PrepU- Exam 6

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. 1. temperature of 38.3° C (101° F) or higher 2. refuse feeding 3. abdominal distention 4. general fussiness 5. approximately eight wet diapers a day

1, 2, 3. 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.

A client at 32 weeks' gestation receives an ultrasound that identifies intrauterine growth restriction. Which findings from the client's nutritional assessment would indicate to the nurse that additional teaching is needed? Select all that apply. 1. eating large quantities of empty-calorie foods 2. difficulty eating because of continuing nausea 3. history of gestational diabetes in previous pregnancy 4. maternal age less than 18 years 5. consuming 5 to 6 small meals each day

1, 2, 4: Low caloric intake because of continued nausea as well as eating large quantities of empty calories can impact fetal growth. Pregnant adolescents also are more likely to have poor fetal growth because the adolescent's growth needs are competing with the fetus for nutrients. Consuming small, frequent meals is a strategy for increasing caloric and nutrient intake during pregnancy. A history of gestational diabetes makes it more likely the client will experience elevated blood glucose levels and fetal macrosomia.

Which finding from a woman's initial prenatal assessment would be considered a possible complication of pregnancy that requires reporting to a primary care provider for management? 1. episodes of double vision 2. increased lumbar curvature 3. nasal congestion and swollen nasal membranes 4. palpitations when lying on her back

1. Difficulty with vision can occur from cerebral edema or is a symptom of hypertension of pregnancy.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? 1. Epstein pearls 2. milia 3. stork bites 4. congenital dermal melanocytosis

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

A gravida woman in her second trimester has shared that she still enjoys a glass of wine about once a week with dinner. What response by the nurse is most appropriate? 1. "Now that you have reached the second trimester you are at a reduced risk for causing complications to your fetus." 2. "There is no amount of alcohol consumption in pregnancy that is considered safe for the fetus." 3. "As long as you do not increase the amount of alcohol you are drinking there is little risk." 4. "The best thing for you to do is to reduce the amount of alcohol you are drinking."

2. Alcohol ingestion during the pregnancy is considered unsafe at all points in the pregnancy. Alcohol can impact the fetus during each of trimester of pregnancy. There are no exact amounts of alcohol that can be ingested safely. Alcohol impacts each pregnancy and fetus differently. The best course of action is to share the dangers with the woman.

A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client? 1. accidental intrathecal block 2. respiratory depression 3. postdural puncture (spinal) headache 4. a failed block

2. Respiratory depression is a complication of epidural anesthesia and should be closely monitored in laboring clients. A failed block, accidental intrathecal block, and a postdural puncture (spinal) headache are all side effects of a spinal epidural block.

A newborn weighing 5 lb (2250 g) needs to eat 3 oz (90 ml) of formula every 3 hours. To meet this goal, how many ounces of formula per day will the parent need to feed the newborn? Record your answer using a whole number.

24. Feeding every 3 hours equates to 8 feedings per day. 3 oz × 8 = 24 oz. This can also be calculated in milliliters and converted back into ounces. 90 ml × 8 = 720 ml

An adolescent who received no prenatal care arrives at the hospital in active labor. Upon examination, the nurse assesses a cluster of pinpoint vesicles with a red base on the vulva; the adolescent asks the nurse to not touch "her rash" because it hurts when touched. At this point, which intervention will the nurse perform next? 1. Ask the adolescent if the father of the baby has a rash as well. 2. Put on gloves and palpate the vulva for enlarged lymph nodes. 3. Report the finding to the primary health care provider. 4. Ask the adolescent if this rash is felt internally as well as externally.

3. A herpes simplex 2 viral infection appears as clustered, pinpoint vesicles on an erythematous (reddened) base on the vulva that feels painful when touched or irritated. It is important that these are detected during pregnancy because the presence of herpes lesions on the vulva or vagina at the time of birth may necessitate cesarean birth to prevent exposing the fetus to the virus during passage through the birth canal. This is not the time to be concerned about the status of the father of the baby. Further assessment and follow-up will be completed later. The nurse should already have PPE on their hands. Enlarged lymph nodes may signify an infection but not pinpoint the specifics. At this point, the fetus is at risk of exposure if outside lesions are present

The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: 1. right upper quadrant. 2. right lower quadrant. 3. left upper quadrant. 4. left lower quadrant.

4. The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.

The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring? 1. Intermittent fetal heart rate auscultation 2. Continuous external fetal monitor 3. No monitoring needed 4. Fetal scalp sampling

1. This client is considered a low-risk pregnancy but some monitoring is still needed. Thus, an acceptable method for monitoring fetal heart rate is intermittent fetal heart rate auscultation. The client is placed on an external fetal monitor for a 20-minute baseline and, if within normal limits, then is checked via a fetoscope or handheld Doppler at intermittent intervals. Continuous external monitoring may be initiated later in the labor process but is not identified from the history. Fetal scalp sampling gives evidence of the fetal status.

The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide? 1. Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. 2. Harlequin sign noted on left upper outer thigh. 3. Mottling noted on left upper outer thigh. 4. Birth trauma noted on left upper outer thigh.

1. A congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spot) is bluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. The Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. Mottling occurs when the lips, hands, and feet appear blue from immature peripheral circulation. Birth trauma is a possibility; however, there would be notations of an incident and possibly other injuries would be noted.

A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse? 1. "Newborns are given vitamin K to help with the digestion to help them absorb fat-soluble vitamins." 2. "Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." 3. "Newborns are given vitamin K and erythromycin ointment to help prevent ophthalmia neonatorum." 4. This vitamin substitutes for vitamin C for newborns to strengthen their immune systems."

2. Vitamin K is needed in newborns to prevent bleeding episodes. It is especially important for male newborns who are being circumcised. The newborn's intestine is sterile and has no symbiotic bacteria in it to produce vitamin K, so the newborn receives a supplement through the vitamin K injection. Vitamin K does not assist in absorbing fat-soluble vitamins, prevent ophthalmia neonatorum, or strengthen the immune system.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? 1. Send a family member to accompany the infant when leaving the room. 2. Check the name on the baby's identification bracelet. 3. Provide a list of approved visitors who came spend time with the infant. 4. Check the identification badge of any health care worker before releasing baby from room.

4. Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.