Questions for chapter 19,21,22,25
A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds: a. "It is an eye ointment to help your baby see you better." b. "It is to protect your baby from contracting herpes from your vaginal tract." c. "Erythromycin is given prophylactically to prevent a gonorrheal infection." d. "This medicine will protect your baby's eyes from drying out over the next few days."
"Erythromycin is given prophylactically to prevent a gonorrheal infection."
A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse's most appropriate response is to ask the woman: a. "Didn't you like your lunch?" b. "Does your doctor know that you are planning to eat that?" c. "What is that anyway?" d. "I'll warm the soup in the microwave for you."
"I'll warm the soup in the microwave for you."
The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them: a. "Infants can see very little until about 3 months of age." b. "Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns." c. "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d. "It's important to shield the newborn's eyes. Overhead lights help them see better."
"Infants can track their parent's eyes and distinguish patterns; they prefer complex patterns."
A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents? a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b. "The drug keeps your baby from requiring too much sedation." c. "Surfactant is used to reduce episodes of periodic apnea." d. "Your baby needs this medication to fight a possible respiratory tract infection."
"Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide."
A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" The nurse's best response is: a. "That's meconium, which is your baby's first stool. It's normal." b. "That's transitional stool." c. "That means your baby is bleeding internally." d. "Oh, don't worry about that. It's okay."
"That's meconium, which is your baby's first stool. It's normal."
A after birth woman overhears the nurse tell the obstetrics clinician that she has a positive Homans' sign and asks what it means. The nurse's best response is: a. "You have pitting edema in your ankles." b. "You have deep tendon reflexes rated 2+." c. "You have calf pain when the nurse flexes your foot." d. "You have a 'fleshy' odor to your vaginal drainage."
"You have calf pain when the nurse flexes your foot."
On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask whether they can hold their infant during his next gavage feeding. Given that this newborn is physiologically stable, what response would the nurse give? a. "Parents are not allowed to hold infants who depend on oxygen." b. "You may hold only your baby's hand during the feeding." c. "Feedings cause more physiologic stress, so the baby must be closely monitored. Therefore, I don't think you should hold the baby." d. "You may hold your baby during the feeding."
"You may hold your baby during the feeding."
A patient is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is: a. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." b. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." c. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." d. "Your baby will get cold stressed easily and needs to be bundled up at all times."
"Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him."
An infant is being discharged from the neonatal intensive care unit after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infant's mother asks the nurse whether her baby will meet developmental milestones on time, as did her son who was born at term. The nurse's most appropriate response is: a. "Your baby will develop exactly like your first child did." b. "Your baby does not appear to have any problems at the present time." c. "Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing." d. "Your baby will need to be followed very closely."
"Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing."
During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurse's best response would be: a. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." b. "You and your baby can be exposed to the human immunodeficiency virus (HIV) in your cats' feces." c. "It's just gross. You should make your husband clean the litter boxes." d. "Cat feces are known to carry Escherichia coli, which can cause a severe infection in both you and your baby."
"Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child."
While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: a. 80 to 100 beats/min. b. 100 to 120 beats/min. c. 120 to 160 beats/min. d. 150 to 180 beats/min.
120 to 160 beats/min.
Under the Newborns' and Mothers' Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth. a. 24, 73 b. 24, 96 c. 48, 96 d. 48, 120
48, 96
Early after birth hemorrhage is defined as a blood loss greater than: a. 500 mL in the first 24 hours after vaginal delivery. b. 750 mL in the first 24 hours after vaginal delivery. c. 1000 mL in the first 48 hours after cesarean delivery. d. 1500 mL in the first 48 hours after cesarean delivery.
500 mL in the first 24 hours after vaginal delivery.
Which woman is at greatest risk for early postpartum hemorrhage (PPH)? a. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress. b. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced. c. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor. d. A primigravida in spontaneous labor with preterm twins.
A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced.
Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? a. After birth depression b. After birth psychosis c. After birth bipolar disorder d. After birth blues
After birth blues
Postpartal overdistention of the bladder and urinary retention can lead to which complications? a. After birth hemorrhage and eclampsia b. Fever and increased blood pressure c. After birth hemorrhage and urinary tract infection d. Urinary tract infection and uterine rupture
After birth hemorrhage and urinary tract infection
A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol b. Cocaine c. Heroin d. Marijuana
Alcohol
A woman delivered a 9-lb, 10-ounce baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? a. Call for help. b. Assess the fundus for firmness. c. Take her blood pressure. d. Check the perineum for lacerations.
Assess the fundus for firmness.
Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder.
Assist the patient in emptying her bladder.
Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Tonic neck c. Stepping d. Plantar grasp
Babinski
Which statement describing physiologic jaundice is incorrect? a. Neonatal jaundice is common, but kernicterus is rare. b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c. Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help. d. Breastfed babies have a lower incidence of jaundice.
Breastfed babies have a lower incidence of jaundice.
If nonsurgical treatment for late after birth hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a. Hysterectomy b. Laparoscopy c. Laparotomy d. D&C
D&C
An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which highly technical method of treatment may be necessary for an infant who does not respond to conventional treatment? a. Extracorporeal membrane oxygenation b. Respiratory support with a ventilator c. Insertion of a laryngoscope and suctioning of the trachea d. Insertion of an endotracheal tube
Extracorporeal membrane oxygenation
What bacterial infection is definitely decreasing because of effective drug treatment? a. Escherichia coli infection b. Tuberculosis c. Candidiasis d. Group B streptococcal infection
Group B streptococcal infection
If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid? a. Putting the patient in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots. b. Having the patient flex, extend, and rotate her feet, ankles, and legs. c. Having the patient sit in a chair. d. Notifying the physician immediately if a positive Homans' sign occurs.
Having the patient sit in a chair.
Which infant would be more likely to have Rh incompatibility? a. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor. b. Infant who is Rh negative and whose mother is Rh negative. c. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor. d. Infant who is Rh positive and whose mother is Rh positive.
Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor.
What PPH conditions are considered medical emergencies that require immediate treatment? a. Inversion of the uterus and hypovolemic shock b. Hypotonic uterus and coagulopathies c. Subinvolution of the uterus and idiopathic thrombocytopenic purpura d. Uterine atony and disseminated intravascular coagulation
Inversion of the uterus and hypovolemic shock
Which statement describing the first phase of the transition period is inaccurate? a. It lasts no longer than 30 minutes. b. It is marked by spontaneous tremors, crying, and head movements. c. It includes the passage of meconium. d. It may involve the infant's suddenly sleeping briefly.
It may involve the infant's suddenly sleeping briefly.
What infection is contracted mostly by first-time mothers who are breastfeeding? a. Endometritis b. Wound infections c. Mastitis d. Urinary tract infections
Mastitis
An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called: a. lanugo. b. vascular nevi. c. nevus flammeus. d. Mongolian spots.
Mongolian spots.
While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive: a. tonic neck reflex. b. glabellar (Myerson) reflex. c. Babinski reflex. d. Moro reflex.
Moro reflex.
Rho immune globulin will be ordered after birth if which situation occurs? a. Mother Rh-, baby Rh+ b. Mother Rh-, baby Rh- c. Mother Rh+, baby Rh+ d. Mother Rh+, baby Rh-
Mother Rh-, baby Rh+
Which instruction should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications? a. Palpate the fundus daily to ensure that it is soft. b. Notify the physician of any increase in the amount of lochia or a return to bright red bleeding. c. Report any decrease in the amount of brownish red lochia. d. The passage of clots as large as an orange can be expected.
Notify the physician of any increase in the amount of lochia or a return to bright red bleeding.
Chapter 19
Nursing care of the family during postpartum period
What marks on a baby's skin may indicate an underlying problem that requires notification of a physician? a. Mongolian spots on the back b. Telangiectatic nevi on the nose or nape of the neck c. Petechiae scattered over the infant's body d. Erythema toxicum anywhere on the body
Petechiae scattered over the infant's body
Chapter 22
Physiological and Behavioral adaptions of the newborn
chapter 21
Postpartum complications
For clinical purposes, preterm and postterm infants are defined as: a. preterm before 34 weeks if appropriate for gestational age (AGA) and before 37 weeks if small for gestational age (SGA). b. Postterm after 40 weeks if large for gestational age (LGA) and beyond 42 weeks if AGA. c. Preterm before 37 weeks, and postterm beyond 42 weeks, no matter the size for gestational age at birth. d. Preterm, SGA before 38 to 40 weeks, and postterm, LGA beyond 40 to 42 weeks.
Preterm before 37 weeks, and postterm beyond 42 weeks, no matter the size for gestational age at birth.
During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is not one of these essential factors? a. Chemical b. Mechanical c. Thermal d. Psychologic
Psychologic
In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Bronchopulmonary dysplasia (BPD) d. Intraventricular hemorrhage (IVH)
Retinopathy of prematurity (ROP)
The laboratory results for a after birth woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data? a. Rubella vaccine should be given. b. A blood transfusion is necessary. c. Rh immune globulin is necessary within 72 hours of birth. d. A Kleihauer-Betke test should be performed.
Rubella vaccine should be given.
An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? a. Rapid bolusing of the entire amount in 15 minutes. b. Warm cloths to the abdomen for the first 10 minutes. c. Slow, small, warm bolus feedings over 30 minutes. d. Cold, medium bolus feedings over 20 minutes.
Slow, small, warm bolus feedings over 30 minutes.
A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a. Physiologic jaundice occurs during the first 24 hours of life. b. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. c. The bilirubin levels of physiologic jaundice peak between 72 to 96 hours of life. d. This condition is also known as "breast milk jaundice."
The bilirubin levels of physiologic jaundice peak between 72 to 96 hours of life.
When providing an infant with a gavage feeding, which of the following should be documented each time? a. The infant's abdominal circumference after the feeding. b. The infant's heart rate and respirations. c. The infant's suck and swallow coordination. d. The infant's response to the feeding.
The infant's response to the feeding.
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.
The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.
A woman gave birth vaginally to a 9-lb, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? a. The woman is a gravida 2, para 2. b. The woman had a vacuum-assisted birth. c. The woman received epidural anesthesia. d. The woman has an episiotomy.
The woman has an episiotomy.
What infant response to cool environmental conditions is either not effective or not available to them? a. Constriction of peripheral blood vessels b. Metabolism of brown fat c. Increased respiratory rates d. Unflexing from the normal position
Unflexing from the normal position
Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: a. hypertonia, tachycardia, and metabolic alkalosis. b. abdominal distention, temperature instability, and grossly bloody stools. c. hypertension, absence of apnea, and ruddy skin color. d. scaphoid abdomen, no residual with feedings, and increased urinary output.
abdominal distention, temperature instability, and grossly bloody stools.
Part of the health assessment of a newborn is observing the infant's breathing pattern. A full-term newborn's breathing pattern is predominantly: a. abdominal with synchronous chest movements. b. chest breathing with nasal flaring. c. diaphragmatic with chest retraction. d. deep with a regular rhythm.
abdominal with synchronous chest movements.
A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called: a. acrocyanosis. b. erythema neonatorum. c. harlequin color. d. vernix caseosa.
acrocyanosis.
The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States? a. Alcohol b. Tobacco c. Marijuana d. Heroin
alcohol
In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: a. the pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. b. two-thirds of newborns with fetal alcohol syndrome (FAS) are boys. c. alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech, and language problems) are often not detected until the child goes to school. d. both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.
alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech, and language problems) are often not detected until the child goes to school.
An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver would then: a. tell the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. b. alert the physician that the infant has a dislocated hip. c. inform the parents and physician that molding has not taken place. d. suggest that, if the condition does not change, surgery to correct vision problems may be needed.
alert the physician that the infant has a dislocated hip.
A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by: a. running warm water on her breasts during a shower. b. applying ice to the breasts for comfort. c. expressing small amounts of milk from the breasts to relieve pressure. d. wearing a loose-fitting bra to prevent nipple irritation.
applying ice to the breasts for comfort.
Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins: a. at the time of admission to the nurse's unit. b. when the infant is presented to the mother at birth. c. during the first visit with the physician in the unit. d. when the take-home information packet is given to the couple.
at the time of admission to the nurse's unit.
Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC: a. early enteral feedings. b. breastfeeding. c. exchange transfusion. d. prophylactic probiotics.
breastfeeding
Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are: a. suffering from sleep or wakeful apnea. b. experiencing severe swings in blood pressure. c. trying to maintain a neutral thermal environment. d. breathing in a respiratory pattern common to premature infants.
breathing in a respiratory pattern common to premature infants.
One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the: a. incompletely developed neuromuscular system. b. primitive reflex system. c. presence of various sleep-wake states. d. cerebellum growth spurt.
cerebellum growth spurt.
A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant's body temperature every hour. Maintaining the newborn's body temperature is important for preventing: a. respiratory depression. b. cold stress. c. tachycardia. d. vasoconstriction.
cold stress.
Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of: a. gonorrhea. b. herpes simplex virus infection. c. congenital syphilis. d. human immunodeficiency virus.
congenital syphilis.
The nurse caring for the after birth woman understands that breast engorgement is caused by: a. overproduction of colostrum. b. accumulation of milk in the lactiferous ducts and glands. c. hyperplasia of mammary tissue. d. congestion of veins and lymphatics.
congestion of veins and lymphatics.
The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as: a. enterohepatic circuit. b. conjugation of bilirubin. c. unconjugation of bilirubin. d. albumin binding.
conjugation of bilirubin.
What are modes of heat loss in the newborn? (Select all that apply.) a. Perspiration b. Convection c. Radiation d. Conduction e. Urination
convection radiatation conduction
Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for after birth hemorrhage from birth until 4 weeks after delivery as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the patient with von Willebrand disease who experiences a after birth hemorrhage is: a. cryoprecipitate. b. factor VIII and vWf. c. desmopressin. d. hemabate.
desmopressin.
While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should: a. notify the physician immediately. b. move the newborn to an isolation nursery. c. document the finding as erythema toxicum. d. take the newborn's temperature and obtain a culture of one of the vesicles.
document the finding as erythema toxicum.
Nurses can prevent evaporative heat loss in the newborn by: a. drying the baby after birth and wrapping the baby in a dry blanket. b. keeping the baby out of drafts and away from air conditioners. c. placing the baby away from the outside wall and the windows. d. warming the stethoscope and the nurse's hands before touching the baby.
drying the baby after birth and wrapping the baby in a dry blanket.
When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is: a. rectal suppositories. b. early and frequent ambulation. c. tightening and relaxing abdominal muscles. d. carbonated beverages.
early and frequent ambulation.
Excessive blood loss after childbirth can have several causes; the most common is: a. vaginal or vulvar hematomas. b. unrepaired lacerations of the vagina or cervix. c. failure of the uterine muscle to contract firmly. d. retained placental fragments.
failure of the uterine muscle to contract firmly.
A woman gave birth to a healthy 7-lb, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: a. transition period. b. first period of reactivity. c. organizational stage. d. second period of reactivity.
first period of reactivity.
While completing a newborn assessment, the nurse should be aware that the most common birth injury is: a. to the soft tissues. b. caused by forceps gripping the head on delivery. c. fracture of the humerus and femur. d. fracture of the clavicle.
fracture of the clavicle.
A newborn was admitted to the neonatal intensive care unit after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurse's most appropriate action would be to: a. wait quietly at the newborn's bedside until the parents come closer. b. go to the parents, introduce himself or herself, and gently encourage the parents to come meet their infant; explain the equipment first, and then focus on the newborn. c. leave the parents at the bedside while they are visiting so they can have some privacy. d. tell the parents only about the newborn's physical condition, and caution them to avoid touching their baby.
go to the parents, introduce himself or herself, and gently encourage the parents to come meet their infant; explain the equipment first, and then focus on the newborn.
The most important nursing action in preventing neonatal infection is: a. good hand washing. b. isolation of infected infants. c. separate gown technique. d. Standard Precautions.
good hand washing.
When assessing the preterm infant the nurse understands that compared with the term infant, the preterm infant has: a. few blood vessels visible through the skin. b. more subcutaneous fat. c. well-developed flexor muscles. d. greater surface area in proportion to weight.
greater surface area in proportion to weight.
When a woman is diagnosed with postpartum depression (PPD) with psychotic features, one of the main concerns is that she may: a. have outbursts of anger. b. neglect her hygiene. c. harm her infant. d. lose interest in her husband.
harm her infant.
A recently delivered mother and her baby are at the clinic for a 6-week after birth checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman: a. discusses her labor and birth experience excessively. b. believes that her baby is more attractive and clever than any others. c. has not given the baby a name. d. has a partner or family members who react very positively about the baby.
has not given the baby a name.
In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she: a. has recovered from epidural or spinal anesthesia. b. has hidden bleeding underneath her. c. has regained some flexibility. d. is a candidate to go home after 6 hours.
has recovered from epidural or spinal anesthesia.
The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. This intervention: a. is adopted from classical British nursing traditions. b. helps infants with motor and central nervous system impairment. c. helps infants to interact directly with their parents and enhances their temperature regulation. d. gets infants ready for breastfeeding.
helps infants to interact directly with their parents and enhances their temperature regulation.
The most common cause of pathologic hyperbilirubinemia is: a. hepatic disease. b. hemolytic disorders in the newborn. c. postmaturity. d. congenital heart defect.
hemolytic disorders in the newborn.
While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has: a. polydactyly. b. clubfoot. c. hip dysplasia. d. webbing.
hip dysplasia
An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: a. birth injury. b. hypocalcemia. c. hypoglycemia. d. seizures.
hypoglycemia.
In the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect: a. hypovolemia and/or shock. b. a nonneutral thermal environment. c. central nervous system injury. d. pending renal failure.
hypovolemia and/or shock.
With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: a. if the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. b. Erb palsy is damage to the lower plexus. c. parents of children with brachial palsy are taught to pick up the child from under the axillae. d. breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.
if the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.
A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to: a. improve the accuracy of blood loss estimation, which usually is a subjective assessment. b. determine which pad is best. c. demonstrate that other nurses usually underestimate blood loss. d. reveal to the nurse supervisor that one of them needs some time off.
improve the accuracy of blood loss estimation, which usually is a subjective assessment.
Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: a. increased pressure in the right atrium. b. increased pressure in the left atrium. c. decreased blood flow to the left ventricle. d. changes in the hepatic blood flow.
increased pressure in the left atrium.
The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: a. closure of fetal shunts in the circulatory system. b. full function of the immune defense system at birth. c. maintenance of a stable temperature. d. initiation and maintenance of respirations.
initiation and maintenance of respirations.
Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is: a. pouring water from a squeeze bottle over the woman's perineum. b. placing oil of peppermint in a bedpan under the woman. c. asking the physician to prescribe analgesics. d. inserting a sterile catheter.
inserting a sterile catheter.
Complicated bereavement: a. occurs when, in multiple births, one child dies, and the other or others live. b. is a state in which the parents are ambivalent, as with an abortion. c. is an extremely intense grief reaction that persists for a long time. d. is felt by the family of adolescent mothers who lose their babies.
is an extremely intense grief reaction that persists for a long time.
To provide adequate after birth care, the nurse should be aware that postpartum depression (PPD) without psychotic features: a. means that the woman is experiencing the baby blues. In addition she has a visit with a counselor or psychologist. b. is more common among older, Caucasian women because they have higher expectations. c. is distinguished by irritability, severe anxiety, and panic attacks. d. will disappear on its own without outside help.
is distinguished by irritability, severe anxiety, and panic attacks.
In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice: a. is inconsistent with the Baby-Friendly Hospital Initiative. b. promotes longer periods of breastfeeding. c. is perceived as supportive to both bottle-feeding and breastfeeding mothers. d. is associated with earlier cessation of breastfeeding.
is inconsistent with the Baby-Friendly Hospital Initiative.
The transition period between intrauterine and extrauterine existence for the newborn: a. consists of four phases, two reactive and two of decreased responses. b. is referred to as the neonatal period and lasts from birth to day 28 of life. c. applies to full-term births only. d. varies by socioeconomic status and the mother's age.
is referred to as the neonatal period and lasts from birth to day 28 of life.
Infants in whom cephalhematomas develop are at increased risk for: a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.
jaundice
A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests: a. uterine atony. b. lacerations of the genital tract. c. perineal hematoma. d. infection of the uterus.
lacerations of the genital tract.
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: a. begin an intravenous (IV) infusion of Ringer's lactate solution. b. assess the woman's vital signs. c. call the woman's primary health care provider. d. massage the woman's fundus.
massage the woman's fundus.
To provide adequate after birth care, the nurse should be aware that postpartum depression (PPD) with psychotic features: a. is more likely to occur in women with more than two children. b. is rarely delusional and then is usually about someone trying to harm her (the mother). c. although serious, is not likely to need psychiatric hospitalization. d. may include bipolar disorder (formerly called "manic depression").
may include bipolar disorder (formerly called "manic depression").
A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: a. may occur with spontaneous vaginal birth. b. happens only as the result of a forceps or vacuum delivery. c. is present immediately after birth. d. will gradually absorb over the first few months of life.
may occur with spontaneous vaginal birth.
A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. The nurse caring for the infant after birth should anticipate: a. meconium aspiration, hypoglycemia, and dry, cracked skin. b. excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome. c. golden yellow- to green stained-skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat. d. hyperglycemia, hyperthermia, and an alert, wide-eyed appearance.
meconium aspiration, hypoglycemia, and dry, cracked skin.
A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 lbs, 6 ounces). The nurse's most appropriate action is to: a. leave the infant in the room with the mother. b. take the infant immediately to the nursery. c. perform a gestational age assessment to determine whether the infant is large for gestational age. d. monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.
monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.
A careful review of the literature on the various recreational and illicit drugs reveals that: a. more longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs. b. heroin and methadone cross the placenta; marijuana, cocaine, and phencyclidine (PCP) do not. c. mothers should discontinue heroin use (detox) any time they can during pregnancy. d. methadone withdrawal for infants is less severe and shorter than heroin withdrawal.
more longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs.
Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: a. pharmacologic treatment. b. reduction of environmental stimuli. c. neonatal abstinence syndrome scoring. d. adequate nutrition and maintenance of fluid and electrolyte balance.
neonatal abstinence syndrome scoring.
To care adequately for infants at risk for neonatal bacterial infection, nurses should be aware that: a. congenital infection progresses more slowly than does nosocomial infection. b. nosocomial infection can be prevented by effective hand washing; early-onset infections cannot. c. infections occur with about the same frequency in boy and girl infants, although female mortality is higher. d. the clinical sign of a rapid, high fever makes infection easier to diagnose.
nosocomial infection can be prevented by effective hand washing; early-onset infections cannot.
In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is: a. important in the production of red blood cells. b. necessary in the production of platelets. c. not initially synthesized because of a sterile bowel at birth. d. responsible for the breakdown of bilirubin and prevention of jaundice. .
not initially synthesized because of a sterile bowel at birth.
Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to: a. formally initializing individualized care by confirming the woman's and infant's identification (ID) numbers on their respective wrist bands. ("This is your baby.") b. teaching the mother to check the identity of any person who comes to remove the baby from the room. ("It's a dangerous world out there.") c. including other family members in the teaching of self-care and child care. ("We're all in this together.") d. nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.
nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.
The first and most important nursing intervention when a nurse observes profuse after birth bleeding is to: a. call the woman's primary health care provider. b. administer the standing order for an oxytocic. c. palpate the uterus and massage it if it is boggy. d. assess maternal blood pressure and pulse for signs of hypovolemic shock.
palpate the uterus and massage it if it is boggy.
As related to the eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that: a. infants will stay in the neonatal intensive care unit (NICU) until they are ready to go home. b. once discharged to home, the high risk infant should be treated like any healthy term newborn. c. parents of high risk infants need special support and detailed contact information. d. if a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.
parents of high risk infants need special support and detailed contact information.
A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is: a. seen at age 3 days. b. the residue of a milk curd. c. passed in the first 12 hours of life. d. lighter in color and looser in consistency.
passed in the first 12 hours of life.
A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to: a. establish venous access. b. perform fundal massage. c. prepare the woman for surgical intervention. d. catheterize the bladder.
perform fundal massage.
Medications used to manage postpartum hemorrhage (PPH) include: (Select all that apply.) a. Pitocin. b. Methergine. c. Terbutaline. d. Hemabate. e. magnesium sulfate.
pitocin methergine hemabate
Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is: a. phobias. b. panic disorder. c. posttraumatic stress disorder (PTSD). d. obsessive-compulsive disorder (OCD).
posttraumatic stress disorder (PTSD).
The goal of treatment of the infant with phenylketonuria (PKU) is to: a. cure mental retardation. b. prevent central nervous system (CNS) damage, which leads to mental retardation. c. prevent gastrointestinal symptoms. d. cure the urinary tract infection.
prevent central nervous system (CNS) damage, which leads to mental retardation.
Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for: (Select all that apply.) a. problems with thermoregulation. b. cardiac distress. c. hyperbilirubinemia. d. sepsis. e. hyperglycemia.
problems with thermoregulation. hyperbilirubinemia sepsis
With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or after birth depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent after birth depression. The most accurate statement as related to these activities is to: a. stay home and avoid outside activities to ensure adequate rest. b. be certain that you are the only caregiver for your baby to facilitate infant attachment. c. keep feelings of sadness and adjustment to your new role to yourself. d. realize that this is a common occurrence that affects many women.
realize that this is a common occurrence that affects many women.
With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that: a. the newborn's cheeks are full because of normal fluid retention. b. the nipple of the bottle or breast must be placed well inside the baby's mouth because teeth have been developing in utero, and one or more may even be through. c. regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head. d. bacteria are already present in the infant's GI tract at birth because they traveled through the placenta.
regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head.
Infants of mothers with diabetes (IDMs) are at higher risk for developing: a. anemia. b. hyponatremia. c. respiratory distress syndrome. d. sepsis.
respiratory distress syndrome.
Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a. Delayed growth and development b. Ineffective thermoregulation c. Ineffective infant feeding pattern d. Risk for infection
risk for infection
A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborn's distress is most likely to be: a. hypoglycemia. b. phrenic nerve injury. c. respiratory distress syndrome. d. sepsis.
sepsis
The perinatal nurse caring for the after birth woman understands that late postpartum hemorrhage (PPH) is most likely caused by: a. subinvolution of the placental site. b. defective vascularity of the decidua. c. cervical lacerations. d. coagulation disorders.
subinvolution of the placental site.
A plan of care for an infant experiencing symptoms of drug withdrawal should include: a. administering chloral hydrate for sedation. b. feeding every 4 to 6 hours to allow extra rest. c. swaddling the infant snugly and holding the baby tightly. d. playing soft music during feeding.
swaddling the infant snugly and holding the baby tightly.
One of the first symptoms of puerperal infection to assess for in the after birth woman is: a. fatigue continuing for longer than 1 week. b. pain with voiding. c. profuse vaginal bleeding with ambulation. d. temperature of 38° C (100.4° F) or higher on two successive days starting 24 hours after birth.
temperature of 38° C (100.4° F) or higher on two successive days starting 24 hours after birth.
By knowing about variations in infants' blood count, nurses can explain to their patients that: a. a somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord. b. the early high white blood cell (WBC) count is normal at birth and should decrease rapidly. c. platelet counts are higher than in adults for a few months. d. even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly.
the early high white blood cell (WBC) count is normal at birth and should decrease rapidly.
With regard to the respiratory development of the newborn, nurses should be aware that: a. the first gasping breath is an exaggerated respiratory reaction within 1 minute of birth. b. Newborns must expel the fluid from the respiratory system within a few minutes of birth. c. Newborns are instinctive mouth breathers. d. Seesaw respirations are no cause for concern in the first hour after birth.
the first gasping breath is an exaggerated respiratory reaction within 1 minute of birth.
Chapter 25
the high risk newborn
With regard to hemolytic diseases of the newborn, nurses should be aware that: a. Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother. b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. c. exchange transfusions frequently are required in the treatment of hemolytic disorders. d. the indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.
the indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.
The nurse should immediately alert the physician when: a. the infant is dusky and turns cyanotic when crying. b. acrocyanosis is present at age 1 hour. c. the infant's blood glucose level is 45 mg/dL. d. the infant goes into a deep sleep at age 1 hour.
the infant is dusky and turns cyanotic when crying.
In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with: a. the father of the infant. b. her mother (the infant's grandmother). c. her eldest daughter (the infant's sister). d. the nurse.
the nurse.
As related to the normal functioning of the renal system in newborns, nurses should be aware that: a. the pediatrician should be notified if the newborn has not voided in 24 hours. b. breastfed infants likely will void more often during the first days after birth. c. "Brick dust" or blood on a diaper is always a cause to notify the physician. d. weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.
the pediatrician should be notified if the newborn has not voided in 24 hours.
With regard to the newborn's developing cardiovascular system, nurses should be aware that: a. the heart rate of a crying infant may rise to 120 beats/min. b. heart murmurs heard after the first few hours are cause for concern. c. the point of maximal impulse (PMI) often is visible on the chest wall. d. persistent bradycardia may indicate respiratory distress syndrome (RDS).
the point of maximal impulse (PMI) often is visible on the chest wall.
A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect __________ and should confirm the diagnosis by ___________. a. disseminated intravascular coagulation; asking for laboratory tests b. von Willebrand disease; noting whether bleeding times have been extended c. thrombophlebitis; using real-time and color Doppler ultrasound d. coagulopathies; drawing blood for laboratory analysis
thrombophlebitis; using real-time and color Doppler ultrasound
HIV may be perinatally transmitted: a. only in the third trimester from the maternal circulation. b. from the use of unsterile instruments. c. only through the ingestion of amniotic fluid. d. through the ingestion of breast milk from an infected mother.
through the ingestion of breast milk from an infected mother.
Human immunodeficiency virus (HIV) may be perinatally transmitted: a. only in the third trimester from the maternal circulation. b. by a needlestick injury at birth from unsterile instruments. c. only through the ingestion of amniotic fluid. d. through the ingestion of breast milk from an infected mother.
through the ingestion of breast milk from an infected mother.
Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance: a. PPH is easy to recognize early; after all, the woman is bleeding. b. traditionally it takes more than 1000 mL of blood after vaginal birth and 2500 mL after cesarean birth to define the condition as PPH. c. if anything, nurses and doctors tend to overestimate the amount of blood loss. d. traditionally PPH has been classified as early or late with respect to birth.
traditionally PPH has been classified as early or late with respect to birth.
When caring for a after birth woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is: a. absence of cyanosis in the buccal mucosa. b. cool, dry skin. c. diminished restlessness. d. urinary output of at least 30 mL/hr.
urinary output of at least 30 mL/hr.
A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-lb, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, "I'm bleeding a lot." The most likely cause of after birth hemorrhage in this woman is: a. retained placental fragments. b. unrepaired vaginal lacerations. c. uterine atony. d. puerperal infection.
uterine atony
The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is: a. uterine atony. b. uterine inversion. c. vaginal hematoma. d. vaginal laceration.
uterine atony
The cheese-like, whitish substance that fuses with the epidermis and serves as a protective coating is called: a. vernix caseosa. b. surfactant. c. caput succedaneum. d. acrocyanosis.
vernix caseosa.
The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is: a. vision. b. hearing. c. smell. d. taste.
vision
As relates to rubella and Rh issues, nurses should be aware that: a. breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus. b. women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination. c. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant. d. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.
women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination.
