory system to take a longer time to return to normal.

The nurse reviews the history of a postpartum woman G3P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client? uterine atony deep venous thrombosis metritis postpartum hemorrhage

deep venous thrombosis Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 34), and multiparity.

Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply.

diabetes mellitus postdates gestation prepregnancy obesity

The nurse assesses an infant. Which finding may indicate heart failure?

diminished peripheral pulses

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely? nausea blood loss diuresis lactation

diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in postpartum week does not cause major weight loss.

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders? preexisting conditions in the client lack of social support from family or friends medications used during labor and birth drop in estrogen and progesterone levels after birth

drop in estrogen and progesterone levels after birth Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology.

The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing? ductus arteriosus umbilical vessels foramen ovale ductus venosus

ductus arteriosus During fetal life, the ductus arteriosus protects the lungs against circulatory overload by shunting blood into the descending aorta, bypassing the pulmonary circulation. The foramen ovale is located in the septum between the atria and allowed blood to flow from the right atrium directly the left atrium. The ductus venous allowed the majority of the blood to bypass the liver. The umbilical vessels carried oxygenated blood to the fetus and removed deoxygenated blood and waste products from the fetus.

A client who gave birth by cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be: using a breast pump to facilitate removal of stagnant breast milk. having the client stand facing in a warm shower. encouraging the client to wear a supportive bra. informing the primary care provider that the client is showing early signs of breast infection.

encouraging the client to wear a supportive bra. These assessment findings are normal for the third postpartum day. Hard, warm breasts indicate engorgement, which occurs approximately 3 days after birth. Vital signs are stable and do not indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production.

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? screening for bacteriuria in the urine increasing oral fluid intake increasing intravenous fluids encouraging the woman to empty her bladder completely every 2 to 4 hours

encouraging the woman to empty her bladder completely every 2 to 4 hours The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure.

The nurse is providing care to a postpartum woman who has given birth vaginally to a healthy term neonate about 4 hours ago. While assessing the client, the client tells the nurse, "I've really been urinating a lot in the past hour." The nurse interprets this finding as suggestive of a decrease in which hormone? progesterone hCG prolactin estrogen

estrogen The endocrine system rapidly undergoes several changes after birth. Levels of circulating estrogen and progesterone drop quickly with delivery of the placenta. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. hCG and prolactin are not associated with postpartum diuresis.

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? first 6 months first month first 3 to 5 days first 30 to 60 minutes

first 30 to 60 minutes Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration? third degree fourth degree second degree first degree

fourth degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

The newborn nursery nurse suspects a newborn of having neonatal abstinence syndrome. What assessment findings would most correlate with the diagnosis?

frequent yawning and sneezing

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? generally after 12 weeks generally within 3 to 6 weeks usually within a couple weeks whenever the couple wishes

generally within 3 to 6 weeks There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.

Prevention and early identification of newborns at risk are necessary nursing functions. A nurse anticipates the need for newborn resuscitation secondary to birth asphyxia based on which prenatal risk factors? Select all that apply.

gestational hypertension maternal infection congenital heart disease

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: stork bites. Mongolian spots. harlequin sign. erythema toxic.

harlequin sign. Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Mongolian spots are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites.

The AGPAR score is based on which 5 parameters? heart rate, breaths per minute, irritability, reflexes, and color heart rate, muscle tone, reflex irritability, respiratory effort, and color heart rate, breaths per minute, irritability, tone, and color heart rate, respiratory effort, temperature, tone, and color

heart rate, muscle tone, reflex irritability, respiratory effort, and color A newborn can receive an APGAR score ranging from 0 to 10. The score is based on 5 factors, each of which is assigned a 0, 1, or 2. Heart rate (should be above 100), muscle tone (should be able to maintain a flexion position), reflex irritability (newborn should cry or sneeze when stimulated), and respiratory effort are evaluted by the presence of a strong cry and by color. Color is evaluated by noting the color of the body and hands and feet.

When the nurse is describing the events that occur in a newborn when he or she experiences a cold environment, which event would the nurse identify as occurring first? increased cardiac output increased blood flow through brown fat breakdown of triglycerides increased release of norepinephrine

increased release of norepinephrine When the newborn experiences a cold environment, the release of norepinephrine increases. This in turn stimulates brown fat metabolism by the breakdown of triglycerides. Cardiac output increases, increasing blood flow through the brown fat tissue. Subsequently, this blood becomes warmed as a result of the increased metabolic activity of the brown fat.

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition? long-term obesity feelings of increased self-esteem increased sex drive diabetes

long-term obesity Women who have not returned to their prepregnant weight by 6 months postpartum are likely to retain extra weight. This inability to lose is a predictor of long-term obesity. It will not necessarily lead to diabetes, but it may decrease a woman's self-esteem and sex drive if she feels less attractive with the extra weight.

A nurse is assigned to care for a high-risk newborn with a periventricular-intraventricular hemorrhage (PVH-IVH) in the home environment after discharge. For which condition should the nurse monitor the infant?

hydrocephalus

The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication? hyperbilirubinemia respiratory distress syndrome transient tachypnea of the newborn polycythemia

hyperbilirubinemia Neonatal red blood cells have a life span of 80 to 100 days and normally have a higher count at birth. This combination leads to increased hemolysis. Complications of this process include hyperbilirubinemia.

When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection? within the blood stream in the reproductive tract in the milk ducts in the urinary bladder

in the reproductive tract The most common site for a postpartum infection is the reproductive tract. This is important for teaching and education of clients.

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? inadequate secretion of prolactin improper positioning of infant cracking of the nipple inability of infant to empty breasts

inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? infection depression hemorrhage pulmonary emboli

infection There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn?

newborn who is type A, mother who is type O

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

lack of body posturing

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea of the newborn. The nurse explains that this is due to which occurrence? lack of thoracic compressions during birth inadequate suctioning of the mouth and nose of the newborn prolonged unsuccessful vaginal birth loss of blood volume due to hemorrhage

lack of thoracic compressions during birth A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn.

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

lethargy and hypotonia The nurse should look for signs of lethargy and hypotonia in the newborn in order to confirm the occurrence of cold stress. Cold stress leads to a decrease, not increase, in the newborn's body temperature, blood glucose, and appetite.

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include? thick skin with deep lying blood vessels expanded stores of glucose and glycogen limited voluntary muscle activity enhanced shivering ability

limited voluntary muscle activity Newborns have limited voluntary muscle activity or movement to produce heat. They have thin skin with blood vessels close to the surface. They cannot shiver to generate heat. They have limited stores of metabolic substances such as glucose and glycogen.

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. loss of confidence bizarre behavior inability to concentrate decreased interest in life manifestations of mania

loss of confidence inability to concentrate decreased interest in life The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis.

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? massaging the fundus firmly administering ergonovine notifying the primary care provider performing bimanual compressions

massaging the fundus firmly Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergonovine maleate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime.

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis? plugged milk duct mastitis engorgement breast yeast

mastitis Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy.

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. Which type of lochia pattern should the nurse point out needs to be reported to her primary care provider immediately during the discharge teaching? moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5 moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 lochia progresses from rubra to serosa to alba within 10 days moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding. Lochia progressing from rubra to serosa to alba within 10 days of delivery is a normal finding. Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5 is a normal finding.

A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: light. moderate. heavy. scant.

moderate. Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-ml loss; light or small- an approximately 4-inch stain or a 10- to 25-ml loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 ml; and large or heavy-a pad is saturated within 1 hour after changing it.

A nurse is assessing a newborn and observes the newborn bringing his hand up to his mouth. The nurse interprets this finding as which behavioral response? orientation self-quieting ability motor maturity habituation

motor maturity Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Bringing the hand up to the mouth is an example of good motor organization. The response of newborns to stimuli is called orientation. They become more alert when they sense a new stimulus in their environment. Habituation is the newborn's ability to process and respond to visual and auditory stimuli. It is a measure of how well and appropriately an infant responds to the environment. Self-quieting ability (also called self-soothing) refers to newborns' ability to quiet and comfort themselves.

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior? positive bonding negative bonding positive attachment negative attachment

negative attachment Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors.

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? after the newborn has received the initial feeding 24 hours after admission to the nursery on admission to the nursery 4 hours after admission to the nursery

on admission to the nursery Typically, a newborn's blood glucose levels are assessed with use of a heel stick sample of blood on admission to the nursery, not 4 or 24 hours after admission to the nursery. It is also not necessary or even reasonable to check the glucose level only after the newborn has been fed.

The Ballard scoring system evaluates newborns on which two factors? body maturity and cranial nerve maturity physical maturity and neuromuscular maturity tone maturity and extremities maturity skin maturity and reflex maturity

physical maturity and neuromuscular maturity When determining a newborn's gestational age using the Ballard scale, the nurse assesses physical signs and neurologic characteristics.

A nursing student is aware that fetal gas exchange takes place in which area? placenta bronchioles lungs uterus

placenta Many different changes occur for the newborn to survive outside the uterus. One such change is that gas exchange that once took place in the placenta now will take place in the lungs.

When palpating for fundal height on a postpartum woman, which technique is preferable? placing one hand at the base of the uterus, one on the fundus palpating the fundus with only fingertip pressure placing one hand on the fundus, one on the perineum resting both hands on the fundus

placing one hand at the base of the uterus, one on the fundus Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation.

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process? policies that allow visitors policies that allow rooming the infant and mother together policies that discourage unwrapping and exploring the infant policies that allow flexibility for cultural differences

policies that discourage unwrapping and exploring the infant Various factors associated with the health care facility or birthing unit can hinder attachment. These may include separation of infant and parents immediately after birth; policies that discourage unwrapping and exploring the infant; intensive care environment; restrictive visiting policies; staff indifference or lack of support for the parent's. Allowing the infant and mother to room together, allowing visitors, and working with cultural differences will enable the attachment process to occur.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? postpartum psychosis postpartum blues postpartum depression postpartum panic disorder

postpartum psychosis The client's signs and symptoms suggest that the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues.

A nurse is providing preoperative care to a female newborn client with the congenital abnormality myelomeningocele. Which intervention is the priority?

preventing infection

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? nonshivering thermogenesis lack of brown adipose tissue radiation, convection, and conduction sweating and peripheral vasoconstriction

radiation, convection, and conduction Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.

A nurse is assessing a newborn with the parents present. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? orientation to surroundings crying response voluntary movements reflex

reflex The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system.

The nurse is documenting assessment of infant reflexes. She strokes the side of the infant's face, and the baby turns toward the stroke. What reflex has the nurse elicited? tonic neck sucking Moro rooting

rooting This is the rooting reflex and is used to encourage the infant to feed. This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle reflex) are total body reflexes and assess neurologic function in the newborn.

When evaluating neurologic maturity to determine gestational age, the nurse understands that which activity is not part of the assessment? square window rooting posture popliteal angle

rooting The six activities the newborn performs when being evaluated for gestational age based on neurologic maturity are as follows: posture, square window, arm recoil, popliteal angel, scar sign, and heel to ear.

A neonate is admitted to the newborn observation nursery with the possible diagnosis of polycythemia. The nurse would be observing for which findings? Select all that apply.

ruddy skin color respiratory distress cyanosis jitteriness

When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?" saturating 1 pad in 6 hours saturating 1 pad in 3 hours saturating 1 pad in 8 hours saturating 1 pad in 1 hour

saturating 1 pad in 1 hour Bleeding is considered heavy when a woman saturates a sanitary pad in 1 hour. Excessive bleeding occurs when a postpartum client saturates 1 pad in 15 minutes. Moderate bleeding occurs when the bleeding saturates less than 15 cm of a pad in 1 hour.

An infant born via a cesarean birth appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant? cardiac murmur hypoglycemia hyperthermia tachypnea

tachypnea The infant born from a cesarean birth has not had the opportunity to exit the birth canal and experience the squeezing of fluid from the lungs. The lungs have more amniotic fluid than the lungs of a baby from a vaginal birth and are at greater risk for respiratory complications, such as tachypnea. An infant born by cesarean birth is not at increased risk for hyperthermia, hypoglycemia, or a cardiac murmur.

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? taking-hold letting-go acquaintance/attachment taking-in

taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.

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

tea-colored urine

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply. temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention general fussiness approximately eight wet diapers a day

temperature of 38.3° C (101° F) or higher refuse feeding abdominal distention Parents should call their health care provider if they note any of the following warning signs: temperature of 38.3° C (101° F) or higher; forceful, persistent vomiting; refusal to take feedings; two or more green, watery diarrheal stools; infrequent wet diapers and change in bowel movements from normal pattern; lethargy or excessive sleepiness; inconsolable crying and extreme fussiness; abdominal distention; or difficult or labored breathing.

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at: the level of the umbilicus. between the umbilicus and symphysis pubis. 1 cm below the umbilicus. 2 cm below the umbilicus.

the level of the umbilicus. Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

Which newborn would the nurse suspect to be most at risk for cognitive challenge due to the mother's actions during pregnancy?

the child of a client who admits to drinking a liter of alcohol daily during the pregnancy

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

this is a normal finding. Newborn stools typically pass through a pattern of meconium, green transitional, and then yellow.

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? hormonal shifting of relaxin and estrogen thromboembolic disorder of the lower extremities infection normal response to the body converting back to prepregnancy state

thromboembolic disorder of the lower extremities Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state.

A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider? writing pictures touching recognizing the meaning of words

touching Nurses caring for families should consider all aspects of culture, including communication. Communication is more than just an understanding of the person's language but also the meaning of touch and gestures. Nurses must be sensitive to how people respond when being touched and should refrain from it if the client's response indicates that it is unwelcomed.

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? urinary tract infection postpartum diuresis trauma to pelvic muscles urinary overflow

trauma to pelvic muscles The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.

After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? two or three times per week once a week once a day every other day

two or three times per week Bathing two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin.

When assessing the newborn's umbilical cord, what should the nurse expect to find? two smaller arteries and one larger vein one smaller artery and two larger veins one smaller vein and two larger arteries two smaller veins and one larger artery

two smaller arteries and one larger vein When inspecting the vessels in the umbilical cord, the nurse should expect to encounter one larger vein and two smaller arteries. In 0.5% of births (3.5% of twin births), there is only one umbilical artery, which can be linked to cardiac or chromosomal abnormalities.

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

undescended testes

A nurse is reviewing the medical record of a postpartum woman in preparation for assessment. Which factor would the nurse identify as increasing the woman's risk for infection? Select all that apply. episiotomy hemoglobin 11.0 g/100 mL white blood cell count 25,000/mm³ urinary stasis denuded endometrial arteries

urinary stasis denuded endometrial arteries episiotomy The urinary system after birth is prone to infection, prompting a focus on cleanliness and frequent urination. The open uterine arteries are at risk for infection, as is any break in skin integrity, such as an episiotomy. An elevated white blood cell count (from 10,000/mm³ to 30,000/mm³) is the body's defense against infection. A count greater than 30,000/mm³ or less than 10,000/mm³ prompts further investigation. A hemoglobin finding lower than 10.5 g/100 ml suggests anemia.

The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse would monitor the client for which condition? stress incontinence urinary tract infection loss of pelvic muscle tone increased urine output

urinary tract infection The nurse would need to monitor the client for signs and symptoms of a urinary tract infection, a risk associated with catheterization. Stress incontinence is caused due to loss of pelvic muscle tone after birth. Increased urinary output is observed in diuresis. Catheterization does not cause loss of pelvic muscle tone, increased urine output, or stress incontinence.

The nursing instructor is teaching a session on techniques which the nursing students can use to properly address concerns of parents with children who are born with a congenital disorder. The instructor determines the session is successful when the students correctly choose which nursing intervention as being the most effective in these situations?

use reflective listening and offer nonjudgmental support.

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine subinvolution uterine contraction uterine atony uterine prolapse

uterine atony Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.

Which factor puts a client on her first postpartum day at risk for hemorrhage? moderate amount of lochia rubra hemoglobin level of 12 g/dl (120 g/L) thrombophlebitis uterine atony

uterine atony Loss of uterine tone places a client at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

During an assessment, the nurse notes that the client has been unable to urinate properly since she gave birth and is still bleeding more than expected. The nurse suspects which condition? postpartum diaphoresis urinary tract infection uterine atony urinary retention

uterine atony Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of postpartum hemorrhage. The client will have increased diaphoresis as the body works to decrease the blood volume that was necessary during the pregnancy.

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply. uterine infection hydramnios early ambulation empty bladder breastfeeding prolonged labor

uterine infection hydramnios prolonged labor Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breast-feeding, early ambulation, and an empty bladder would facilitate uterine involution.

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? lochia serosa diaphoresis edematous vagina uterus 1 cm below umbilicus

uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. head-to-toe assessment of newborn pain level vital signs of mother newborn's vital signs head-to-toe assessment

vital signs of mother pain level head-to-toe assessment Postpartum assessment of the mother usually includes vital signs, pain level, and a systematic head-to-toe assessment of the mother. The others are care of the newborn and done by the nurse in the nursery.

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

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

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? within the first 2 to 4 hours, when the newborn reaches the nursery prior to the newborn being discharged 24 hours after the newborn's birth within 30 minutes after birth, in the birthing area

within the first 2 to 4 hours, when the newborn reaches the nursery The nurse should complete the second assessment for the newborn within the first 2 to 4 hours, when the newborn is in the nursery. The nurse should complete the initial newborn assessment in the birthing area and the third assessment before the newborn is discharged, whenever that may be.

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. women using street drugs women on antithyroid medications women who had difficulties with breastfeeding in the past women on antineoplastic medications women with more than one infant

women on antithyroid medications women on antineoplastic medications women using street drugs While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.

A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment? heart rate of 130 bpm abdominal distention yellow sclera respiratory rate of 24 breaths/minute

yellow sclera The nurse should monitor for yellow skin or sclera in a newborn at risk for developing jaundice due to a high bilirubin. A heart rate of 130 bpm is normal for a newborn, as is a respiratory rate of 24 breaths/minute. Abdominal distention is not a consequence of elevated bilirubin.

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply. formed in consistency firm in shape stringy to pasty consistency completely odorless yellowish gold color

yellowish gold color stringy to pasty consistency The stools of a breastfed newborn are yellowish gold in color. They are not firm in shape or solid. The smell is usually sour. A formula-fed infant's stools are formed in consistency, whereas a breastfed infant's stools are stringy to pasty in consistency.

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

• Dress the newborn in ways to preserve warmth. • Take the newborn's temperature often. • Supply oxygen for the newborn, if necessary.

Four weeks before the birth of a client's already large child, the primary care provider has told the client that if the baby gets bigger and the baby's lungs are ready, the care provider would like to perform a cesarean birth. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse?

"As the baby passes through the birth canal some of the excess fluid is expelled from the lungs, if that doesn't happen there's a higher risk of respiratory distress."

After assessing the status of a newborn, the nurse is concerned that this newborn has persistent pulmonary hypertension. When explaining it to the parents, the nurse would integrate knowledge about which event as having most likely occurred?

Foramen ovale has not closed.

The nurse is admitting to the nursery a newborn of a mother who continued to drink alcohol during her pregnancy. Which finding does the nurse predict to encounter on the newborn's assessment?

Hyperactive and irritable

The nurse is teaching the parents of a newborn who was born with a high type of imperforate anus the care the newborn will need at home after surgery. The parents need to be aware that the newborn will require which measure temporarily?

colostomy

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

conduction

The nurse is caring for an infant born to a mother who abused cocaine during her pregnancy. The nurse would likely notice that this infant:

cries when touched.

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

ductus arteriosus remains open.

A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings?

esophageal atresia

A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area?

face

A nurse is explaining to the parents the preoperative care for their infant born with bladder exstrophy. The parents ask, "What will happen to the bladder while waiting for the surgery?" What is the nurse's best response?

"The bladder will covered in a sterile plastic bag to keep it moist."

A nurse is caring for a child with complex esophageal atresia who will be undergoing surgery for repair. What comment by the parents indicates further teaching is required?

"After this surgery is done tomorrow, my baby will be able to eat and drink"

The nurse is teaching the caregivers of an infant diagnosed with hypospadias how to properly care for the infant. The nurse determines the session is successful when the caregivers make which statement?

"Being able to most likely correct this in one stage rather than several is reassuring."

The nurse is working with an adult female who has PKU and desires to become pregnant. The nurse notes on her assessment her current serum phenylalanine level is 10 mg/dL. Which instruction should the nurse prioritize for this client?

"It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg."

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

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

A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply.

-encouraging kangaroo care during procedures -removing tape gently from the skin -using a colorful mobile for distraction

A nurse is preparing to administer epinephrine intravenously to a preterm newborn. The newborn weighs 1,500 g, and the primary care provider prescribes 0.1 mL/kg. How much would the nurse administer?

0.15 mL

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

Prepare for repeat hematocit levels q12h.

A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn?

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

The nurse is checking a newborn for the presence of Ortolani and Barlow signs. For which health problem are these assessments used?

The nurse is checking a newborn for the presence of Ortolani and Barlow signs. For which health problem are these assessments used?

A nurse is reading a journal article about birth defects and finds that some birth defects are preventable. Which risk factor would the nurse expect to find as being cited as the current leading preventable cause of birth defects?

alcohol

A pregnant woman gives birth to a small for gestational age neonate who is admitted to the neonatal intensive care unit with seizure activity. The neonate appears to have abnormally small eyes and a thin upper lip. The infant is noted to be microcephalic. Based on these findings, which substance would the nurse suspect the women of using during pregnancy?

alcohol

Assessment reveals that a young mother has several risk factors for giving birth to an infant with a neural tube defect. Which laboratory test would the nurse expect to be used to monitor the fetus for this birth defect?

alpha-fetoprotein levels

A newborn with high serum bilirubin is receiving phototherapy. Which nursing intervention is the most appropriate for this client?

application of eye dressings to the infant

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

newly born preterm infant

A woman who has a history of cocaine abuse gives birth to a newborn. Which findings would the nurse expect to assess in the newborn? Select all that apply.

piercing cry poor sucking inconsolable

A 30 weeks' gestation neonate born with low Apgar scores is in the neonatal intensive care unit with respiratory distress syndrome and underwent an exchange transfusion for anemia. Which factors place the neonate at risk for necrotizing enterocolitis? Select all that apply

preterm birth respiratory distress syndrome low Apgar scores exchange transfusion

A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as:

respiratory distress.

A nurse working in the newborn observational unit is assigned four newborns closely being monitored. Which newborn is at greatest risk of developing respiratory distress syndrome?

the male preterm infant born by cesarean birth with cold stress

A nurse is assessing a newborn. The nurse suspects that the newborn was exposed to drugs while in utero based on which findings? Select all that apply.

tremors nasal flaring frequent yawning