ATI Testbank Questions- OB Exam #2 part VI

In the newborn nursery, you are reviewing the maternal medication list to ascertain if there is any significant risk to the newborn. Which medications would pose a potential risk to the newborn in terms of clotting ability? (Select all that apply.) a. Carbamazepine b. Phenytoin (Dilantin) c. Phenobarbital d. INH (Isoniazid)

a. Carbamazepine b. Phenytoin (Dilantin) c. Phenobarbital d. INH (Isoniazid) Carbamazepine, phenytoin (Dilantin), phenobarbital, and isoniazid (INH) when taken by the mother can affect the newborns clotting ability. Anticonvulsant usage can cause bleeding problems.

Which newborn reflex is elicited by stroking the lateral sole of the infants foot from the heel to the ball of the foot? a. Babinski b. Stepping c. Tonic neck d. Plantar grasp

a. Babinski The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The stepping reflex occurs when infants are held upright, with their heel touching a solid surface, and the infant appears to be walking. The tonic neck reflex (also called the fencing reflex) refers to the posture assumed by newborns when in a supine position. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infants toes curl over the nurses finger.

An Asian-American expectant father tells the nurse that he seems to be gaining weight, just like his wife. The nurse recognizes that this behavior is most likely a reflection of which? a. Couvade b. Embarrassment c. Ambivalence regarding the pregnancy d. Limited interest in the well-being of his wife

a. Couvade Couvade is when expectant fathers sometimes experience physical symptoms similar to those of pregnant women, such as loss of appetite, nausea, headache, fatigue, and weight gain. The father did not express anything that would indicate embarrassment. There is no indication in the fathers statement that he is ambivalent to the pregnancy. There is no data in the question that indicates that the father is not interested in his wife.

An infant at 36 weeks gestation was just delivered; included in the protocol for a preterm infant is an initial blood glucose assessment. The nurse obtains the blood and the reading is 58 mg/dL. What is the priority nursing action based on this reading? a. Document the finding in the newborns chart. b. Double-wrap the newborn under a warming unit. c. Feed the newborn a 10% dextrose solution. d. Notify the neonatal intensive care unit (NICU) of the pending admission.

a. Document the finding in the newborns chart. In the term infant, glucose levels should be 40 to 60 mg/dL on the first day and 50 to 90 mg/dL thereafter. There is no general consensus about the level of blood glucose that defines hypoglycemia, but a level below 40 to 45 mg/dL in the term infant is often used. If an infant is placed in a warming unit, the skin needs to be exposed. Because the glucose level is normal, no supplemental feeding is necessary. Dextrose solution is only administered when the glucose levels are very low. There is no information in the stem indicating the need for admission to the NICU.

Margaret, a 36-year-old divorcee with a successful modeling career, finds out that her 18-year-old married daughter is expecting her first child. Which is a major factor in determining how Margaret will respond to becoming a grandmother? a. Her age b. Her career c. Being divorced d. Age of the daughter

a. Her age Age is a major factor in determining the emotional response of prospective grandparents. Young grandparents may not be happy with the stereotype of grandparents as being old. Career responsibilities may have demands that make the grandparents not as accessible but are not a major factor in determining the womans response to becoming a grandmother. Being divorced is not a major factor that determines the adaptation of grandparents. The age of the daughter is not a major factor that determines the adaptation of grandparents. The age of the grandparent is a major factor.

The nurse is performing a gestational age assessment on a newborn. Which characteristics indicate a preterm newborn? (Select all that apply.) a. Translucent skin b. Extended limp arms and legs c. The ear springs back when folded d. Square window angle of 45 degrees or less e. Large clitoris and labia minora in the female newborn

a. Translucent skin b. Extended limp arms and legs e. Large clitoris and labia minora in the female newborn The very preterm infants skin is translucent because it is thin and has little subcutaneous fat beneath the surface. Preterm neonates have immature flexor muscles and little energy or muscle tone. Therefore they have extended and limp arms and legs that offer little resistance to movement by the examiner. In the preterm female infant, the labia majora are small and separated, and the clitoris and labia minora are large by comparison. In the term neonate, the ear springs back to its original position immediately. The more mature the neonate, the smaller the angle of the square window assessment until the palm folds flat against the forearm at term, the result of maternal hormones at the end of pregnancy.

The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding? a. Depress the tip of the nose. b. Stroke the outer aspect of the foot. c. Place a finger in the palm of the hand. d. Rotate the hips in an upward and outward direction.

a. Depress the tip of the nose. The nurse assesses for jaundice at least every 8 to 12 hours and is particularly watchful when infants are at increased risk for hyperbilirubinemia. Jaundice is identified by pressing the infants skin over a firm surface, such as the end of the nose or the sternum. The skin blanches as the blood is pressed out of the tissues, making it easier to see the yellow color that remains. Jaundice is more obvious when the nurse assesses in natural light. Jaundice begins at the head and moves down the body, and the areas of the body involved should be documented. Jaundice becomes visible when the bilirubin level is greater than 5 mg/dL. The Babinski reflex is assessed by stroking the outer aspect of the foot. The grasp reflex is determined by placing a finger in the newborns palm. The Barlow and Ortolani tests are methods of assessing for hip instability in the newborn period. Both legs should abduct equally in normal infants. Abducting the affected hip may be difficult. A hip click may be felt or heard but is usually normal and is different from the clunk of hip dysplasia when the femoral head moves in the hip socket.

In some Middle Eastern and African cultures, female genital mutilation is a prerequisite for marriage. Women who now live in North America need care from nurses who are knowledgeable about the procedure and comfortable with the abnormal appearance of their genitalia. When caring for this client, the nurse can formulate a diagnosis with the understanding that the client may be at risk for which of the following? (Select all that apply.) a. Infection b. Laceration c. Hemorrhage d. Obstructed labor e. Increased signs of pain response

a. Infection b. Laceration c. Hemorrhage d. Obstructed labor The client is at risk for infection, laceration, hemorrhage, and obstructed labor. Female genital mutilation, cutting, or circumcision involves removal of some or all of the external female genitalia. The labia majora are often stitched together over the vaginal and urethral openings as part of this practice. Enlargement of the vaginal opening may be performed before or during the birth. The woman is unlikely to give any verbal or nonverbal signs of pain. This lack of response does not indicate lack of pain. In fact, pelvic examinations are likely to be very painful because the introitus is so small, and inelastic scar tissue makes the area especially sensitive. A pediatric speculum may be necessary, and the client should be made as comfortable as possible.

Which are early signs of hypoglycemia in the newborn for which the nurse should assess? (Select all that apply.) a. Jitteriness b. Poor feeding c. Respiratory difficulty d. An increase in temperature e. A capillary refill of 2 seconds

a. Jitteriness b. Poor feeding c. Respiratory difficulty Early signs of hypoglycemia include jitteriness and other central nervous system signs and signs of respiratory difficulty, a decrease in temperature, and poor feeding. A capillary refill of 2 seconds is a normal finding in the newborn.

The nurse is conducting a body system assessment of the newborn. Which are abnormal findings that the nurse should report? (Select all that apply.) a. Low-set ears b. Yellow sclera c. A dolls eye sign d. Edema of the eyelids e. Absence of the grasp reflex

a. Low-set ears b. Yellow sclera e. Absence of the grasp reflex Low-set ears may indicate chromosomal abnormalities. The sclera should be white or bluish white. A yellow color indicates jaundice. Absence of reflexes may indicate a serious neurologic problem. The dolls eye sign is a normal finding in the newborn; when the head is turned quickly to one side, the eyes move toward the other side. Edema of the eyelids and subconjunctival hemorrhages (reddened areas of the sclera) result from pressure on the head during birth, which causes capillary rupture in the sclera.

Which newborn is at higher risk for developing hypoglycemia? (Select all that apply.) a. Post-term newborn b. 38 weeks gestation newborn c. Small-for-gestational-age newborn d. Large-for-gestational-age newborn e. Term newborn born by cesarean birth

a. Post-term newborn c. Small-for-gestational-age newborn d. Large-for-gestational-age newborn Many newborns are at increased risk for hypoglycemia. In the preterm, late preterm (born between 34 weeks and 36 6/7 weeks of gestation), and small-for-gestational-age infant, adequate stores of glycogen or even fat for metabolism may not have accumulated. Stores may be used up before birth in the post-term infant because of poor intrauterine nourishment from a deteriorating placenta. Large-for-gestational-age infants and those with diabetic mothers may produce excessive insulin that consumes available glucose quickly. The newborn born at 38 weeks and the newborn born by cesarean at term have lower risk for hypoglycemia.

The nurse is performing an initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system? a. Respiratory b. Cardiovascular c. Gastrointestinal d. Musculoskeletal

a. Respiratory Tachypnea, a respiratory rate of more than 60 breaths/min, is the most common sign of respiratory distress. Retractions occur when the soft tissue around the bones of the chest is drawn in with the effort of pulling air into the lungs. Xiphoid (substernal) retractions occur when the area under the sternum retracts each time the infant inhales. When the muscles between the ribs are drawn in so that each rib is outlined, intercostal retractions are present. A reflex widening of the nostrils occurs when the infant is receiving insufficient oxygen. Nasal flaring helps decrease airway resistance and increase the amount of air entering the lungs.

The nurse is assessing a client in her 37th week of pregnancy for the psychological responses commonly experienced as birth nears. Which psychological responses should the nurse expect to asses? (Select all that apply.) a. The client is excited to see her baby. b. The client has not started to prepare the nursery for the new baby. c. The client expresses concern about how to know if labor has started. d. The client and her spouse are concerned about getting to the birth center in time. e. The client and her spouse have not discussed how they will share household tasks.

a. The client is excited to see her baby. c. The client expresses concern about how to know if labor has started. d. The client and her spouse are concerned about getting to the birth center in time. As birth nears, the expectant client will express a desire to see the baby. Most pregnant clients are concerned with their ability to determine when they are in labor. Many couples are anxious about getting to the birth facility in time for the birth. As birth nears, a nesting behavior occurs, which means getting the nursery ready. Not preparing the nursery at this stage is not a response that the nurse should expect to assess. Negotiation of tasks is done during this stage. No discussion of division of household chores is not a response that the nurse should expect to assess at this stage.

The nurse is teaching the postpartum client about newborn transitional stools. Which should the nurse include in the teaching session with regard to transitional stools? (Select all that apply.) a. They are a greenish brown color. b. They are of a looser consistency. c. They have a tarlike consistency. d. They have a consistency of mustard. e. They are seedy, with a sweet-sour smell.

a. They are a greenish brown color. b. They are of a looser consistency. Meconium stools are followed by transitional stools, a combination of meconium and milk stools. They are greenish brown and of a looser consistency than meconium. Stools that are tarlike are meconium stools. Infants fed with breast milk are seedy, with a sweet-sour smell; the meconium has the consistency of mustard.

The clients says, My baby is so thin and wrinkled. It looks like he has too much skin. Which is the most therapeutic response by the nurse to the new clients statement? a. You sound disappointed about how your infant looks. b. All mothers are concerned about how their babies look. c. Dont worry. In no time hell fill out his skin and look just fine. d. You know, all the cigarettes you smoked interfered with the nourishment he needed.

a. You sound disappointed about how your infant looks. The nurse should clarify the clients statement and allow her to verbalize her feelings. All mothers are concerned about how their babies look generalizes her concerns and does not answer the mothers question. Dont worry. In no time hell fill out his skin and look just fine does not directly answer the mothers question and could leave her feeling like she asked an unacceptable question. You know, all the cigarettes you smoked interfered with the nourishment he needed is condescending and hurtful and would not allow for further conversation between the nurse and mother.

An infant at term was born at 0105, or 1:05 AM. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score? a. 0115-0130 b. 0200-0600 c. 1400-1800 d. 2000-2300

b. 0200-0600 The new Ballard score is often used to assess gestational age based on neuromuscular and physical characteristics. It is designed to assess gestational age from 20 to 44 weeks and provides accurate information within 2 weeks. It is most accurate when performed within 12 hours of birth.

Which infant is at greater risk to develop cold stress? a. Full-term infant delivered vaginally without complications b. 36-week infant with an Apgar score of 7 to 9 c. 38-week female infant delivered via cesarean section because of cephalopelvic disproportion d. Term infant delivered vaginally with epidural anesthesia

b. 36-week infant with an Apgar score of 7 to 9 Preterm infants are at greater risk to develop cold stress because of thin skin, decreased subcutaneous fat, and poor muscle tone.

The postpartum nurse is providing care to a woman 2 hours after birth and to her newborn. On review of the newborns chart, the nurse sees a notation of caput succedaneum. What will the nurse expect to find in the mothers chart? a. Racenon-white b. A longer than usual labor c. Administration of an epidural d. Delivery by cesarean section

b. A longer than usual labor A caput succedaneum is an area of localized edema that appears over the vertex of the newborns head as a result of pressure against the mothers cervix during labor. The pressure interferes with blood flow from the area, causing localized edema at birth. The edematous area crosses suture lines, is soft, and varies in size. The longer the labor, the more pronounced the caput. Mongolian spots are associated with infants born to non-white parents. An epidural may be a contributing factor to a prolonged labor, but it is the pressure of the head against the cervix that gives rise to the caput. If labor is prolonged without descent of the head, a cesarean section may follow but is not the cause of the caput.

Which is the most likely cause of regurgitation when a newborn is fed? a. The gastrocolic reflex b. A relaxed cardiac sphincter c. An underdeveloped pyloric sphincter d. Placing the infant in a prone position following a feeding

b. A relaxed cardiac sphincter The underlying cause of newborn regurgitation is a relaxed cardiac sphincter. The gastrocolic reflex increases intestinal peristalsis after the stomach fills. The pyloric sphincter goes from the stomach to the intestines. The infant should be placed in a supine position.

The nurse is explaining how a newly delivered baby initiates respirations. Which statement explains this process? a. Drying off the infant b. Chemical, thermal, and mechanical factors c. An increase in the PO2 and a decrease in the PCO2 d. The continued functioning of the foramen ovale

b. Chemical, thermal, and mechanical factors A variety of these factors are responsible for initiation of respirations. Tactile stimuli aid in initiating respirations but are not the main cause. The PO2 decreases at birth and the PCO2 increases. The foramen ovale closes at birth.

Which method of heat loss may occur if a newborn is placed on a cold scale or touched with cold hands? a. Radiation b. Conduction c. Convection d. Evaporation

b. Conduction Conduction occurs when the infant comes in contact with cold objects. Radiation is the transfer of heat to a cooler object that is not in direct contact with the infant. Convection occurs when heat is transferred to the air surrounding the infant. Evaporation can occur during birth or bathing as a result of wet linens or clothes, or insensible heat loss.

An expectant client in her third trimester reports that she developed a strong tie to her baby from the beginning and now is really in tune to her babys temperament. The nurse interprets this as the development of which maternal task of pregnancy? a. Learning to give of herself b. Developing attachment with the baby c. Securing acceptance of the baby by others d. Seeking safe passage for herself and her baby

b. Developing attachment with the baby Developing a strong tie in the first trimester and progressing to be in tune is the process of commitment, attachment, and interconnection with the infant. This stage begins in the first trimester and continues throughout the neonatal period. Learning to give of herself is the task that occurs during pregnancy as the woman allows her body to give space to the fetus. She continues with giving to others in the form of food and presents. Securing acceptance of the baby is a process that continues throughout pregnancy as the woman reworks relationships. Seeking safe passage is the task that ends with birth. During this task, the woman seeks health care and carries out cultural practices.

What is the term for the step in maternal role attainment that relates to the woman giving up certain aspects of her previous life? a. Fantasy b. Grief work c. Role-playing d. Looking for a fit

b. Grief work The woman experiences sadness as she realizes that she must give up certain aspects of her previous self and that she can never go back. This is called grief work. Fantasies allow the woman to try on a variety of possibilities or behaviors. This usually deals with how the child will look and the characteristics of the child. Role-playing involves searching for opportunities to provide care for infants in the presence of another person. Looking for a fit is when the woman observes the behaviors of mothers and compares them with her own expectations.

Which of the following would be considered to be a system barrier to the birth of prenatal care? a. Adolescent pregnant client b. Inability to schedule an appointment with the health care provider because of a busy medical practice c. Pregnant client has no health insurance d. Having to sign in for the initial appointment and complete health history records

b. Inability to schedule an appointment with the health care provider because of a busy medical practice A delay in the ability to schedule an appointment with a health care provider is an example of a system barrier to the birth of prenatal care. An adolescent pregnant client would not be considered to be a system barrier but rather a psychosocial factor that would affect the pregnancy state. Having no health insurance is an example of a financial barrier to the birth of prenatal care. Completing a health history record is part of a comprehensive assessment.

A Vietnamese client who speaks little English is admitted to the labor and birth unit in early labor. The nurse plans to use an interpreter during an initial assessment. Which should the nurse plan to implement with regard to using an interpreter? (Select all that apply.) a. Face the interpreter when speaking. b. Listen carefully to what the client says. c. Speak slowly and smile when appropriate. d. Plan to use a male interpreter, even if a female interpreter is available. e. Ask the interpreter to explain exactly what is said as much as possible, instead of paraphrasing.

b. Listen carefully to what the client says. c. Speak slowly and smile when appropriate. e. Ask the interpreter to explain exactly what is said as much as possible, instead of paraphrasing. The nurse planning to use an interpreter should listen carefully to what the client says. The nurse should speak slowly and smile when appropriate. Ask the interpreter to explain exactly what is said, as much as possible, instead of paraphrasing. It is preferable to use a trained female interpreter when one is available instead of a male interpreter. The nurse should face the client when speaking, not the interpreter.

Which organs are nonfunctional during fetal life? a. Eyes and ears b. Lungs and liver c. Kidneys and adrenals d. Gastrointestinal system

b. Lungs and liver Most of the fetal blood flow bypasses the nonfunctional lungs and liver. Near term, the eyes are open and the fetus can hear. Kidneys and adrenals function during fetal life. The fetus continuously swallows amniotic fluid, which is filtered through the kidneys. The gastrointestinal system functions during fetal life.

Which is a major concern among members of lower socioeconomic groups? a. Practicing preventive health care b. Meeting health needs as they occur c. Maintaining an optimistic view of life d. Maintaining group health insurance for their families

b. Meeting health needs as they occur Because of their economic uncertainty, lower socioeconomic groups place more emphasis on meeting the needs of the present rather than on future goals. Lower socioeconomic groups may value health care but generally cannot afford preventive health care. They may struggle for basic needs and often do not see a way to improve their situation. It is difficult to maintain optimism. Lower socioeconomic groups usually do not have group health insurance.

A newborn is admitted to the newborn nursery with hypothermia. Which complication should the nurse monitor related to hypothermia in the newborn? a. Hyperglycemia b. Metabolic acidosis c. Respiratory acidosis d. Vasodilation of peripheral blood vessels

b. Metabolic acidosis Cold stress can cause a significant rise in oxygen demands. Metabolism of glucose in the presence of insufficient oxygen causes increased production of acids. Metabolism of brown fat also releases fatty acids. The result can be metabolic acidosis, which can be a life-threatening condition. Cold stress causes hypoglycemia because glucose is being metabolized. Cold stress does not cause respiratory acidosis. As the infants body attempts to conserve heat, vasoconstriction, not vasodilation, of the peripheral blood vessels occurs to reduce heat loss from the skin surface.

Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Maintain room temperature at 70 F. b. Place a blanket over the scale before weighing the infant. c. Take the rectal temperature every hour to detect early changes. d. Undress the infant completely for assessments so that they can be finished quickly.

b. Place a blanket over the scale before weighing the infant. Padding the scale prevents heat loss from the infant to a cold surface by conduction. The room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. Hourly assessments are not necessary for a normal newborn with a stable temperature. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature by convection.

A client who is 7 months pregnant states, Im worried that something will happen to my baby. Which is the nurses best response? a. Your baby is doing fine. b. Tell me about your concerns. c. There is nothing to worry about. d. The doctor is taking good care of you and your baby.

b. Tell me about your concerns. Encouraging the client to discuss her feelings is the best approach. The nurse should not disregard or belittle the clients feelings. Responding that your baby is doing fine disregards the clients feelings and treats them as unimportant. Responding that there is nothing to worry about does not answer the clients concerns. Saying that the doctor is taking good care of you and your baby is belittling the clients concerns.

Which comment made by a new mother to her own mother is most likely to encourage the grandmothers participation in the infants care? a. Could you help me with the housework today? b. The baby is spitting up a lot. What should I do? c. I know you are busy, so Ill get Johns mother to help me. d. The baby has a stomachache. Ill call the nurse to find out what to do.

b. The baby is spitting up a lot. What should I do? Looking to the grandmother for advice encourages her to become involved in the care of the infant. Housework does not encourage the grandmother to participate in the infants care. Getting Johns mother to help and calling the nurse about advice excludes the grandmother.

Which explains why a newborn with a congenital defect of the penis should not be circumcised? a. There is increased risk of infection. b. The foreskin might be needed for future repairs. c. A circumcision will make the defect more visible. d. There is no medical rationale for a circumcision.

b. The foreskin might be needed for future repairs. The foreskin may be used to correct a defect. There is no significant increase in infection. A circumcision would not make the defect more noticeable. A circumcision is a decision made by the parents, but in this case the foreskin might be used to correct a defect.

The nurse is performing a gestational age assessment on a newborn. Which characteristic shows the greatest gestational maturity? a. The infants arms and legs are extended. b. There is some peeling and cracking of the skin. c. There are few rugae on the scrotum and the testes are high in the scrotum. d. The arm can be positioned with the elbow beyond the midline of the chest.

b. There is some peeling and cracking of the skin. Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. Extended arms and legs is a sign of preterm infants. Few rugae on the scrotum show a younger age in the newborn. The arm being able to be positioned with the elbow beyond the midline of the chest is a result of the scarf sign and indicates a newborn of a younger age.

Parents ask the nurse, What makes the opening between the babys atriums close at birth? The nurses response is that cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: a. changes in the hepatic blood flow. b. increased pressure in the left atrium. c. increased pressure in the right atrium. d. decreased blood flow to the left ventricle.

b. increased pressure in the left atrium. With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale. The pressure in the right atrium decreases at birth. It is higher during fetal life. Blood flow increases to the left ventricle after birth.

Infants who develop cephalohematoma are at increased risk for: a. infection. b. jaundice. c. caput succedaneum. d. erythema toxicum.

b. jaundice. Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalohematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas.

During fetal circulation the pressure is greatest in the: a. left atrium. b. right atrium. c. hepatic system. d. pulmonary veins.

b. right atrium. Pressure in the fetal circulation is greatest in the right atrium, which allows right-to-left shunting that aids in bypassing the lungs during intrauterine life. The pressure increases in the left atrium after birth and will close the foramen ovale. The liver does not filter the blood during fetal life until the end. It is functioning by birth. Blood bypasses the pulmonary vein during fetal life.

The nurse is planning to conduct the initial assessment of a full-term newborn. Included in the plan is providing a neutral thermal environment. To accomplish this plan, what is the desired environmental temperature to conduct the assessment? a. 24 to 27 C (75.2 to 80.6 F) b. 28 to 31.5 C (82.4 to 88.7 F) c. 32 to 33.5 C (89.6 to 92.3 F) d. 34 to 37.5 C (93.2 to 99.5 F)

c. 32 to 33.5 C (89.6 to 92.3 F) A neutral thermal environment is one in which the infant can maintain a stable body temperature with minimal oxygen need and without an increase in metabolic rate. The range of environmental temperature that allows this stability is called the thermoneutral zone. In healthy, unclothed, full-term newborns, an environmental temperature of 32 to 33.5 C (89.6 to 92.3 F) provides a thermoneutral zone. When the infant is dressed, the thermoneutral range is 24 to 27 C (75.2 to 80.6 F).

The nurse is receiving a shift report in the newborn nursery. Which client should the nurse assess first? a. 38-weeks gestation female newborn with a blood sugar level of 60 mg/dL b. Term male newborn with a noted axillary temperature of 37.2 C (99 F) c. 40-weeks gestation female newborn with reported poor feed at last attempt d. 39-weeks gestation male newborn who has been crying prior to initial bath

c. 40-weeks gestation female newborn with reported poor feed at last attempt Newborns who are poor feeds may be showing initial signs of hypoglycemia, so this newborn should be assessed first at the start of the shift. Although the newborn is term, and it is more likely to see hypoglycemia with preterm infants, sometimes hypoglycemia is asymptomatic. Blood sugar results are within normal range and the newborn is considered to be term. Temperature is within normal range and the newborn is term. This newborn is considered to be term, and crying alone does not increase risk stratification.

To differentiate between caput succedaneum and cephalohematoma in a newborn, the nurse would consider the following clinical information. (Select all that apply.) a. These are both normal presentations because of the birth process and will resolve within 24 to 48 hours. b. Cephalohematoma manifests as a localized area of swelling as compared with caput succedaneum, which appears as a general swelling of the head. c. A cephalohematoma can develop several hours or days after the birth event, whereas caput succedaneum is noted shortly before or immediately after the birth event. d. Edema that crosses suture lines is observed with caput succedaneum. e. With a cephalohematoma, bleeding occurs between the bone and skull.

c. A cephalohematoma can develop several hours or days after the birth event, whereas caput succedaneum is noted shortly before or immediately after the birth event. d. Edema that crosses suture lines is observed with caput succedaneum. e. With a cephalohematoma, bleeding occurs between the bone and skull. Cephalohematoma can be detected up to 24 to 48 hours after the birth process. This clinical condition is caused by bleeding between the periosteum and skull and is a serious medical condition. Caput succedaneum occurs in the presence of pressure from the vaginal canal on the fetal head during the birth process. Swelling is localized and crosses the suture line, whereas with cephalohematoma the swelling is more generalized and crosses the suture line. Caput resolves within 12 to 48 hours after the birth event.

Which situation best describes a man trying on fathering behaviors? a. Reading books on newborn care b. Spending more time with his siblings c. Coaching a little league baseball team d. Exhibiting physical symptoms related to pregnancy

c. Coaching a little league baseball team Coaching a little league baseball team shows interaction with children and assuming the behavior and role of a father. This best describes a man trying on the role of being a father. Men do not normally read information that is provided in advance. The nurse should be prepared to present information after the baby is born, when it is more relevant. The man will normally seek closer ties with his father. Exhibiting physical symptoms related to pregnancy is called couvade.

How can nurses prevent evaporative heat loss in the newborn? a. Placing the baby away from the outside wall and the windows b. Keeping the baby out of drafts and away from air conditioners c. Drying the baby after birth and wrapping the baby in a dry blanket d. Warming the stethoscope and nurses hands before touching the baby

c. Drying the baby after birth and wrapping the baby in a dry blanket Wet linens or wet clothes can cause heat loss by evaporation. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is termed a radiation heat loss. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. Conduction heat loss occurs when the baby comes into contact with cold objects or surfaces.

A pregnant client relates a story of how her boyfriend is feeling her aches and pains associated with her pregnancy. She is concerned that her boyfriend is making fun of her concerns. How would you respond to this client statement? a. Tell her not to worry because it is natural for her boyfriend to make her feel better by identifying with her pregnancy. b. Refer the client to a psychologist for counseling to deal with this problem because it is clearly upsetting her. c. Explain that her boyfriend may be experiencing couvade syndrome and that this is a normal finding seen with male partners. d. Ask the client specifically to define her concerns related to her relationship with her boyfriend and suggest methods to stop this type of behavior by her significant other.

c. Explain that her boyfriend may be experiencing couvade syndrome and that this is a normal finding seen with male partners. Provide factual information that will help reduce stress and modify acceptance. Telling her not to worry does not address the possibility that her boyfriend may be experiencing couvade syndrome. The client is expressing concern but does not have all the facts related to couvade syndrome and requires education, rather than referral. Couvade syndrome is not an abnormal condition and should be treated with acceptance and understanding.

A newborn who is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight? a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th

c. Greater than the 90th The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. An infant between the 10th and 90th percentiles is average for gestational age. An infant in less than the 10th percentile is small for gestational age.

A reported hematocrit level for a newborn vaginal birth is 75%. Based on this lab value, which complication is the newborn least at risk to develop? a. Hypoglycemia b. Respiratory distress c. Infection d. Jaundice

c. Infection The presence of polycythemia as indicated by this lab result could result in the infant being at risk to develop hypoglycemia, respiratory distress, and jaundice. Possible infection would be unrelated to this diagnostic value.

A new client asks, Why are you doing a gestational age assessment on my baby? The nurses best response is: a. It was ordered by your physician. b. This must be done to meet insurance requirements. c. It helps us identify infants who are at risk for any problems. d. The gestational age determines how long the infant will be hospitalized.

c. It helps us identify infants who are at risk for any problems. The nurse should provide the mother with accurate information about various procedures performed on the newborn. Assessing gestational age is a nursing assessment and does not have to be ordered. It is not needed for insurance needs. Gestational age does not dictate hospital stays. Problems that occur because of gestational age may prolong the stay.

The nurse is preparing to administer a vitamin K injection to the infant shortly after birth. Which is important to understand about vitamin K? a. It is necessary for the production of platelets. b. It is important for the production of red blood cells. c. It is not initially synthesized because of a sterile bowel at birth. d. It is responsible for the breakdown of bilirubin and the prevention of jaundice.

c. It is not initially synthesized because of a sterile bowel at birth. The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors. Vitamin K is important for blood clotting. Vitamin K is necessary to activate the clotting factors.

The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which should the nurse include as an explanation of hypothermia in the newborn? a. Newborns shiver to generate heat. b. Newborns have decreased oxygen demands. c. Newborns have increased glucose demands. d. Newborns have a decreased metabolic rate.

c. Newborns have increased glucose demands. In hypothermia, the basal metabolic rate (BMR) is increased in an attempt to compensate, thus requiring more glucose. Shivering is not an effective method of heat production for newborns. Oxygen demands increase with hypothermia. The metabolic rate increases with hypothermia.

Which assessment finding of a newborn requires prompt action by the nurse? a. Respiratory rate of 50 breaths/min b. Cyanosis of the extremities c. Pause in breathing lasting 20 seconds d. Pause in breathing for 15 seconds followed by rapid respirations

c. Pause in breathing lasting 20 seconds Apnea is a pause in breathing lasting 20 seconds or more, or accompanied by cyanosis, pallor, bradycardia, and/or decreased muscle tone. Apnea is abnormal and requires prompt intervention. A respiratory rate of 50 breaths/min is still within the normal range. Tachypnea is considered to be 60 breaths/min or more. Cyanosis of the extremities or acrocyanosis is normal during the first day after birth and if the infant becomes cold. Periodic breathing is pauses in breathing lasting 5 to 10 seconds without other changes followed by rapid respirations for 10 to 15 seconds. This occurs in some full-term infants during the first few days but is more common in preterm infants.

Which action should the nurse take if a discrepancy is found between the measurements of a newborn and the normative criteria? a. Remeasure the infant. b. Consider this a normal deviation. c. Perform an expanded assessment. d. Inform the parents so that they can follow the infants growth.

c. Perform an expanded assessment. An expanded assessment is necessary to look for data to verify the measurements of the infant. Remeasuring the infant is helpful but an expanded assessment would be a better action. A discrepancy is not a normal deviation. An expanded assessment is needed first so as not to alarm the parents unnecessarily.

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as: a. albumin binding. b. enterohepatic circuit. c. conjugation of bilirubin. d. deconjugation of bilirubin.

c. conjugation of bilirubin. Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product. Albumin binding attaches something to a protein molecule. Enterohepatic circuit is the route whereby part of the bile produced by the liver enters the intestine, is resorbed by the liver, and then is recycled into the intestine. Unconjugated bilirubin is fat-soluble.

Inspection of a newborns head following birth reveals a hard ridged area and significant molding. The anterior and posterior fontanels show no sign of depression. Delivery history indicates that the mother was pushing for over 3 hours and had epidural anesthesia, and vacuum extraction was used. Based on this information the nurse would first: a. continue to monitor newborn and anticipate that molding will subside. b. inspect and document location of fontanels to complete the head assessment. c. contact the neonatologist. d. note findings as being within normal limits as a result of the strenuous birth process.

c. contact the neonatologist. Assessment data reveal a significant finding, and the nurse should suspect craniosynostosis (premature closing of sutures) and therefore should contact the neonatologist immediately. Even though the birth process was difficult and vacuum extraction was used, this does not account for the physical findings. Continuing to monitor is not a prudent action and, because this is more than molding, it will not go away. Although it is important to note the presence of fontanels, the immediate action would be to make the appropriate referral for medical intervention.

A maculopapular rash with a red base and a small white papule in the center is: a. milia. b. Mongolian spots. c. erythema toxicum. d. caf-au-lait spots.

c. erythema toxicum. A maculopapular rash with a red base and a small white papule in the center is a description of erythema toxicum, a normal rash in the newborn. Milia are minute epidermal cysts on the face of the newborn. Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sacrum. Caf-au-lait spots are pale tan (the color of coffee with milk) macules. Occasional spots occur normally in newborns.

During the course of the pregnancy, the client states that she feels a deep connection with her unborn child. This behavior illustrates the maternal task acquisition of: a. safe passage. b. gaining acceptance. c. fostering an interconnection. d. developing empathy through physical actions.

c. fostering an interconnection. During pregnancy, it is important for the mother to relate to and connect with the unborn child as part of the initial attachment and bonding experience. Safe passage refers to securing safety as a primary concern through the pregnancy and birth process. Gaining acceptance relates to behaviors acknowledging the pregnancy as a part of ones maternal role. Pregnant woman may appear to be more nurturing during pregnancy, but this is not necessarily associated through physical actions.

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is: a. seen at 3 days of age. b. the residue of a milk curd. c. passed in the first 24 hours of life. d. lighter in color and looser in consistency.

c. passed in the first 24 hours of life. Meconium should be passed in the first 24 hours of life. Meconium stool is the first stool of the newborn. Meconium stool is made up of matter in the intestines during intrauterine life. Meconium is dark in color and sticky.

Which client may require more help and understanding when integrating the newborn into the family? a. A primipara from an upper income family b. A primipara who comes from a large family c. A multipara (gravida 2) who has a supportive husband and mother d. A multipara (gravida 6) who has two children younger than 3 years

d. A multipara (gravida 6) who has two children younger than 3 years Pregnancy tasks are more complex for the multipara (gravida 6), and she may need special assistance to integrate the infant into the family structure. A primipara from an upper income family has the financial resources to assist her with daily care of the home. This leaves her free to concentrate on the newborns needs. The primipara with a large support system has help available to her. The multipara (gravida 2) who has a supportive husband and mother has a support system to assist with integrating the infant into the family structure.

While teaching an Asian client about prenatal care, the nurse notes that the client refuses to make eye contact. Which is the most likely cause? a. A submissive attitude b. Lack of understanding c. Embarrassment about the subject d. Cultural beliefs about eye contact

d. Cultural beliefs about eye contact The nurse must understand that making eye contact means different things in different cultures. The nurse should have a basic understanding of normal responses of various cultures within her community. Asians believe that eye contact shows disrespect, not submission. Many Asian women may nod and smile during client teaching, but this does not show understanding. They are responding that they heard you; validation of information is important. Modesty is important in some cultures, but the main response with this questions is the cultural beliefs.

A patient arrives to the clinic 2 hours late for her prenatal appointment. This is the third time she has been late. What is the nurses best action in response to this patients tardiness? a. Ask the patient if she has a way to tell the time. b. Ask the patient if she is deliberately being late for her appointments. c. Determine if the patient wants this baby and if this is her way of acting out. d. Determine if the patient arrives after the start time for other types of appointments.

d. Determine if the patient arrives after the start time for other types of appointments. Time orientation is viewed differently by other cultures. Native-Americans, Middle Easterners, Hispanics, and American Eskimos tend to emphasize the moment rather than the future. This causes conflicts in the health care setting, in which tests or appointments are scheduled at particular times. If a woman does not place the same importance on keeping appointments, she may encounter anger and frustration in the health care setting. Asking if she has a way to tell time does not get to the potential root of the problem. Asking if she is deliberately late is inconsiderate and nontherapeutic. Although her action may be an acting-out behavior, there are other considerations that must be considered first.

During the first few minutes after birth, which physiologic change occurs in the newborn as a response to vascular pressure changes in increased oxygen levels? a. Increased pulmonary vascular resistance b. Decreased systemic resistance c. Decreased pressure in the left heart d. Dilation of pulmonary vessels

d. Dilation of pulmonary vessels Dilation of pulmonary vessels occurs in response to increased oxygen levels. Decrease in pulmonary vascular resistance occurs. Increase in systemic vascular resistance occurs. Increased pressure in the left heart occurs.

Which comment made by a client in her first trimester indicates ambivalent feelings? a. My body is changing so quickly. b. I havent felt well since this pregnancy began. c. Im concerned about the amount of weight Ive gained. d. I wanted to become pregnant, but Im scared about being a mother.

d. I wanted to become pregnant, but Im scared about being a mother. Ambivalence refers to conflicting feelings. Expressing a concern about being a mother indicates conflicting or ambivalent feelings. Not feeling well since the pregnancy began does not reflect conflicting feelings. The woman is trying to confirm the pregnancy when she is stating the rapid changes to her body. She is not expressing conflicting feelings. By expressing concerns over gaining weight, which is normal, the woman is trying to confirm the pregnancy.

An expectant couple asks the nurse about intercourse during pregnancy and whether it is safe for the baby. What should the nurse tell the couple? a. Intercourse is safe until the third trimester. b. Safer sex practices should be used once the membranes rupture. c. Intercourse should be avoided if any spotting from the vagina occurs afterward. d. Intercourse and orgasm are often contraindicated if a history of or signs of preterm labor are present.

d. Intercourse and orgasm are often contraindicated if a history of or signs of preterm labor are present. Uterine contractions that accompany orgasm can stimulate labor and would be problematic if the woman is at risk for or has a history of preterm labor. Intercourse can continue as long as the pregnancy is progressing normally. Rupture of the membranes may require abstaining from intercourse. Safer sex practices are always recommended. Some spotting can normally occur as a result of the increased fragility and vascularity of the cervix and vagina during pregnancy.

A pregnant client comes into the medical clinic stating that her family and friends are telling her that she is always talking about the pregnancy and nothing else. She is concerned that something is wrong with her. What psychological behavior is she exhibiting? a. Antepartum obsession b. Ambivalence c. Uncertainty d. Introversion

d. Introversion The client is exhibiting behaviors associated with introversion and/or narcissism. These are normal findings during pregnancy as long as they do not become obsessive to the exclusion of everything else. The client is talking about the pregnancy but there is no evidence that it is affecting her perception of reality and/or ability to perform ADLs. It is normal for pregnant women to focus on the self as being of prime importance in their life initially during the pregnancy. Some women may feel ambivalent about their pregnancy, which is a normal reaction. However, this clients behavior does not support this finding. Some women react with uncertainty at the news of being pregnant, which is a normal reaction. However, this clients behavior does not support this finding.

The nurse in labor and birth is caring for a Muslim client during the active phase of labor. The nurse notes that the client quickly draws away when touched. Which intervention should the nurse implement? a. Ask the charge nurse to reassign you to another client. b. Assume that she doesnt like you and decrease your time with her. c. Continue to touch her as much as you need to while providing care. d. Limit touching to a minimum because physical contact may not be acceptable in her culture.

d. Limit touching to a minimum because physical contact may not be acceptable in her culture. Touching is an important component of communication in various cultures, but if the client appears to find it offensive, the nurse should respect her cultural beliefs and limit touching her. Asking the charge nurse to reassign you could be offensive to the client. A Muslims response to touch does not reflect like or dislike. By continuing to touch her, the nurse is showing disrespect for her cultural beliefs.

Which comment made by a new mother exhibits understanding of her toddlers response to a new sibling? a. I cant believe he is sucking his thumb again. b. He is being difficult and I dont have time to deal with him. c. When we brought the baby home, we made Michael stop sleeping in the crib. d. My husband is going to stay with the baby so I can take Michael to the park tomorrow.

d. My husband is going to stay with the baby so I can take Michael to the park tomorrow. It is important for a mother to seek time alone with her toddler to reassure him that he is loved. It is normal for a child to regress when a new sibling is introduced into the home. The toddler may have feelings of jealousy and resentment toward the new baby taking attention away from him. Frequent reassurance of parental love and affection are important. Changes in sleeping arrangements should be made several weeks before the birth so the child does not feel displaced by the new baby.

A multiparous patient arrives to the labor unit and urgently states, The baby is coming RIGHT NOW! The nurse assists the patient into a comfortable position and delivers the infant. To prevent infant heat loss from conduction, what is the priority nursing action? a. Dry the baby off. b. Turn up the temperature in the patients room. c. Pour warmed water over the baby immediately after birth. d. Place the baby on the patients abdomen after the cord is cut.

d. Place the baby on the patients abdomen after the cord is cut. Movement of heat away from the body occurs when newborns have direct contact with objects that are cooler than their skin. Placing infants on cold surfaces or touching them with cool objects causes this type of heat loss. The reverse is also true; contact with warm objects increases body heat by conduction. Warming objects that will touch the infant or placing the unclothed infant against the mothers skin (skin to skin) helps prevent conductive heat loss. Drying the baby off helps prevent heat loss through evaporation. Adjusting the temperature in the patients room helps with heat loss through convection. Pouring warm water over a baby occurs with the first bath, which is conducted after the babys temperature has stabilized. Pouring warm water over the baby prior to that time will increase heat loss through evaporation.

Which action by the nurse can cause hyperthermia in the newborn? a. Placing a cap on the newborn b. Wrapping the newborn in a warm blanket c. Placing the newborn in a skin to skin position with the mother d. Placing the newborn in the radiant warmer without attaching the skin probe

d. Placing the newborn in the radiant warmer without attaching the skin probe Newborns may be overheated by poorly regulated equipment designed to keep them warm. When radiant warmers, warming lights, or warmed incubators are used, the temperature mechanism must be set to vary the heat according to the infants skin temperature; this prevents too much or too little heat. Alarms to signal that the infants temperature is too high or too low should be functioning properly. If the skin probe is not used, the alarms will not function properly. Putting a hat on the newborn, wrapping the newborn in a warm blanket, or placing the newborn skin to skin with the mother will not cause hyperthermia.

Which infant has the lowest risk of developing high levels of bilirubin? a. The infant who developed a cephalohematoma b. The infant who was bruised during a difficult birth c. The infant who uses brown fat to maintain temperature d. The infant who is breastfed during the first hour of life

d. The infant who is breastfed during the first hour of life The infant who is fed early will be less likely to retain meconium and resorb bilirubin from the intestines back into the circulation. Cephalohematomas will release bilirubin into the system as the red blood cells die off. Bruising will release more bilirubin into the system. Brown fat is normally used to produce heat in the newborn.

A nursing student is helping the nursery nurse with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. Which is the best interpretation of this information? a. This is an 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.

d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth. The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and birth. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. This is a common condition for infants delivered by cesarean section. Surfactant is produced by the lungs, so aspiration is not a concern. It is common to have some fluid left in the lungs; this will be absorbed within a few hours.

The hips of a newborn are examined for developmental dysplasia. Which sign indicates an incomplete development of the acetabulum? a. Negative Barlow test b. Equal knee heights c. Negative Ortolani sign d. Thigh and gluteal creases are asymmetric

d. Thigh and gluteal creases are asymmetric Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. If the hip is dislocated, the knee on the affected side will be lower. A positive Ortolani sign yields a clunking sensation and indicates a dislocated femoral head moving into the acetabulum. During a positive Barlow test, the examiner can feel the femoral head move out of the acetabulum.

An expectant client asks the nurse about the behavior of mimicry. Which is an example of mimicry that the nurse should relate to the client? a. Daydreaming about the newborn b. Imagining oneself as a good mother c. Babysitting for a neighbors children d. Wearing maternity clothes before they are needed

d. Wearing maternity clothes before they are needed Mimicry involves observing and copying the behaviors of other women who are pregnant or are mothers. Wearing maternity clothes before they are needed helps the expectant mother feel what its like to be obviously pregnant. Daydreaming is a type of fantasy in which the woman tries out a variety of behaviors in preparation for motherhood. Imagining herself as a good mother is the womans effort to look for a good role fit. She observes behavior of other mothers and compares them with her own expectations. Babysitting other children is a form of role-playing in which the woman practices the expected role of motherhood.

he nurse reveals to the patient that the over-the-counter test is verified and that she is pregnant. The patient confides to the nurse, We have wanted to be pregnant for some time. These last few days I have been questioning our decision. I am feeling really bad right now. What is the nurses best response? a. You will come around in time and you will grow to love this baby. b. Dont feel bad. It is the hormones of pregnancy talking right now. c. Why do you think you are feeling bad when you wanted to be pregnant? d. Your feelings are understandable. Ambivalence is not uncommon right now.

d. Your feelings are understandable. Ambivalence is not uncommon right now. Early in pregnancy, ambivalence is not uncommon because pregnancy is a life-changing event, even if planned and strongly desired. The client needs reassurance and validation of these natural feelings. Although it is true that the patient will grow to love the baby, this statement does not acknowledge her ambivalent feelings. Dont feel bad dismisses the patients natural feelings and is a nontherapeutic response. Why is nontherapeutic and places the patient on the defensive in her response.

The infants heat loss immediately at birth is predominantly from: a. radiation. b. conduction. c. convection. d. evaporation.

d. evaporation. Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Radiation occurs with the transfer of heat to a cooler object that is not in direct contact with the infant. Conduction occurs when the infant comes into contact with a cold surface. The crib should be preheated to prevent this from occurring. Convection occurs when heat is transferred to the air surrounding the infant.