376 Exam III
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? a. Remove wet blankets b. Assess APGAR score c. Insert eye prophylaxis d. Elicit the Moro reflex.
A to prevent conduction and evaporation
1. In the delivery room, which of the following infant care interventions must a nurse perform when a neonate with a meningomyelocele is born? a. Perform nasogastric suctioning. b. Place baby in the prone position. c. Administer oxygen via face mask. d. Swaddle the baby in warmed blankets.
B
1. Thirty seconds after birth a baby, who appears preterm, has exhibited no effort to breathe even after being stimulated. The heart rate is assessed at 50bpm. Which of the following actions should the nurse perform first? a. Perform a gestational age assessment. b. Inflate the lungs with positive pressure. c. Provide external chest compressions. d. Assess the oxygen saturation level.
B
elicited when the nurse strokes from the heel to the ball of the foot
Babinski reflex
poorly demarcated soft tissue swelling.
Caput
white spots are noted on her hard palate.
Epstein pearls
completed on her after 24 hours to rule out congenital deafness.
Universal newborn hearing screen
thick white substance that provides protection for the newborn's skin in utero
Vernix caseosa
6. Heart murmurs in newborns a. are fairly common. b. are not very common. c. frequently require intervention. d. are almost always indicative of heart disease.
a
Is a protruding xiphoid normal
yes
14) The Obstetrician has ordered that Angelique's post-op patient-controlled analgesia (PCA) be discontinued. Which of the following actions by her nurse is appropriate? a) Discard the remaining medication in the presence of another nurse. b) Recommend waiting until her pain level is zero to discontinue the medication. c) Discontinue the medication only after the analgesia is completely absorbed. d) Return the unused portion of medication to the narcotics cabinet.
A
2) What symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? a) Pain b) Bleeding c) Fever d) Redness
A
5) A client is 24 hours postpartum from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the Provider? a) Foul smelling lochia b) Engorged breasts c) Cracked nipples d) Cluster of hemorrhoids
A
6) The nurse informs Sally that Ibuprofen is especially effective for afterbirth pains. What is the rationale for this? a) Ibuprofen is taken every 2 hours. b) Ibuprofen has an antiprostaglandin effect. c) Ibuprofen is given via the parenteral route. d) Ibuprofen is administered in high doses.
B
7) A Mom, G4P4004, is 15 minutes postpartum. Her baby weighed 4595g at birth. For which of the following complications should the nurse monitor this patient? a) Seizures b) Hemorrhage c) Infection d) Thrombosis
B
A full-term neonate has brown adipose fat tissue (BAT) stores that were deposited during the latter part of the third trimester. What does the nurse understand is the function of BAT stores? a. To promote melanin production in the neonatal period. b. To provide heat production when the baby is hypothermic. c. To protect the bony structures of the body from injury. d. To provide calories for neonatal growth between feedings.
B
A newborn nursery nurse notes that a 36-hour-old baby's body is jaundiced. Which of the following nursing interventions will be most therapeutic? a. Maintain a warm ambient environment. b. Have the mother feed the baby frequently. c. Have the mother hold the baby skin to skin. d. Place the baby naked by a closed, but sunlit window.
B More baby eats, more they poop more they get conjugated bilirubin out
1) In dealing with parents experiencing a perinatal loss, which of the following nursing interventions would be most appropriate? a. Sheltering the parents from the bad news b. Making all the decisions regarding care c. Encouraging them to participate in the newborn's care d. Leaving them by themselves to allow time to grieve
C
1. A 42-week gravida is delivering her baby. A nurse and a pediatrician are present at the birth. The amniotic fluid is green and thick. The baby fails to breathe spontaneously. Which of the following actions should the nurse take next? a. Stimulate the baby to breathe. b. Assess neonatal heart rate. c. Assist with intubation. d. Place the baby in the prone position.
C
1. In the fetus, blood bypasses the liver by traveling through which vessel? a. hepatic portal vein b. ductus arteriosus c. ductus venosus d. umbilical artery
C
3. In the fetus, oxygenated blood from the placenta first enters the___________ of the heart. a. left atrium b. left ventricle c. right atrium d. right ventricle
C
5. The ductus arteriosus is the opening from the a. carotid to the inferior vena cava. b. umbilical vein to the left ventricle. c. fetal pulmonary artery to the aorta. d. descending aorta to the right atrium.
C
3) Sally, now 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? a) Take Sally's temperature. b) Advise the woman to decrease her fluid intake. c) Reassure Sally that this is normal. d) Inform the neonate's pediatrician.
C : Diaphoresis is normal due to the diuresis that is occurring after birth (need to rid 3,000 + mL's of fluid in post 24 hours)
1. Which of the following neonates is at highest risk for cold stress syndrome? a. Infant of diabetic mother. b. Infant with Rh incompatibility. c. Postdates neonate. d. Down syndrome neonate.
C Brown fat stores are burned in a post date pregnancy DM : risk for profound hypoglycemia or LGA
1) Sally is a G2P1102, who delivered 8 hours ago. She now has a temperature of 100.2 F. Which of the following is the appropriate nursing intervention at this time? a) Notify the Provider to get an order for acetaminophen. b) Request an infectious disease consult from the Provider. c) Provide Sally with a cool compress. d) Encourage intake of water and other fluids.
D
1) The nurse should suspect puerperal infection when a client exhibits which of the following? a) Temperature of 100.2 F. b) White blood cell count of 14,500 cells/mm3. c) Diaphoresis during the night. d) Malodorous lochial discharge.
D
1. A baby born by vacuum extraction has been admitted to the well baby nursery. The nurse should assess this baby for which of the following? a. Pedal abrasions. b. Hypobilirubinemia. c. Hyperglycemia. d. Cephalohematoma.
D
10) The nurse is evaluating the involution of Mary Jane who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? a) Fundus 1 cm above the umbilicus, lochia rosa. b) Fundus 2 cm below the umbilicus, lochia alba. c) Fundus 2 cm above the umbilicus, lochia rubra. (concerned if above) d) Fundus 3 cm below the umbilicus, lochia serosa.
D
A physician writes in a breastfeeding mother's chart, "Ampicillin 500 mg q 6 hour po. Baby should be bottle fed until medication is discontinued." What should be the nurse's next action? a. Follow the order as written. b. Call the doctor and question the order. c. Implement the antibiotic order but ignore the order to bottle feed the baby. d. Refer to a reliable resource to see whether the antibiotic is safe while breastfeeding.
D
Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate? a. The neonate with T 98.9 degrees F and weight of 3000 grams. b. The neonate with white spots on the bridge of the nose. c. The neonate with raised white specks on the gums. d. The neonate with respirations of 72 and heartrate of 166.
D
9) Mary Jane, a G2P2002, who is 6 hours postpartum from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia (you DON'T ever want active bleeding), and perineal sutures are intact. Which of the following actions should the nurse take at this time? a) Do nothing. This is a normal finding. b) Massage Mary Jane's fundus c) Take Mary Jane to the bathroom to void d) Notify Mary Jane's Obstetrician.
D You would massage funds if uterus was boggy If you think bladder is pushed up and out of the way you would take her to void
To reduce the risk of hypoglycemia in a full-term newborn weighing 2900 grams, what should the nurse do? a. Maintain the infant's temperature above 97.7 degrees F. b. Feed the infant glucose water every 3 hours until breastfeeding well. c. Assess blood glucose levels every 3 hours for the first 12 hours. d. Encourage the mother to breastfeed every 4 hours.
a
Which of the following are important topics to educate parents on prior to discharge? Select all that apply. a. Feeding, Bathing, and Elimination b. Introduction of infant cereal c. Cord and Circ (if applicable) care d. Safe Infant Travel in appropriate car seat e. Holding and Positioning f. Sleep Patterns g. Follow-up care and Danger Signs
a c d e f g Introduce cereal around 6 months
1. What are the 4 consequences of Cold Stress? Select all that apply. a. Respiratory distress and Hypoxemia b. Hyperglycemia c. Hypoglycemia d. Babinski e. Hyperbilirubinemia f. Erythema toxicum neonatorum g. Metabolic acidosis
a c e g
blue or purple areas found on buttocks or lower extremities
Mongolian spot
1. A newborn in the nursery is exhibiting signs of neonatal abstinence syndrome. Which of the following signs/symptoms is the nurse observing? Select all that apply. a. Hyperphagia. b. Lethargy, with prolonged periods of sleep. c. Hyporeflexia. d. Persistent shrill cry.
A D
1. A baby is in the NICU whose mother is addicted to heroin during the pregnancy. Which of the following nursing actions would be appropriate? a. Tightly swaddle the baby. b. Place the baby prone in the crib. c. Provide needed stimulation to the baby. d. Feed the baby half-strength formula.
A
2. Oxygenated blood travels from the placenta to the fetus through the: a. umbilical vein b. umbilical artery c. aorta d. ductus arteriosus
A
1. A neonate is being assessed for necrotizing enterocolitis (NEC). Which of the following actions by the nurse is appropriate? Select all that apply. a. Perform hemoccult test on stools. b. Monitor for an increase in abdominal girth. c. Measure gastric contents before each feed. d. Assess bowel sounds before each feed. e. Maintain a strict every 3 hour feeding schedule.
A B C D
The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence of which of the following diseases in the newborn? Select all that apply. a. Hypothyroidism b. Sickle cell disease c. Galactosemia d. Cerebral palsy e. Cystic fibrosis
A B C E
5) A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take? Select all that apply. a. Swaddle the baby in a baby blanket. b. Discuss funeral options for the baby. c. Encourage the couple to try to get pregnant again in the near future. d. Ask the couple whether they would like to hold the baby. e. Advise the couple that the baby's death was probably for the best.
A B D
1. A full term infant admitted to the newborn nursery has a blood glucose level of 35mg/dl. Which of the following actions should the nurse perform at this time? a. Feed the baby formula or breastmilk. b. Assess the baby's blood pressure. c. Tightly swaddle the baby. d. Monitor the baby's urinary output.
A If you would tightly swaddle, this might hide symptoms of hypoglycemia
2) In order to help to prevent infection, the nurse teaches Sally to perform which of the following tasks? a) Apply antibiotic ointment to the perineum daily. b) Change the peripad at each voiding. c) Void at least every two hours. d) Spray the perineum with a povidone-iodine solution after toileting.
B
The nurse has provided anticipatory guidance to a couple that has just delivered a baby. Which of the following is an appropriate short-term goal for the care of their new baby? a. The baby will have a bath with soap every morning. b. During a supervised play period, the baby will be place on the tummy every day. c. The baby will be given a pacifier after each feeding. d. For the first month of life, the baby will sleep on its side in a crib next to the parents.
B
The nurse should warm his or her hands and stethoscope prior to assessing an infant's vital signs to prevent heat loss resulting from: a. Evaporation b. Conduction c. Radiation d. Convection
B
A nurse is assessing the bonding of the father with his newborn baby. Which of the following actions by the father would be of concern to the nurse? a. He holds the baby in the en face position. b. He calls the baby by a full name rather than a nickname. c. He tells the mother to pick up the crying baby. d. He falls asleep in the chair with the baby on his chest.
C
11) Susie informs the nurse she intends to bottlefeed her baby. Which of the following actions should the nurse encourage Susie to perform? a) Increase her fluid intake for a few days. b) Massage her breasts every 4 hours. c) Apply heat packs to her axillae. d) Wear a supportive bra 24 hours a day.
D
general transient rash that looks like flea bites
Erthema toxicum neonatorum
unopened sebaceous glands many times found on infant's nose
Milia
superficial vascular pink areas found at nape of neck, eyelids
Stork bite
3) A client with a fetal demise is admitted to labor and delivery in the latent phase of labor. Which of the following behaviors would the nurse expect this client to exhibit? a. Crying and sad b. Talkative and excited c. Quietly doing rapid breathing d. Loudly chanting songs
A
4) During the same conversation, Sally states to her nurse, "I think that I must have a urinary tract infection. I don't have any urgency or burning, but I do have to go to the bathroom all the time!" Which of the following actions should the nurse take? a) Reassure the woman that frequent urination is normal after delivery. b) Obtain an order for a urine culture. c) Assess the urine for cloudiness. d) Ask the woman if she is prone to urinary tract infections.
A
7) Immediately after delivery, Mary Jane is shaking uncontrollably. Which of the following nursing actions is most appropriate? a) Provide Mary Jane with warm blankets. b) Put Mary Jane in Trendelenburg position. c) Notify the Provider. d) Increase the intravenous infusion.
A
12) The nurse in the obstetric clinic receives a telephone call from Susie, a bottle feeding mother of a 3 day old infant. Susie states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise Sally to perform? a) Intermittently apply cool packs to her axillae and breasts. b) Apply lanolin to her breasts and nipples every 3 hours. (lanolin helps with irritation or cracking from breastfeeding) c) Express milk from the breasts every 3 hours d) Ask her Obstetrician to order a milk suppressant.
A
2) The nurse is admitting a 38-week-gestation client in labor. The nurse is unable to find the fetal heartbeat with the Doppler. Which of the following comments by the nurse would indicate that the nurse is in denial? a. "I'll keep trying until I find the heartbeat." b. "I am sure it is the machine. If I change the battery, I'm sure it'll work." c. "I am so sorry. I am not able to find your baby's heartbeat." d. "Sometimes I really hate these machines."
A
1. A baby was born 24 hours ago to a mother who received no prenatal care. The infant has tremors, sneezes excessively, constantly mouths for food, and has a shrill, high-pitched cry. The baby's serum glucose levels are normal. For which of the following should the nurse request an order from the pediatrician? a. Urine drug toxicology. b. Biophysical profile test. c. Chest and abdominal ultrasound evaluations. d. Oxygen saturation and blood gas assessments.
A
10) A nurse is assessing a 1 day postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving Ibuprofen 600mg po, the client is complaining of perineal pain of a 9 on a 10 point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client? a) She should be assessed by her Provider. b) She should have a sitz bath. c) She may have a hidden laceration. d) She needs a narcotic analgesic.
A
1. A neonate is found to have choanal atresia on admission to the nursery. Which of the following physiological actions will be hampered by this diagnosis? a. Feeding. b. Digestion. c. Immune response. d. Glomerular filtration.
A (Choanal atresia - a stenosis or blocking in the nose)
13) While on the phone with the nurse, Susie asks to be reminded, "When may my husband and I begin having intercourse again?" The nurse should encourage the couple to wait until after which of the following has occurred? a) The client has had her 6 week postpartum check-up. b) The lochia has turned pink and the vagina is no longer tender. c) The client has her first postpartum menstrual period. d) The infant has slept through the night for the first time.
A (by this time the lochia should've stopped indicating healing in the mothers body)
A 40 week gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time? Select all that apply. a. Encourage the parents to bond with their baby. b. Notify the neonatologist of the finding. c. Encourage and support parents in feeding their baby. d. Perform the gestational age assessment. e. Place the baby under the overhead warmer. f. Swaddle the infant snuggly and sway, hoping to help settle the infant to sleep. g. Encourage extended family to visit so they can see the baby while awake.
A C
A 2-day old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate? a. Continue to monitor, as this is a normal weight loss. b. Notify the neonatologist of the significant weight loss. c. Advise the mother to bottle feed the baby at the next feed. d. Assess the baby for hypoglycemia with a glucose monitor.
A OK if baby looses up to 7% or more then we are concerned
1. Four full-term babies were admitted to the neonatal nursery. The mothers of each of the babies had labors of 4 hours or less. The nursery nurse should carefully monitor which of the babies for hypothermia? a. The baby whose mother cultured positive for group B strep during her third trimester. b. The baby whose mother had gestational diabetes. c. The baby whose mother was hospitalized for 3 months with complete placenta previa. d. The baby whose mother previously had a stillbirth.
A The baby has risk of contracting group b strep during delivery. if baby is ill, the baby will have a lower temp vs. a fever because they have temperature instability. IDM: measure for profound hypoglycemia
15) The nurse is caring for Angelique, who had an emergency cesarean section, with her husband in attendance, the day before. The baby's Apgars were 9 and 9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate? a) "Sometimes babies just don't deliver the way we expect them to." b) "With all of your preparations, how are you feeling about delivering by cesarean?" c) "I know you had to have surgery, but you are very lucky that your baby was born healthy." d) "At least your husband was able to be with you when the baby was born."
B
1. A nurse is assisting a mother to feed a baby born with cleft lip and palate. Which of the following should the nurse teach the mother? a. The baby is likely to cry from pain during the feeding. b. The baby is likely to expel milk through the nose. c. The baby will feed more quickly than other babies. d. The baby will need to be fed high calorie formula.
B (may use a Haberman nipple - a longer nipple)
A 1000 gram neonate is being admitted to the NICU. The surfactant Survanta (beractant) has just been prescribed to prevent respiratory distress syndrome. Which of the following actions should the nurse take while administering this medication? a. Flush the intravenous line with normal saline solution. b. Assist the neonatologist during the intubation procedure. c. Inject the medication deep into the vastus lateralis muscle. d. Administer the reconstituted liquid via an oral syringe.
B (you administer through the ET tube)
Four babies have just been admitted to the newborn nursery. Which of the babies should the nurse assess first? a. Baby with respirations 42, oxygen saturation 96% b. Baby with APGARs 9 and 9, weight 4666 grams c. Baby with a temperature 98.0 degrees F, length 21 inches d. Baby with glucose 55 mg/dl, heart rate 121 What weight are we concerned about?
B Baby is LGA mom probably had a IDM so we are concerned about BS levels 4536g / 4.5 kg
Which of the following behaviors should nurses know are characteristic of infant abductors? Select all that apply. a. Act on the spur of the moment. b. Create a diversion on the unit. c. Ask questions about the routine of the unit. d. Choose rooms near stairwells. e. Wear over-sized clothing.
B C D E
A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? a. Hemolysis of neonatal red blood cells by the maternal antibodies b. Physiological destruction of fetal red blood cells during the extrauterine period. c. Pathological liver function resulting from hypoxemia during the birthing process. d. Delayed meconium excretion resulting in the production of direct bilirubin.
B Peak for physiologic jaundice 3-4 days
6) A nurse has administered Methergine 0.2mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates the medication is effective? a) Blood pressure 120/80 b) Pulse rate 80 bpm and regular c) Fundus firm at the umbilicus d) Increase in prothrombin time.
C
8) At 45 minutes postpartum, the nurse returns to the room to find the Mom (from #7 above) disoriented and lying in a pool of vaginal blood. What is the nurse's priority action? a) Take vital signs and check the bladder. b) Call the MD. c) Assess and massage the fundus. d) Step out into the hall to call for assistance.
C Assess and massage b/c we suspect the uterus will have a hard time coming down. In order to encourage uterus to come down, massaging aggressively and assessing mom. Then get help.
1. An infant in the neonatal nursery has low-set ears, Simian creases, and slanted eyes. The nurse should monitor this infant for which of the following signs/symptoms? a. Blood-tinged urine. b. Hemispheric paralysis. c. Cardiac murmurs. d. Hemolytic jaundice.
C (Thinking about downs syndrome)
1. A baby is born with esophageal atresia and tracheoesophageal fistula. Which of the following complications of pregnancy would the nurse expect to note in the mother's history? a. Preeclampsia. b. Idiopathic thrombocytopenia. c. Polyhydramnios. d. Severe iron deficiency anemia.
C Both are defects where there are passages (usually closed off) that could connect the trachea and esophagus
1. A 1-day old neonate, 32 weeks gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9 F. Which of the following could explain this assessment finding? a. This is a normal temperature for a preterm neonate. b. Axillary temperatures are not valid for preterm babies. c. The supply of brown adipose tissue is incomplete. d. Conduction heat loss is pronounced in the baby.
C Brown fat is less in a pre-term baby
1. A baby has been admitted to the NICU with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal factors would predispose the baby to this diagnosis. Select all that apply. a. Hyperopia. b. Gestational diabetes. c. Substance abuse. d. Chronic hypertension. e. Advanced maternal age.
C D E
The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist first? a. 1 day old, HR 110 beats per minute, in deep sleep b. 2 day old, T 97.7 degrees F, slightly jaundiced c. 3 day old, breastfeeding every 3 hours, jittery d. 4 day old, crying, papular rash on erythematous base
C Hypoglycemia or neonatal abstinence syndrome
1. There is a baby in the neonatal intensive care unit (NICU) who is exhibiting signs of neonatal abstinence syndrome. Which of the following medications is contraindicated for this neonate? a. Morphine. b. Opium. c. Narcan. d. Phenobarbital.
C if baby gets narcan they will further withdraw
4) The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby who exhibited visible birth defects. Which of the following actions by the nurse is appropriate? a. Discourage the parents from naming the baby. b. Advise the parents that the baby's defects would be too upsetting for them to see. c. Transport the baby to the morgue as soon as possible. d. Give the parents a lock of the baby's hair and a copy of the footprint sheet.
D
4. When a baby is born and takes its first breath, the change in pulmonary pressure causes which embryonic vessel to constrict? a. ductus venosus b. umbilical vein c. umbilical artery d. ductus arteriosus
D
5) Now 2 days postpartum, Sally who is breastfeeding her baby, states "I'm sick of being fat! When can I go on a diet?" Which of the following responses is appropriate? a) "It is fine for you to start dieting right now as long as you drink plenty of milk." b) "Your breastmilk will be low in vitamins if you start to diet while breastfeeding." c) "You must eat at least 3000 calories per day in order to produce enough milk for your baby." d) "Many mothers lose weight when they breastfeed because breastfeeding consumes an extra 500-600 calories a day."
D
What is the name of the screening test that includes phenylketonuria, and when is it done? a. PKU, one week of age b. CF, one month of age c. Eyes and Thighs, after 24 hours d. Wisconsin State Screen, after 24 hours What other two tests would be completed before discharge?
D Would also do hearing and Congenital heart disease test
1. The staff on the maternity unit is developing a protocol for nurses to follow after a baby is delivered who fails to breathe spontaneously. Which of the following should be included in the protocol as the first action for the nurse to take? a. Prepare epinephrine for administration. b. Provide positive pressure oxygen. c. Administer chest compressions. d. Rub the back and feet of the baby.
D Tactile stimulation
well demarcated swelling that does not cross suture line.
cephalohematoma
3) A breastfeeding Mom calls the pediatric nurse it the following concern: "I woke up this morning with a terrible cold. I don't want the baby to get sick. Which kind of formula should I have my husband feed the baby until I get better?" Which of the following replies by the nurse is appropriate at this time? a) "Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes." b) "Don't forget to pump your breasts every 3 hours while the baby is being fed the prescribed formula." c) "The best way to keep your baby from getting sick is for you to keep breastfeeding the baby rather than switching him to formula." d) "In addition to giving the baby formula, you should wear a surgical face mask when you are around him."
C
9) Considering Mom's history (from #7 above), which possible cause of postpartum hemorrhage is most likely? a) Perineal laceration b) Retained placenta c) Uterine atony d) Coagulopathy
C
The nurse allows Janet to latch Baby Lily on to her breast for feeding. Which of the following actions indicates the need for further teaching in breastfeeding technique? a. Aim the nipple to the baby's nose b. Wait for the baby's mouth to open wide c. Mother leans forward to bring her breast toward the baby d. The baby's lower lip is flanged out and covers the breast tissue
C want to bring baby to breast
elongated shaping of the infant's head to allow passage through the birth canal.
Molding
8) On Mary Jane's transfer to the postpartum unit from labor and delivery, which of the following tasks should the nurse delegate to the nursing care assistant? a) Assess client's fundal height. b) Teach the client how to massage her fundus. c) Take the client's vital signs. d) Document in the patient's chart the quantity of lochia.
C
Given the above situation with Baby Lily, the nurse determines, the most important priority intervention would be: For cold stress b. Wrap the baby in two blankets and reassess the temperature in one hour c. Warm the baby slowly in a Neutral Thermal environment d. Initiate IV therapy with Dextrose solution e. Feed the baby
C
1. A macrosomic infant of a non-insulin dependent diabetic mother has been admitted to the neonatal nursery. The baby's glucose level on admission to the nursery is 25mg/dl and after a feeding of mother's expressed breastmilk is 35mg/dl. Which of the following actions should the nurse take at this time? a. Nothing, because the glucose level is normal for an infant of a diabetic mother. b. Administer intravenous glucagon slowly over five minutes. c. Feed the baby a bottle of dextrose and water and reassess the glucose level. d. Notify the neonatologist of the abnormal glucose levels.
D 35 is on the lower side, feed the baby and if that doesn't help, then you need to notify b/c something else is going on
A nurse, when providing discharge instructions to parents, emphasizes actions to prevent plagiocephaly and to promote gross motor development in their full-term infant. Which of the following actions should the nurse advise the parents to take? a. Breastfeed the baby frequently. b. Make sure the baby receives vaccinations at recommended intervals. c. Change the diapers regularly. d. Minimize supine positioning during supervised play periods.
D Plagiocephaly (when babies are on back for so long it can cause deformation to the skull because bones are still pliable and can be misshapen)
A mother questions why the ophthalmic medication is given to the baby. Which of the following responses by the nurse would be appropriate to make at this time? a. "I am required by law to give the medicine." b. "The medication is given to prevent eye infections." c. "The medicine promotes neonatal health." d. "All babies receive the medicine at delivery."
B
4) In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)? a) The woman complains of numbness in the toes and heel of one foot. b) The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed. c) One of the woman's calves is swollen, red and warm to the touch. d) The veins in the ankle of one of the woman's legs are spider-like and purple.
C
Four newborns are in the nursery, none of whom are crying or in distress. Which of the babies should the nurse report to the neonatologist? a. 16 hour old baby who has yet to pass meconium b. 16 hour old baby whose blood glucose is 50 mg/dL c. 2 day old baby who is breathing irregularly at 70 breaths per minute d. 2 day old baby who is excreting a milky discharge from both nipples
C
