Chapter 15: 25: 18: 17: 23: 24

The healthy infant must accomplish both behavioral and biologic tasks to develop normally. Behavioral characteristics form the basis of the social capabilities of the infant. Newborns pass through a hierarchy of developmental challenges as they adapt to their environment and caregivers. This progression in behavior is the basis for the Brazelton Neonatal Behavioral Assessment (NBAS). Match the cluster of neonatal behaviors with the correct level on the NBAS scale. a.Habituation b.Orientation c.Range of state d.Autonomic stability e.Regulation of state 1. Signs of stress related to homeostatic adjustment 2. Ability to respond to discrete stimuli while asleep 3. Measure of general arousability 4. How the infant responds when aroused 5. Ability to attend to visual and auditory stimuli while alert

1. ANS: D DIF: Cognitive Level: Apply REF: p. 544 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 2. ANS: A DIF: Cognitive Level: Apply REF: p. 544 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 3. ANS: C DIF: Cognitive Level: Apply REF: p. 544 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 4. ANS: E DIF: Cognitive Level: Apply REF: p. 544 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 5. ANS: B DIF: Cognitive Level: Apply REF: p. 544 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

Fetal well-being in labor can be measured by the response of the FHR to uterine contractions. Match the characteristic of normal uterine activity during labor with the correct description. a.Frequency b.Duration c.Strength d.Resting tone e.Relaxation time 1. Commonly 45 seconds or more in the second stage of labor 2. Generally ranging from two to five contractions per 10 minutes of labor 3. Average of 10 mm Hg 4. Peaking at 40 to 70 mm Hg in the first stage of labor 5. Remaining fairly stable throughout the first and second stages

1. ANS: E DIF: Cognitive Level: Analyze REF: p. 411 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: If the FHR responds outside of these evidence-based parameters for uterine activity during labor, then interventions may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies observed in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to higher than 80 mm Hg in the second stage. The resting tone averages 10 mm Hg, and the uterus should feel soft if palpation is used. In the first stage of labor, relaxation time is commonly 60 seconds or longer, and 45 seconds or longer in the second stage. 2. ANS: A DIF: Cognitive Level: Analyze REF: p. 411 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: If the FHR responds outside of these evidence-based parameters for uterine activity during labor, then interventions may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies observed in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to higher than 80 mm Hg in the second stage. The resting tone averages 10 mm Hg, and the uterus should feel soft if palpation is used. In the first stage of labor, relaxation time is commonly 60 seconds or longer, and 45 seconds or longer in the second stage. 3. ANS: D DIF: Cognitive Level: Analyze REF: p. 411 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: If the FHR responds outside of these evidence-based parameters for uterine activity during labor, then interventions may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies observed in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to higher than 80 mm Hg in the second stage. The resting tone averages 10 mm Hg, and the uterus should feel soft if palpation is used. In the first stage of labor, relaxation time is commonly 60 seconds or longer, and 45 seconds or longer in the second stage. 4. ANS: C DIF: Cognitive Level: Analyze REF: p. 411 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: If the FHR responds outside of these evidence-based parameters for uterine activity during labor, then interventions may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies observed in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to higher than 80 mm Hg in the second stage. The resting tone averages 10 mm Hg, and the uterus should feel soft if palpation is used. In the first stage of labor, relaxation time is commonly 60 seconds or longer, and 45 seconds or longer in the second stage. 5. ANS: B DIF: Cognitive Level: Analyze REF: p. 411 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: If the FHR responds outside of these evidence-based parameters for uterine activity during labor, then interventions may be required. Contraction frequency generally ranges from two to five contractions per 10 minutes during labor, with lower frequencies observed in the first stage of labor and higher frequencies during the second stage. Duration of contractions remains fairly stable throughout the first and second stages and rarely exceeds 90 seconds. The strength of uterine contractions ranges from 40 to 70 mm Hg in the first stage and may rise to higher than 80 mm Hg in the second stage. The resting tone averages 10 mm Hg, and the uterus should feel soft if palpation is used. In the first stage of labor, relaxation time is commonly 60 seconds or longer, and 45 seconds or longer in the second stage.

16. Which explanation will assist the parents in their decision on whether they should circumcise their son? a. The circumcision procedure has pros and cons during the prenatal period. b. American Academy of Pediatrics (AAP) recommends that all male newborns be routinely circumcised. c. Circumcision is rarely painful, and any discomfort can be managed without medication. d. The infant will likely be alert and hungry shortly after the procedure.

A (Parents need to make an informed choice regarding newborn circumcision, based on the most current evidence and recommendations. Health care providers and nurses who care for childbearing families should provide factual, unbiased information regarding circumcision and give parents opportunities to discuss the risks and benefits of the procedure. The AAP and other professional organizations note the benefits but stop short of recommending routine circumcision. Circumcision is painful and must be managed with environmental, nonpharmacologic, and pharmacologic measures. After the procedure, the infant may be fussy for several hours, or he may be sleepy and difficult to awaken for feeding.)

21. A 3.8-kg infant was vaginally delivered at 39 weeks of gestation after a 30-minute second stage. A nuchal cord occurred. After the birth, the infant is noted to have petechiae over the face and upper back. Based on the nurses knowledge, which information regarding petechiae should be shared with the parents? a. Petechiae (pinpoint hemorrhagic areas) are benign if they disappear within 48 hours of childbirth. b.These hemorrhagic areas may result from increased blood volume. c.Petechiae should always be further investigated. d. Petechiae usually occur with a forceps delivery.

A (Petechiae that are acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this infant, the presence of petechiae is more likely a soft-tissue injury resulting from the nuchal cord at birth. Unless the lesions do not dissipate in 2 days, no reason exists to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.)

28. Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct? a. Ideally, the visit is scheduled within 72 hours after discharge. b. Home visits are available in all areas. c. Visits are completed within a 30-minute time frame. d. Blood draws are not a part of the home visit.

A (The home visit is ideally scheduled within 72 hours after discharge. This timing allows early assessment and intervention for problems with feedings, jaundice, newborn adaptation, and maternal-infant interaction. Because of geographic distances, home visits are not available in all locales. Visits are usually 60 to 90 minutes in length to allow enough time for assessment and teaching. When jaundice is found, the nurse can discuss the implications and check the transcutaneous bilirubin level or draw blood for testing.)

10. A mother is changing the diaper of her newborn son and notices that his scrotum appears large and swollen. The client is concerned. What is the best response from the nurse? a. A large scrotum and swelling indicate a hydrocele, which is a common finding in male newborns. b. I don't know, but I'm sure it is nothing. c. Your baby might have testicular cancer. d. Your babys urine is backing up into his scrotum.

A (Explaining what a hydrocele is and its characteristics is the most appropriate response by the nurse. The swelling usually decreases without intervention. Telling the mother that the condition is nothing important is inappropriate and does not address the mothers concern. Furthermore, if the nurse is unaware of any abnormal-appearing condition, then she should seek assistance from additional resources. Telling the mother that her newborn might have testicular cancer is inaccurate, inappropriate, and could cause the new mother undue worry. Urine will not back up into the scrotum if the infant has a hydrocele. Any nurse caring for the normal newborn should understand basic anatomy.)

5. The nurse is using the New Ballard Scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? a. Flexed posture b. Abundant lanugo c. Smooth, pink skin with visible veins d. Faint red marks on the soles of the feet

A (Term infants typically have a flexed posture. Abundant lanugo; smooth, pink skin with visible veins; and faint red marks are usually observed on preterm infants.)

25. The nurse should be cognizant of which important statement regarding care of the umbilical cord? a. The stump can become easily infected. b. If bleeding occurs from the vessels of the cord, then the nurse should immediately call for assistance. c. The cord clamp is removed at cord separation. d. The average cord separation time is 5 to 7 days.

A (The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If bleeding occurs and does not stop, then the nurse should call for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.)

17. The most serious complication of an infant heelstick is necrotizing osteochondritis resulting from lancet penetration of the bone. What approach should the nurse take when performing the test to prevent this complication? a. Lancet should penetrate at the outer aspect of the heel. b. Lancet should penetrate the walking surface of the heel. c. Lancet should penetrate the ball of the foot. d. Lancet should penetrate the area just below the fifth toe.

A (The stick should be made at the outer aspect of the heel and should penetrate no deeper than 2.4 mm. Repeated trauma to the walking surface of the heel can cause fibrosis and scarring that can lead to problems with walking later in life. The ball of the foot and the area below the fifth toe are inappropriate sites for a heelstick.)

1. Pain should be regularly assessed in all newborns. If the infant is displaying physiologic or behavioral cues that indicate pain, then measures should be taken to manage the pain. Which interventions are examples of nonpharmacologic pain management techniques? (Select all that apply.) a. Swaddling b. Nonnutritive sucking c. Skin-to-skin contact with the mother d. Sucrose e. Acetaminophen

A, B, C, D (Swaddling, nonnutritive sucking, skin-to-skin contact with the mother, and sucrose are all appropriate nonpharmacologic techniques used to manage pain in neonates. Acetaminophen is a pharmacologic method of treating pain.)

3. The Period of Purple Crying is a program developed to educate new parents about infant crying and the dangers of shaking a baby. Each letter in the acronym PURPLE represents a key concept of this program. Which concepts are accurate? (Select all that apply.) a. P: peak of crying and painful expression b. U: unexpected c. R: baby is resting at last d. L: extremely loud e. E: evening

A, B, E (P: peak of crying; U: unexpectedcomes and goes; R: resists soothing; P: painline face; L: longlasting up to 5 hours a day; and E: evening or late afternoon. Many hospitals now provide parents with an educational DVD and provide education before discharge.)

2. As recently as 2005, the AAP revised safe sleep practices to assist in the prevention of SIDS. The nurse should model these practices in the hospital and incorporate this information into the teaching plan for new parents. Which practices are ideal for role modeling? (Select all that apply.) a. Fully supine position for all sleep b. Side-sleeping position as an acceptable alternative c. Tummy time for play d. Infant sleep sacks or buntings e. Soft mattress

A, C, D (The back to sleep position is now recommended as the only position for every sleep period. To prevent positional plagiocephaly (flattening of the head) the infant should spend time on his or her abdomen while awake and for play. Loose sheets and blankets may be dangerous because they could easily cover the babys head. The parents should be instructed to tuck any bedding securely around the mattress or use sleep sacks or bunting bags instead. The side-sleeping position is no longer an acceptable alternative position, according to the AAP. Infants should always sleep on a firm surface, ideally a firm crib mattress covered by a sheet only. Quilts and sheepskins, among other bedding, should not be placed under the infant.)

4. Which statements concerning the benefits or limitations of breastfeeding are accurate? (Select all that apply.) a.Breast milk changes over time to meet the changing needs as infants grow. b.Breastfeeding increases the risk of childhood obesity. c, Breast milk and breastfeeding may enhance cognitive development. d.Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. e.Benefits to the infant include a reduced incidence of SIDS

A, C, D, E (Breastfeeding actually decreases the risk of childhood obesity. Human milk is the perfect food for human infants. Breast milk changes over time to meet the demands of the growing infant. Scientific evidence is clear that human milk provides the best nutrients for infants with continued benefits long after weaning. Fatty acids in breast milk promote brain growth and development and may lead to enhanced cognition. Infants who are breastfed experience a reduced incidence of SIDS.)

4. Hearing loss is one of the genetic disorders included in the universal screening program. Auditory screening of all newborns within the first month of life is recommended by the AAP. What is the rationale for having this testing performed? (Select all that apply.) a. Prevents or reduces developmental delays b. Reassures concerned new parents c. Provides early identification and treatment d. Helps the child communicate better e. Is recommended by the Joint Committee on Infant Hearing

A, C, D, E (New parents are often anxious regarding auditory screening and its impending results; however, parental anxiety is not the reason for performing the screening test. Auditory screening is usually performed before hospital discharge. Importantly, the nurse ensures the parents that the infant is receiving appropriate testing and fully explains the test to the parents. For infants who are referred for further testing and follow-up, providing further explanation and emotional support to the parents is an important responsibility for the nurse. All other responses are appropriate reasons for auditory screening of the newborn. Infants who do not pass the screening test should have it repeated. If the infant still does not pass the test, then he or she should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in an early intervention program by 6 months of age.)

The nurse caring for a newborn checks the record to note clinical findings that occurred before her shift. Which finding related to the renal system would be of increased significance and require further action? a.The pediatrician should be notified if the newborn has not voided in 24 hours. b.Breastfed infants will likely void more often during the first days after birth. c.Brick dust or blood on a diaper is always cause to notify the physician. d.Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.

ANS: A A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants will void less during this time because the mother's breast milk has not yet come in. Brick dust may be uric acid crystals; blood spotting could be attributable to the withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if the cause of bleeding is not apparent. Weight loss from fluid loss might take 14 days to regain.

Nursing care measures are commonly offered to women in labor. Which nursing measure reflects the application of the gate-control theory? a.Massage the woman's back. b.Change the woman's position. c.Give the prescribed medication. d.Encourage the woman to rest between contractions.

ANS: A According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques, such as massage or stroking, music, focal points, and imagery, reduce or completely block the capacity of the nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the woman's position, administering pain medication, and resting between contractions do not reduce or block the capacity of the nerve pathways to transmit pain using the gate-control theory.

A new mother states that her infant must be cold because the baby's hands and feet are blue. This common and temporary condition is called what? a.Acrocyanosis b.Erythema toxicum neonatorum c.Harlequin sign d.Vernix caseosa

ANS: A Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and intermittently appears over the first 7 to 10 days after childbirth. Erythema toxicum neonatorum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. One half of the body is pale, and the other one half is ruddy or bluish-red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering for the newborn.

Under which circumstance should the nurse immediately alert the pediatric provider? a.Infant is dusky and turns cyanotic when crying. b.Acrocyanosis is present 1 hour after childbirth. c.The infant's blood glucose level is 45 mg/dl. d.The infant goes into a deep sleep 1 hour after childbirth.

ANS: A An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. Acrocyanosis is an expected finding during the early neonatal life and is within the normal range for a newborn.Infants enter the period of deep sleep when they are approximately 1 hour old.

Which intervention can nurses use to prevent evaporative heat loss in the newborn? a.Drying the baby after birth, and wrapping the baby in a dry blanket b.Keeping the baby out of drafts and away from air conditioners c.Placing the baby away from the outside walls and windows d.Warming the stethoscope and the nurse's hands before touching the baby

ANS: A Because the infant is wet with amniotic fluid and blood, heat loss by evaporation quickly occurs. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold surfaces.

The nurse should be cognizant of which important information regarding nerve block analgesia and anesthesia? a.Most local agents are chemically related to cocaine and end in the suffix -caine. b.Local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once. c.Pudendal nerve block is designed to relieve the pain from uterine contractions. d.Pudendal nerve block, if performed correctly, does not significantly lessen the bearing-down reflex.

ANS: A Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions. A pudendal nerve block lessens or shuts down the bearing-down reflex.

A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on high. The nurse instructs the mother that the fan should not be directed toward the newborn and that the newborn should be wrapped in a blanket. The mother asks why. How would the nurse respond? a."Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." b."Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." c."Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." d."Your baby will easily get cold stressed and needs to be bundled up at all times."

ANS: A Convection is the flow of heat from the body surface to cooler ambient air. Because of heat loss by convection, all newborns in open bassinets should be wrapped to protect them from the cold. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is a loss of heat that occurs when a liquid is converted into a vapor. In the newborn, heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss; however, this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infant's temperature.

A client is experiencing back labor and complains of intense pain in her lower back. Which measure would best support this woman in labor? a.Counterpressure against the sacrum b.Pant-blow (breaths and puffs) breathing techniques c.Effleurage d.Conscious relaxation or guided imagery

ANS: A Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. The pain management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for contractions per the gate-control theory

A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" What is the nurse's best response? a."That's meconium, which is your baby's first stool. It's normal." b."That's transitional stool." c."That means your baby is bleeding internally." d."Oh, don't worry about that. It's okay."

ANS: A Explaining what meconium is and that it is normal is an accurate statement and the most appropriate response. Transitional stool is greenish-brown to yellowish-brown and usually appears by the third day after the initiation of feeding. Telling the father that the baby is internally bleeding is not an accurate statement. Telling the father not to worry is not appropriate. Such responses are belittling to the father and do not teach him about the normal stool patterns of his daughter.

Part of the health assessment of a newborn is observing the infant's breathing pattern. What is the predominate pattern of newborn's breathing? a.Abdominal with synchronous chest movements b.Chest breathing with nasal flaring c.Diaphragmatic with chest retraction d.Deep with a regular rhythm

ANS: A In a normal infant respiration, the chest and abdomen synchronously rise and infant breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is also a sign of respiratory distress.

The nurse should be cognizant of which physiologic effect of pain? a.Predominant pain of the first stage of labor is visceral pain that is located in the lower portion of the abdomen. b.Referred pain is the extreme discomfort experienced between contractions. c.Somatic pain of the second stage of labor is more generalized and related to fatigue. d.Pain during the third stage is a somewhat milder version of the pain experienced during the second stage.

ANS: A Predominant pain comes from cervical changes, the distention of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is similar to that of the first stage.

Which alterations in the perception of pain by a laboring client should the nurse understand? a.Sensory pain for nulliparous women is often greater than for multiparous women during early labor. b.Affective pain for nulliparous women is usually less than for multiparous women throughout the first stage of labor. c.Women with a history of substance abuse experience more pain during labor. d.Multiparous women have more fatigue from labor and therefore experience more pain.

ANS: A Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

Breathing patterns are taught to laboring women. Which breathing pattern should the nurse support for the woman and her coach during the latent phase of the first stage of labor if the couple has attended childbirth preparation classes? a.Slow-paced breathing b.Deep abdominal breathing c.Modified-paced breathing d.Patterned-paced breathing

ANS: A Slow-paced breathing is approximately one half the woman's normal breathing rate and is used during the early stages of labor when a woman can no longer walk or talk through her contractions. No such pattern called deep abdominal breathing exists in childbirth preparation. Modified-paced breathing is shallow breathing that is twice the woman's normal breathing rate. It is used when labor progresses and the woman can no longer maintain relaxation through paced breathing. Patterned-pace breathing is a fast, 4:1 breathe, breathe, breathe, blow pattern that is used during the transitional phase of labor just before pushing and delivery.

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

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

How would the nurse optimally reassure the parents of an infant who develops a cephalhematoma? a.A cephalhematoma may occur with a spontaneous vaginal birth. b.A cephalhematoma only happens as a result of a forceps- or vacuum-assisted delivery. c.It is present immediately after birth. d.The blood will gradually absorb over the first few months of life.

ANS: A The nurse should explain that bleeding between the skull and the periosteum of a newborn may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. Low forceps and other difficult extractions may result in bleeding. However, a cephalhematoma can also spontaneously occur. Swelling may appear unilaterally or bilaterally, is usually minimal or absent at birth, and increases over the first 2 to 3 days of life. Cephalhematomas gradually disappear over 2 to 3 weeks. A less common condition results in the calcification of the hematoma, which may persist for months.

What is the correct term for the cheeselike, white substance that fuses with the epidermis and serves as a protective coating? a.Vernix caseosa b.Surfactant c.Caput succedaneum d.Acrocyanosis

ANS: A The protection provided by vernix caseosa is needed because the infant's skin is so thin. Surfactant is a protein that lines the alveoli of the infant's lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

Which component of the sensory system is the least mature at birth? a.Vision b.Hearing c.Smell d.Taste

ANS: A The visual system continues to develop for the first 6 months after childbirth. As soon as the amniotic fluid drains from the ear (in minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell and can distinguish and react to various tastes.

Conscious relaxation is associated with which method of childbirth preparation? a.Grantly Dick-Read childbirth method b.Lamaze method c.Bradley method d.Psychoprophylactic method

ANS: A With the Grantly Dick-Read method, women are taught to consciously and progressively relax different muscle groups throughout the body until a high degree of skill at relaxation is achieved. The Lamaze method combines controlled muscular relaxation with breathing techniques. The Bradley method advocates natural labor, without any form of anesthesia or analgesia, assisted by a husband-coach and using breathing techniques for labor. The psychoprophylactic method is another name for the Lamaze method.

Which statements regarding physiologic jaundice are accurate? (Select all that apply.) a.Neonatal jaundice is common; however, kernicterus is rare. b.Appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c.Because jaundice may not appear before discharge, parents need instruction on how to assess for jaundice and when to call for medical help. d.Jaundice is caused by reduced levels of serum bilirubin. e.Breastfed babies have a lower incidence of jaundice

ANS: A, B, C Neonatal jaundice occurs in 60% of term newborns and in 80% of preterm infants. The complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to be taught how to evaluate their infant for signs of jaundice. Jaundice is caused by elevated levels of serum bilirubin. Breastfeeding is associated with an increased incidence of jaundice.

A woman has requested an epidural block for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's IV fluid for a preprocedural bolus. Before the initiation of the epidural, the woman should be informed regarding the disadvantages of an epidural block. Which concerns should the nurse share with this client? (Select all that apply.) a.Ability to move freely is limited. b.Orthostatic hypotension and dizziness may occur. c.Gastric emptying is not delayed. d.Higher body temperature may occur. e.Blood loss is not excessive.

ANS: A, B, D The woman's ability to move freely and to maintain control of her labor is limited, related to the use of numerous medical interventions (IV lines and electronic fetal monitoring [EFM]). Significant disadvantages of an epidural block include the occurrence of orthostatic hypotension, dizziness, sedation, and leg weakness. Women who receive an epidural block have a higher body temperature (38° C or higher), especially when labor lasts longer than 12 hours, and may result in an unnecessary neonatal workup for sepsis. An advantage of an epidural block is that blood loss is not excessive. Other advantages include the following: the woman remains alert and able to participate, good relaxation is achieved, airway reflexes remain intact, and only partial motor paralysis develops.

Which alternative approaches to relaxation have proven successful when working with the client in labor? (Select all that apply.) a.Aromatherapy b.Massage c.Hypnosis d.Cesarean birth e.Biofeedback

ANS: A, B, C, E Approaches to relaxation can include neuromuscular relaxation, aromatherapy, music, massage, imagery, hypnosis, or touch relaxation. Cesarean birth is a method of delivery, not a method of relaxation.

During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. What are these four essential factors? a.Chemical b.Mechanical c.Thermal d.Psychologic e.Sensory

ANS: A, B, C, E Chemical factors are essential to initiate breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations and results in a drop in the level of prostaglandins, which are known to inhibit breathing. Mechanical factors are also necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. After the birth, the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. The stimulation of these receptors also contributes to the initiation of breathing. Sensory factors include handling by the health care provider, drying by the nurse, lights, smells, and sounds. Psychologic factors do not contribute to the initiation of respirations.

While developing an intrapartum care plan for the client in early labor, which psychosocial factors would the nurse recognize upon the client's pain experience? (Select all that apply.) a.Culture b.Anxiety and fear c.Previous experiences with pain d.Intervention of caregivers e.Support systems

ANS: A, B, C, E Culture: A woman's sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: Extreme anxiety and fear magnify the sensitivity to pain and impair a woman's ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Previous experiences with pain: Fear and withdrawal are a natural response to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience. Support systems: An anxious partner is less able to provide help and support to a woman during labor. A woman's family and friends can be an important source of support if they convey realistic and positive information about labor and delivery. Although the intervention of caregivers may be necessary for the well-being of the woman and her fetus, some interventions add discomfort to the natural pain of labor (i.e., fetal monitor straps, IV lines).

Which statements describe the first stage of the neonatal transition period? (Select all that apply.) a.The neonatal transition period lasts no longer than 30 minutes. b.It is marked by spontaneous tremors, crying, and head movements. c.Passage of the meconium occurs during the neonatal transition period. d.This period may involve the infant suddenly and briefly sleeping. e.Audible grunting and nasal flaring may be present during this time

ANS: A, B, C, E The first stage is an active phase during which the baby is alert; this stage is referred to as the first period of reactivity. Decreased activity and sleep mark the second stage, the period of decreased responsiveness. The first stage is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. Audible grunting, nasal flaring, and chest retractions may be present; however, these behaviors usually resolve within 1 hour of life.

The class of drugs known as opioid analgesics (butorphanol, nalbuphine) is not suitable for administration to women with known opioid dependence. The antagonistic activity could precipitate withdrawal symptoms (abstinence syndrome) in both mothers and newborns. Which signs would indicate opioid or narcotic withdrawal in the mother? (Select all that apply.) a.Yawning, runny nose b.Increase in appetite c.Chills or hot flashes d.Constipation e.Irritability, restlessness

ANS: A, C, E The woman experiencing maternal opioid withdrawal syndrome will exhibit yawning, runny nose, sneezing, anorexia, chills or hot flashes, vomiting, diarrhea, abdominal pain, irritability, restlessness, muscle spasms, weakness, and drowsiness. Assessing both the mother and the newborn and planning the care accordingly are important steps for the nurse to take

What is the correct terminology for the nerve block that provides anesthesia to the lower vagina and perineum? a.Epidural b.Pudendal c.Local d.Spinal block

ANS: B A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and the use of low forceps, if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

Anxiety is commonly associated with pain during labor. Which statement regarding anxiety is correct? a.Even mild anxiety must be treated. b.Severe anxiety increases tension, increases pain, and then, in turn, increases fear and anxiety, and so on. c.Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. d.Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.

ANS: B Anxiety and pain reinforce each other in a negative cycle that will slow the progress of labor. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can sufficiently build to slow the progress of labor. Unfortunately, an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy.

What is the rationale for evaluating the plantar crease within a few hours of birth? a.Newborn has to be footprinted. b.As the skin dries, the creases will become more prominent. c.Heel sticks may be required. d.Creases will be less prominent after 24 hours.

ANS: B As the infant's skin begins to dry, the creases will appear more prominent, and the infant's gestation could be misinterpreted. Footprinting nor heel sticks will not interfere with the creases. The creases will appear more prominent after 24 hours.

Developing a realistic birth plan with the pregnant woman regarding her care is important for the nurse. How would the nurse explain the major advantage of nonpharmacologic pain management? a.Greater and more complete pain relief is possible. b.No side effects or risks to the fetus are involved. c.The woman will remain fully alert at all times. d.Labor will likely be more rapid.

ANS: B Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. However, pain relief is lessened with nonpharmacologic pain management during childbirth. Although the woman's alertness is not altered by medication, the increase in pain may decrease alertness. Pain management may or may not alter the length of labor. At times when pain is decreased, the mother relaxes and labor progresses at a quicker pace.

A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the client place the infant to her breast within 15 minutes after birth. The nurse is aware that the initiation of breastfeeding is most effective during the first 30 minutes after birth. What is the correct term for this phase of alertness? a.Transition period b.First period of reactivity c.Organizational stage d.Second period of reactivity

ANS: B The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. The transition period is the phase between intrauterine and extrauterine existence. An organizational stage is not a valid stage. The second period of reactivity occurs approximately between 4 and 8 hours after birth, after a period of sleep.

Which statement best describes the transition period between intrauterine and extrauterine existence for the newborn? a.Consists of four phases, two reactive and two of decreased responses b.Lasts from birth to day 28 of life c.Applies to full-term births only d.Varies by socioeconomic status and the mother's age

ANS: B Changes begin immediately after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. This transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition period, regardless of age or type of birth. Although stress can cause variations in the phases, the mother's age and wealth do not disturb the pattern.

The process during which bilirubin is changed from a fat-soluble product to a water-soluble product is known as what? a.Enterohepatic circuit b.Conjugation of bilirubin c.Unconjugated bilirubin d.Albumin binding

ANS: B Conjugation of bilirubin is the process of changing the bilirubin from a fat-soluble to a water-soluble product and is the route by which part of the bile produced by the liver enters the intestine, is reabsorbed by the liver, and is then recycled into the intestine. Unconjugated bilirubin is a fat-soluble product. Albumin binding is the process during which something attaches to a protein molecule.

The nurse is circulating during a cesarean birth of a preterm infant. The obstetrician requests that cord clamping be delayed. What is the rationale for this directive? a.To reduce the risk for jaundice b.To reduce the risk of intraventricular hemorrhage c.To decrease total blood volume d.To improve the ability to fight infection

ANS: B Delayed cord clamping provides the greatest benefits to the preterm infant. These benefits include a significant reduction in intraventricular hemorrhage, a reduced need for a blood transfusion, and improved blood cell volume. The risk of jaundice can increase, requiring phototherapy. Although no difference in the newborn's infection fighting ability occurs, iron status is improved, which can provide benefits for 6 months.

What is the role of the nurse as it applies to informed consent? a.Inform the client about the procedure, and ask her to sign the consent form. b.Act as a client advocate, and help clarify the procedure and the options. c.Call the physician to see the client. d.Witness the signing of the consent form.

ANS: B Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the woman's advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the woman of her options, explaining the procedure, and advising the client about potential risk factors. The physician must be present to explain the procedure to the client. However, the nurse's responsibilities go further than simply asking the physician to see the client. The nurse may witness the signing of the consent form. However, depending on the state's guidelines, the woman's husband or another hospital health care employee may sign as a witness.

According to professional standards (the Association of Women's Health, Obstetric and Neonatal Nurses [AWHONN], 2007), which action cannot be performed by the nonanesthetist registered nurse who is caring for a woman with epidural anesthesia? a.Monitoring the status of the woman and fetus b.Initiating epidural anesthesia c.Replacing empty infusion bags with the same medication and concentrate d.Stopping the infusion, and initiating emergency measures

ANS: B Only qualified, licensed anesthesia care providers are permitted to insert a catheter, initiate epidural anesthesia, verify catheter placement, inject medication through the catheter, or alter the medication or medications including type, amount, or rate of infusion. The nonanesthetist nurse is permitted to monitor the status of the woman, the fetus, and the progress of labor. Replacement of the empty infusion bags or syringes with the same medication and concentration is permitted. If the need arises, the nurse may stop the infusion, initiate emergency measures, and remove the catheter if properly educated to do so. Complications can require immediate interventions. Nurses must be prepared to provide safe and effective care during an emergency situation.

What should the laboring client who receives an opioid antagonist be told to expect? a.Her pain will decrease. b.Her pain will return. c.She will feel less anxious. d.She will no longer feel the urge to push.

ANS: B Opioid antagonists such as naloxone (Narcan) promptly reverse the CNS-depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if the labor is more rapid than expected and the birth is anticipated when the opioid is at its peak effect. The woman should be told that the pain that was relieved by the opioid analgesic will return with the administration of the opioid antagonist. Her pain level will increase rather than decrease. Opioid antagonists have no effect on anxiety levels. They are primarily administered to reverse the excessive CNS depression in the mother, newborn, or both. An opioid antagonist (e.g., naloxone) has no effect on the mother's urge or ability to push. The practice of giving lower doses of IV opioids has reduced the incidence and severity of opioid-induced CNS depression; therefore, opioid antagonists are used less frequently.

A first-time mother is concerned about the type of medications she will receive during labor. The client is in a fair amount of pain and is nauseated. In addition, she appears to be very anxious. The nurse explains that opioid analgesics are often used along with sedatives. How should the nurse phrase the rationale for this medication combination? a."The two medications, together, reduce complications." b."Sedatives enhance the effect of the pain medication." c."The two medications work better together, enabling you to sleep until you have the baby." d."This is what your physician has ordered for you."

ANS: B Sedatives may be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractic drugs reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause two drugs to work together more effectively, but it does not ensure zero maternal or fetal complications. Sedation may be a related effect of some ataractic drugs; however, sedation is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. Although the physician may have ordered the medication, "This is what your physician has ordered for you" is not an acceptable comment for the nurse to make.

The condition during which infants are at an increased risk for subgaleal hemorrhage is called what? a.Infection b.Jaundice c.Caput succedaneum d.Erythema toxicum neonatorum

ANS: B Subgaleal hemorrhage is bleeding into the subgaleal compartment and is the result of the transition from a forceps or vacuum application. Because of the breakdown of the red blood cells within a hematoma, infants are at greater risk for jaundice. Subgaleal hemorrhage does not increase the risk for infections. Caput succedaneum is an edematous area on the head caused by pressure against the cervix. Erythema toxicum neonatorum is a benign rash of unknown cause that consists of blotchy red areas.

The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. What information provided by the nurse would be most useful to these new parents? a."Infants can see very little until approximately 3 months of age." b."Infants can track their parents' eyes and can distinguish patterns; they prefer complex patterns." c."The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." d."It's important to shield the newborn's eyes. Overhead lights help them see better."

ANS: B Telling the parents that infants can track their parents' eyes and can distinguish patterns is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. They prefer low illumination and withdraw from bright lights.

A primiparous woman is watching her newborn sleep. She wants him to wake up and respond to her. The mother asks the nurse how much he will sleep every day. What is an appropriate response by the nurse? a."He will only wake up to be fed, and you should not bother him between feedings." b."The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing." c."He will probably follow your same sleep and wake patterns, and you can expect him to be awake soon." d."He is being stubborn by not waking up when you want him to. You should try to keep him awake during the daytime so that he will sleep through the night."

ANS: B Telling the woman that the newborn sleeps approximately 17 hours a day with periods of wakefulness that gradually increase is both accurate and the most appropriate response by the nurse. Periods of wakefulness are dictated by hunger, but the need for socializing also appears. Telling the woman that her infant is stubborn and should be kept awake during the daytime is an inappropriate nursing response.

Which information about variations in the infant's blood counts is important for the nurse to explain to the new parents? a.A somewhat lower-than-expected red blood cell count could be the result of a delay in clamping the umbilical cord. b.An early high white blood cell (WBC) count is normal at birth and should rapidly decrease. c.Platelet counts are higher in the newborn than in adults for the first few months. d.Even a modest vitamin K deficiency means a problem with the blood's ability to properly clot.

ANS: B The WBC count is normally high on the first day of birth and then rapidly declines. Delayed cord clamping results in an increase in hemoglobin and the red blood cell count. The platelet count is essentially the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the deficiency of vitamin K is significant.

The nurse should be aware of what important information regarding systemic analgesics administered during labor? a.Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. b.Effects on the fetus and newborn can include decreased alertness and delayed sucking. c.Intramuscular (IM) administration is preferred over IV administration. d.IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

ANS: B The effects of analgesics depend on the specific drug administered, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in a decrease in the use of an analgesic.

What is the rationale for the use of a blood patch after spinal anesthesia? a.Hypotension b.Headache c.Neonatal respiratory depression d.Loss of movement

ANS: B The subarachnoid block may cause a postspinal headache resulting from the loss of cerebrospinal fluid from the puncture in the dura. When blood is injected into the epidural space in the area of the dural puncture, it forms a seal over the hole to stop the leaking of cerebrospinal fluid. Hypotension is prevented by increasing fluid volume before the procedure. Neonatal respiratory depression is not an expected outcome with spinal anesthesia. Loss of movement is an expected outcome of spinal anesthesia.

Which cardiovascular changes cause the foramen ovale to close at birth? a.Increased pressure in the right atrium b.Increased pressure in the left atrium c.Decreased blood flow to the left ventricle d.Changes in the hepatic blood flow

ANS: B 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 pressure in the right atrium decreases at birth and is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes but is not the reason for the closure of the foramen ovale.

What are the various modes of heat loss in the newborn? (Select all that apply.) a.Perspiration b.Convection c.Radiation d.Conduction e.Urination

ANS: B, C, D Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn.

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could the nurse use to increase the client's blood pressure? (Select all that apply.) a.Place the woman in a supine position. b.Place the woman in a lateral position. c.Increase IV fluids. d.Administer oxygen. e.Perform a vaginal examination.

ANS: B, C, D Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman's legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until the woman is stable. Placing the client in a supine position causes venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure.

Which FHR decelerations would require the nurse to change the maternal position? (Select all that apply.) a.Early decelerations b.Late decelerations c.Variable decelerations d.Moderate decelerations e.Prolonged decelerations

ANS: B, C, E Early decelerations (and accelerations) do not generally need any nursing intervention. Late decelerations suggest that the nurse should change the maternal position (lateral). Variable decelerations also require a maternal position change (side to side). Moderate decelerations are not an accepted category. Prolonged decelerations are late or variable decelerations that last for a prolonged period (longer than 2 minutes) and require intervention.

A tiered system of categorizing FHR has been recommended by professional organizations. Nurses, midwives, and physicians who care for women in labor must have a working knowledge of fetal monitoring standards and understand the significance of each category. What is the correct nomenclature for these categories? (Select all that apply.) a.Reassuring b.Category I c.Category II d.Nonreassuring e.Category III

ANS: B, C, E The three-tiered system of FHR tracings include category I, II, and III. Category I is a normal tracing requiring no action. Category II FHR tracings are indeterminate and includes tracings that do not meet category I or III criteria. Category III tracings are abnormal and require immediate intervention.

According to the National Institute of Child Health and Human Development (NICHD) Three-Tier System of FHR Classification, category III tracings include all FHR tracings not categorized as category I or II. Which characteristics of the FHR belong in category III? (Select all that apply.) a.Baseline rate of 110 to 160 beats per minute b.Tachycardia c.Absent baseline variability not accompanied by recurrent decelerations d.Variable decelerations with other characteristics such as shoulders or overshoots e.Absent baseline variability with recurrent variable decelerations f.Bradycardia

ANS: B, D, E, F Tachycardia, variable decelerations with other characteristics, absent baseline variability with recurrent variable decelerations, and bradycardia are characteristics that are considered nonreassuring or abnormal and belong in category III. A FHR of 110 to 160 beats per minute is considered normal and belongs in category I. Absent baseline variability not accompanied by recurrent decelerations is a category II characteristic

A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. Which statement regarding this procedure is correct? a.The application of nitrous oxide gas is not often used anymore. b.An inhalation of gas is likely to be used in the second stage of labor, not during the first stage. c.An application of nitrous oxide gas is administered for pain relief. d.The application of gas is a prelude to a cesarean birth.

ANS: C A mixture of nitrous oxide with oxygen in a low concentration can be used in combination with other nonpharmacologic and pharmacologic measures for pain relief. This procedure is still commonly used in Canada and in the United Kingdom. Nitrous oxide inhaled in a low concentration will reduce but not eliminate pain during the first and second stages of labor. Nitrous oxide inhalation is not generally used before a caesarean birth. Nitrous oxide does not appear to depress uterine contractions or cause adverse reactions in the newborn.

Which statement is not an expected outcome for the client who attends a reputable childbirth preparation program? a.Childbirth preparation programs increase the woman's sense of control. b.Childbirth preparation programs prepare a support person to help during labor. c.Childbirth preparation programs guarantee a pain-free childbirth. d.Childbirth preparation programs teach distraction techniques.

ANS: C All methods try to increase a woman's sense of control, prepare a support person, and train the woman in physical conditioning, which includes breathing techniques. These programs cannot, and reputable ones do not, promise a pain-free childbirth. Increasing a woman's sense of control is the goal of all childbirth preparation methods. Preparing a support person to help in labor is a vitally important component of any childbirth education program. The coach may learn how to touch a woman's body to detect tense and contracted muscles. The woman then learns how to relax in response to the gentle stroking by the coach. Distraction techniques are a form of care that are effective to some degree in relieving labor pain and are taught in many childbirth programs. These distractions include imagery, feedback relaxation, and attention-focusing behaviors.

A laboring woman has received meperidine (Demerol) intravenously (IV), 90 minutes before giving birth. Which medication should be available to reduce the postnatal effects of meperidine on the neonate? a.Fentanyl (Sublimaze) b.Promethazine (Phenergan) c.Naloxone (Narcan) d.Nalbuphine (Nubain)

ANS: C An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists, such as naloxone (Narcan), can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl (Sublimaze), promethazine (Phenergan), and nalbuphine (Nubain) do not act as opioid antagonists to reduce the postnatal effects of meperidine on the neonate.

The nurse should be cognizant of which important information regarding the gastrointestinal (GI) system of the newborn? a.The newborn's cheeks are full because of normal fluid retention. b.The nipple of the bottle or breast must be placed well inside the baby's mouth because teeth have been developing in utero, and one or more may even be through. c.Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head. d.Bacteria are already present in the infant's GI tract at birth because they traveled through the placenta.

ANS: C Avoiding overfeeding can also reduce regurgitation. The newborn's cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices.

While assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action is the highest priority for the nurse to take at this time? a.Immediately notify the physician. b.Move the newborn to an isolation nursery. c.Document the finding as erythema toxicum neonatorum. d.Take the newborn's temperature, and obtain a culture of one of the vesicles.

ANS: C Erythema toxicum neonatorum (or erythema neonatorum) is a newborn rash that resembles flea bites. Notification of the physician, isolation of the newborn, or additional interventions are not necessary when erythema toxicum neonatorum is present.

Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help their clients. Which clients may initially appear very stoic but then become quite vocal as labor progresses until late in labor, when they become more vocal and request pain relief? a.Chinese b.Arab or Middle Eastern c.Hispanic d.African-American

ANS: C Hispanic women may be stoic early in labor but more vocal and ready for medications later. Chinese women may not show reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in response to labor pain from the start; they may prefer pain medications. African-American women may openly express pain; the use of medications for pain is more likely to vary with the individual.

How would the nurse differentiate a meconium stool from a transitional stool in the healthy newborn? a.Observed at age 3 days b.Is residue of a milk curd c.Passes in the first 12 hours of life d.Is lighter in color and looser in consistency

ANS: C Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, then obstruction is suspected. Meconium stool is the first stool of the newborn and is made up of matter remaining in the intestines during intrauterine life. Meconium is dark and sticky.

What marks on a baby's skin may indicate an underlying problem that requires notification of a physician? a.Mongolian spots on the back b.Telangiectatic nevi on the nose or nape of the neck c.Petechiae scattered over the infant's body d.Erythema toxicum neonatorum anywhere on the body

ANS: C Petechiae (bruises) scattered over the infant's body should be reported to the pediatrician because they may indicate underlying problems. Mongolian spots are bluish-black spots that resemble bruises but gradually fade over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum neonatorum is an appalling-looking rash; however, it has no clinical significance and requires no treatment.

A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? a.Physiologic jaundice occurs during the first 24 hours of life. b.Physiologic jaundice is caused by blood incompatibilities between the mother and the infant blood types. c.Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life. d.Physiologic jaundice is also known as breast milk jaundice.

ANS: C Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dl or higher when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice, not physiologic jaundice, occurs during the first 24 hours of life and is caused by blood incompatibilities that result in excessive destruction of erythrocytes; this condition must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids.

While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what? a.Polydactyly b.Clubfoot c.Hip dysplasia d.Webbing

ANS: C The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.

The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)? a.80 to 100 b.100 to 120 c.120 to 160 d.150 to 180

ANS: C The average infant heart rate while awake is 120 to 160 beats per minute. The newborn's heart rate may be approximately 85 to 100 beats per minute while sleeping and typically a little higher than 100 to 120 beats per minute when alert but quiet. A heart rate of 150 to 180 beats per minute is typical when the infant cries.

The nurse is cognizant of which information related to the administration of vitamin K? a.Vitamin K is important in the production of red blood cells. b.Vitamin K is necessary in the production of platelets. c.Vitamin K is not initially synthesized because of a sterile bowel at birth. d.Vitamin K is responsible for the breakdown of bilirubin and the prevention of jaundice.

ANS: C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is necessary to activate blood-clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other blood-clotting factors.

A woman in labor has just received an epidural block. What is the most important nursing intervention at this time? a.Limit parenteral fluids. b.Monitor the fetus for possible tachycardia. c.Monitor the maternal blood pressure for possible hypotension. d.Monitor the maternal pulse for possible bradycardia.

ANS: C The most important nursing intervention for a woman who has received an epidural block is for the nurse to monitor the maternal blood pressure frequently for signs of hypotension. IV fluids are increased for a woman receiving an epidural to prevent hypotension. The nurse also observes for signs of fetal bradycardia and monitors for signs of maternal tachycardia, secondary to hypotension.

A newborn is placed under a radiant heat warmer. The nurse understands that thermoregulation presents a problem for the newborn. What is the rationale for this difficulty? a.The renal function of a newborn is not fully developed, and heat is lost in the urine. b.The small body surface area of a newborn favors more rapid heat loss than does an adult's body surface area. c.Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation. d.Their normal flexed posture favors heat loss through perspiration.

ANS: C The newborn has little thermal insulation. Furthermore, the blood vessels are closer to the surface of the skin. Changes in environmental temperature alter the temperature of the blood, thereby influencing temperature regulation centers in the hypothalamus. Heat loss does not occur through urination. Newborns have a higher body surface-to-weight ratio than adults. The flexed position of the newborn helps guard against heat loss, because it diminishes the amount of body surface exposed to the environment.

Which information related to the newborn's developing cardiovascular system should the nurse fully comprehend? a.The heart rate of a crying infant may rise to 120 beats per minute. b.Heart murmurs heard after the first few hours are a cause for concern. c.The point of maximal impulse (PMI) is often visible on the chest wall. d.Persistent bradycardia may indicate respiratory distress syndrome (RDS).

ANS: C The newborn's thin chest wall often allows the PMI to be observed. The normal heart rate for infants who are not sleeping is 120 to 160 beats per minute. However, a crying infant could temporarily have a heart rate of 180 beats per minute. Heart murmurs during the first few days of life have no pathologic significance; however, an irregular heart rate beyond the first few hours should be further evaluated. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's IV fluid for a preprocedural bolus. The nurse reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for this woman? a.She is too far dilated. b.She is anemic. c.She has thrombocytopenia. d.She is septic.

ANS: C The platelet count indicates a coagulopathy, specifically, thrombocytopenia (low platelets), which is a contraindication to epidural analgesia and anesthesia. Typically, epidural analgesia and anesthesia are used in the laboring woman when a regular labor pattern has been achieved, as evidenced by progressive cervical change. The laboratory values show that the woman's hemoglobin and hematocrit levels are in the normal range and show a slight increase in the WBC count that is not uncommon in laboring women.

The baseline FHR is the average rate during a 10-minute segment. Changes in FHR are categorized as periodic or episodic. These patterns include both accelerations and decelerations. The labor nurse is evaluating the client's most recent 10-minute segment on the monitor strip and notes a late deceleration. Which is likely to have caused this change? (Select all that apply.) a.Spontaneous fetal movement b.Compression of the fetal head c.Placental abruption d.Cord around the baby's neck e.Maternal supine hypotension

ANS: C, E Late decelerations are almost always caused by uteroplacental insufficiency. Insufficiency is caused by uterine tachysystole, maternal hypotension, epidural or spinal anesthesia, IUGR, intraamniotic infection, or placental abruption. Spontaneous fetal movement, vaginal examination, fetal scalp stimulation, fetal reaction to external sounds, uterine contractions, fundal pressure, and abdominal palpation are all likely to cause accelerations of the FHR. Early decelerations are most often the result of fetal head compression and may be caused by uterine contractions, fundal pressure, vaginal examination, and the placement of an internal electrode. A variable deceleration is likely caused by umbilical cord compression, which may happen when the umbilical cord is around the baby's neck, arm, leg, or other body part or when a short cord, a knot in the cord, or a prolapsed cord is present.

An African-American woman noticed some bruises on her newborn daughter's buttocks. The client asks the nurse what causes these. How would the nurse best explain this integumentary finding to the client? a.Lanugo b.Vascular nevus c.Nevus flammeus d.Mongolian spot

ANS: D A Mongolian spot is a bluish-black area of pigmentation that may appear over any part of the exterior surface of the infant's body and is more commonly noted on the back and buttocks and most frequently observed on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair observed on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port wine stain, is most frequently found on the face.

The obstetric nurse is preparing the client for an emergency cesarean birth, with no time to administer spinal anesthesia. The nurse is aware of and prepared for the greatest risk of administering general anesthesia to the client. What is this risk? a.Respiratory depression b.Uterine relaxation c.Inadequate muscle relaxation d.Aspiration of stomach contents

ANS: D Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia but can be monitored and prevented. Inadequate muscle relaxation can be improved with medication.

Which statement correctly describes the effects of various pain factors? a.Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth. b.Upright positions in labor increase the pain factor because they cause greater fatigue. c.Women who move around trying different positions experience more pain. d.Levels of pain-mitigating beta-endorphins are higher during a spontaneous, natural childbirth.

ANS: D Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving freely to find more comfortable positions is important for reducing pain and muscle tension.

A woman who is pregnant for the first time is dilated 3 cm and having contractions every 5 minutes. She is groaning and perspiring excessively; she states that she did not attend childbirth classes. What is the optimal intervention for the nurse to provide at this time? a.Notify the woman's health care provider. b.Administer the prescribed narcotic analgesic. c.Assure her that her labor will be over soon. d.Assist her with simple breathing and relaxation instructions.

ANS: D By reducing tension and stress, both focusing and relaxation techniques will allow the woman in labor to rest and conserve energy for the task of giving birth. For those who have had no preparation, instruction in simple breathing and relaxation can be given in early labor and is often successful. The nurse can independently perform many functions in labor and birth, such as teaching and support. Pain medication may be an option for this client. However, the initial response of the nurse should include teaching the client about her options. The length of labor varies among individuals, but the first stage of labor is the longest. At 3 cm of dilation with contractions every 5 minutes, this woman has a significant amount of labor yet to experience.

An 18-year-old pregnant woman, gravida 1, para 0, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The client states, "My contractions are so strong, I don't know what to do." Before making a plan of care, what should the nurse's first action be? a.Assess for fetal well-being. b.Encourage the woman to lie on her side. c.Disturb the woman as little as possible. d.Recognize that pain is personalized for each individual.

ANS: D Each woman's pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. This scenario includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. This client clearly needs support.

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a.The nurse should immediately notify the pediatrician for this emergency situation. b.The neonate must have aspirated surfactant. c.If this baby was born vaginally, then a pneumothorax could be indicated. d.The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth.

ANS: D Moist lung sounds will resolve within a few hours. A surfactant acts to keep the expanded alveoli partially open between respirations for this common condition of newborns. In a vaginal birth, absorption of the remaining lung fluid is accelerated by the process of labor and delivery. The remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. Moist lung sounds are particularly common in infants delivered by cesarean section. The surfactant is produced by the lungs; therefore, aspiration is not a concern.

A client states that she does not drink milk. Which foods should the nurse encourage this woman to consume in greater amounts to increase her calcium intake? a.Fresh apricots b.Canned clams c.Spaghetti with meat sauce d.Canned sardines

ANS: D Sardines are rich in calcium. Fresh apricots, canned clams, and spaghetti with meat sauce are not high in calcium.

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive _____ reflex. a.tonic neck b.glabellar (Myerson) c.Babinski d.Moro

ANS: D The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar (Myerson) reflex is elicited by tapping on the infant's head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.

What is the most critical physiologic change required of the newborn after birth? a.Closure of fetal shunts in the circulatory system b.Full function of the immune defense system c.Maintenance of a stable temperature d.Initiation and maintenance of respirations

ANS: D The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes significantly after birth as a result of fetal respirations, which reduce pulmonary vascular resistance to the pulmonary blood flow and initiate a chain of cardiac changes that support the cardiovascular system. After the establishment of respirations, heat regulation is critical to newborn survival. The infant relies on passive immunity received from the mother for the first 3 months of life.

Which infant response to cool environmental conditions is either not effective or not available to them? a.Constriction of peripheral blood vessels b.Metabolism of brown fat c.Increased respiratory rates d.Unflexing from the normal position

ANS: D The newborn's flexed position guards against heat loss, because it reduces the amount of body surface exposed to the environment. The newborn's body is able to constrict the peripheral blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may rise to stimulate muscular activity, which generates heat.

The brain is vulnerable to nutritional deficiencies and trauma in early infancy. What is the rationale for this physiologic adaptation in the newborn? a.Incompletely developed neuromuscular system b.Primitive reflex system c.Presence of various sleep-wake states d.Cerebellum growth spurt

ANS: D The vulnerability of the brain is likely due to the cerebellum growth spurt. By the end of the first year, the cerebellum ends its growth spurt that began at approximately 30 weeks of gestation. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant to the cerebellum growth spurt. The various sleep-wake states are not relevant to the cerebellum growth spurt.

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is approximately twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. Which intervention should the nurse immediately initiate? a.Contact the woman's physician. b.Tell the woman to slow her pace of her breathing. c.Administer oxygen via a mask or nasal cannula. d.Help her breathe into a paper bag.

ANS: D This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis and enable her to rebreathe carbon dioxide and replace the bicarbonate ion.

A client is in early labor, and her nurse is discussing the pain relief options she is considering. The client states that she wants an epidural "no matter what!" What is the nurse's best response? a."I'll make sure you get your epidural." b."You may only have an epidural if your physician allows it." c."You may only have an epidural if you are going to deliver vaginally." d."The type of analgesia or anesthesia used is determined, in part, by the stage of your labor and the method of birth."

ANS: D To avoid suppressing the progress of labor, pharmacologic measures for pain relief are generally not implemented until labor has advanced to the active phase of the first stage and the cervix is dilated approximately 4 to 5 cm. A plan of care is developed for each woman that addresses her particular clinical and nursing problems. The nurse collaborates with the primary health care provider and the laboring woman in selecting features of care relevant to the woman and her family. The decision whether to use an epidural to relieve labor pain is multifactorial. The nurse should not make a blanket statement guaranteeing the client one pharmacologic option over another until a complete history and physical examination has been obtained. A physician's order is required for pharmacologic options for pain management. However, expressing this requirement is not the nurse's best response. An epidural is an effective pharmacologic pain management option for many laboring women. It can also be used for anesthesia control if the woman undergoes an operative delivery.

Maternity nurses often have to answer questions about the many, sometimes unusual, ways people have tried to make the birthing experience more comfortable. Which information regarding nonpharmacologic pain relief isaccurate? a.Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine. b.Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. c.Effleurage is permissible, but counterpressure is almost always counterproductive. d.Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.

ANS: D Transcutaneous electrical nerve stimulation (TENS) may help and is most useful for lower back pain that occurs during the first stage of labor. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks might be more effective than one long bath. Counterpressure can help the woman cope with lower back pain.

27. Which intervention by the nurse would reduce the risk of abduction of the newborn from the hospital? a. Instructing the mother not to give her infant to anyone except the one nurse assigned to her that day b. Applying an electronic and identification bracelet to the mother and the infant c. Carrying the infant when transporting him or her in the halls d. Restricting the amount of time infants are out of the nursery

B (A measure taken by many facilities is to band both the mother and the baby with matching identification bracelets and band the infant with an electronic device that will sound an alarm if the infant is removed from the maternity unit. It is impossible for one nurse to be on call for one mother and baby for the entire shift; therefore, parents need to be able to identify the nurses who are working on the unit. Infants should always be transported in their bassinette for both safety and security reasons. All maternity unit nursing staff should have unique identification bracelets in comparison with the rest of the hospital. Infants should remain with their parents and spend as little time in the nursery as possible.)

12. At 1 minute after birth a nurse assesses an infant and notes a heart rate of 80 beats per minute, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. Which Apgar score does the nurse calculate based upon these observations and signs? a. 4 b. 5 c. 6 d. 7

B (Each of the five signs the nurse notes scores a 1 on the Apgar scale, for a total of 5. A score of 4 is too low for this infant. A score of 6 is too high for this infant. A score of 7 is too high for an infant with this presentation.)

23. What is the nurses initial action while caring for an infant with a slightly decreased temperature? a. Immediately notify the physician. b. Place a cap on the infants head, and have the mother perform kangaroo care. c. Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d. Change the formula; a decreased body temperature is a sign of formula intolerance.

B (Keeping the head well covered with a cap prevents further heat loss from the head, and placing the infant skin-to-skin against the mother should increase the infants temperature. Nursing actions are needed first to correct the problem. If the problem persists after the interventions, physician notification may then be necessary. A slightly decreased temperature can be treated in the mothers room, offering an excellent time for parent teaching on the prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days after childbirth as the infant adapts to external life.)

2. A new father wants to know what medication was put into his infants eyes and why it is needed. How does the nurse explain the purpose of the erythromycin (Ilotycin) ophthalmic ointment? a. Erythromycin (Ilotycin) ophthalmic ointment destroys an infectious exudate caused by Staphylococcus that could make the infant blind. b. This ophthalmic ointment prevents gonorrheal and chlamydial infection of the infants eyes, potentially acquired from the birth canal. c. Erythromycin (Ilotycin) prevents potentially harmful exudate from invading the tear ducts of the infants eyes, leading to dry eyes. d. This ointment prevents the infants eyelids from sticking together and helps the infant see.

B (The nurse should explain that prophylactic erythromycin ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal and chlamydial infection that potentially could have been acquired from the birth canal. This prophylactic ophthalmic ointment is not instilled to prevent dry eyes and has no bearing on vision other than to protect against infection that may lead to vision problems.)

14. The nurse is completing a physical examination of the newborn 24 hours after birth. Which component of the evaluation is correct? a. The parents are excused to reduce their normal anxiety. b. The nurse can gauge the neonates maturity level by assessing his or her general appearance. c. Once often neglected, blood pressure is now routinely checked. d. When the nurse listens to the neonates heart, the S1 and S2 sounds can be heard; the S1sound is somewhat higher in pitch and sharper than the S2 sound.

B (The nurse is looking at skin color, alertness, cry, head size, and other features. The parents presence actively involves them in child care and gives the nurse the chance to observe their interactions. Blood pressure is not usually taken unless cardiac problems are suspected. The S2 sound is higher and sharper than the S1 sound.)

1. A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until the baby is frantically crying. Which feeding cue would indicate that the baby is ready to eat? a.Waves her arms in the air b.Makes sucking motions c.Has the hiccups d.Stretches out her legs straight

B (Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding readiness cues. Waving her arms in the air, having the hiccups, and stretching out her extremities are not typical feeding readiness cues.)

15. The nurse is teaching new parents about metabolic screening for the newborn. Which statement is most helpful to these clients? a. All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b. Federal law prohibits newborn genetic testing without parental consent. c. If genetic screening is performed before the infant is 24 hours old, then it should be repeated at age 1 to 2 weeks. d. Hearing screening is now mandated by federal law.

C (If testing is performed before the infant is 24 hours old, then genetic screening should be repeated when the infant is 1 to 2 weeks old. All states test for PKU and hypothyroidism but not for other genetic defects. Federal law mandates newborn genetic screening; however, parents can decline the testing. A waiver should be signed, and a notation made in the infants medical record. Federal law does not mandate screening for hearing problems; however, the majority of states have enacted legislation mandating newborn hearing screening. In the United States, the majority (95%) of infants are screened for hearing loss before discharge from the hospital.)

18. If the newborn has excess secretions, the mouth and nasal passages can be easily cleared with a bulb syringe. How should the nurse instruct the parents on the use of this instrument? a. Avoid suctioning the nares. b. Insert the compressed bulb into the center of the mouth. c. Suction the mouth first. d. Remove the bulb syringe from the crib when finished.

C (The mouth should always be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. After compressing the bulb, the syringe should be inserted into one side of the mouth. If it is inserted into the center of the mouth, then the gag reflex is likely to be initiated. When the infants cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The nasal passages should be suctioned one nostril at a time. The bulb syringe should remain in the crib so that it is easily accessible if needed again.)

4. What is the rationale for the administration of vitamin K to the healthy full-term newborn? a. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be administered by injection. c. Bacteria that synthesize vitamin K are not present in the newborns intestinal tract. d. The supply of vitamin K in the healthy full-term newborn is inadequate for at least 3 to 4 months and must be supplemented.

C (Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week. The maternal diet has no bearing on the amount of vitamin K found in the newborn. Vitamin K promotes the formation of clotting factors in the liver and is used for the prevention and treatment of hemorrhagic disease in the newborn. Vitamin K is not produced in the intestinal tract of the newborn until after microorganisms are introduced. By day 8, normal newborns are able to produce their own vitamin K.)

9. The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. This clinical finding may be indicative of what? a. Excessive saliva is a normal finding in the newborn. b. Excessive saliva in a neonate indicates that the infant is hungry. c. It may indicate that the infant has a tracheoesophageal fistula or esophageal atresia. d. Excessive saliva may indicate that the infant has a diaphragmatic hernia.

C (The presence of excessive saliva in a neonate should alert the nurse to the possibility of a tracheoesophageal fistula or esophageal atresia. Excessive salivation may not be a normal finding and should be further assessed for the possibility that the infant has an esophageal abnormality. The hungry infant reacts by making sucking motions, rooting, or making hand-to-mouth movements. The infant with a diaphragmatic hernia exhibits severe respiratory distress.)

3. A nurse is assessing a newborn girl who is 2 hours old. Which finding warrants a call to the health care provider? a. Blood glucose of 45 mg/dl using a Dextrostix screening method b. Heart rate of 160 beats per minute after vigorously crying c. Laceration of the cheek d. Passage of a dark black-green substance from the rectum

C (Accidental lacerations can be inflicted by a scalpel during a cesarean birth. They are most often found on the scalp or buttocks and may require an adhesive strip for closure. Parents would be overly concerned about a laceration on the cheek. A blood glucose level of 45 mg/dl and a heart rate of 160 beats per minute after crying are both normal findings that do not warrant a call to the physician. The passage of meconium from the rectum is an expected finding in the newborn.)

13. Which statement accurately describes an appropriate-for-gestational age (AGA) weight assessment? a. AGA weight assessment falls between the 25th and 75th percentiles for the infants age. b. AGA weight assessment depends on the infants length and the size of the newborns head. c. AGA weight assessment falls between the 10th and 90th percentiles for the infants age. d. AGA weight assessment is modified to consider intrauterine growth restriction (IUGR).

C (An AGA weight falls between the 10th and 90th percentiles for the infants age. The AGA range is larger than the 25th and 75th percentiles. The infants length and head size are measured, but these measurements do not affect the normal weight designation. IUGR applies to the fetus, not to the newborns weight.)

1. An infant boy was delivered minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. When should the Apgar assessment be performed? a. Only if the newborn is in obvious distress b. Once by the obstetrician, just after the birth c. At least twice, 1 minute and 5 minutes after birth d. Every 15 minutes during the newborns first hour after birth

C (Apgar scoring is performed at 1 minute and at 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts. The Apgar score is performed on all newborns. Apgar score can be completed by the nurse or the birth attendant. The Apgar score permits a rapid assessment of the newborns transition to extrauterine life. An interval of every 15 minutes is too long to wait to complete this assessment.)

22. A mother expresses fear about changing her infants diaper after he is circumcised. What does the client need to be taught to care for her newborn son? a.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. b.Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. c.Gently cleanse the penis with water and apply petroleum jelly around the glans after each diaper change. d.Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.

C (Gently cleansing the penis with water and applying petroleum jelly around the glans after each diaper change are appropriate techniques when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed with warm water to remove any urine or feces. If bleeding occurs, then the mother should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates are part of normal healing and cover the glans penis 24 hours after the circumcision; yellow exudates are not an infective process and should not be removed.)

11. What is the primary rationale for nurses wearing gloves when handling the newborn? a. To protect the baby from infection b. As part of the Apgar protocol c. To protect the nurse from contamination by the newborn d. Because the nurse has the primary responsibility for the baby during the first 2 hours

C (With the possibility of transmission of viruses such as HBV and the human immunodeficiency virus (HIV) through maternal blood and amniotic fluid, the newborn must be considered a potential contamination source until proven otherwise. As part of Standard Precautions, nurses should wear gloves when handling the newborn until blood and amniotic fluid are removed by bathing. Proper hand hygiene is all that is necessary to protect the infant from infection. Wearing gloves is not necessary to complete the Apgar score assessment. The nurse assigned to the mother-baby couplet has primary responsibility for the newborn, regardless of whether or not she wears gloves.)

6. A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. What is the most appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy? a. Applying an oil-based lotion to the newborns skin to prevent dying and cracking b. Limiting the newborns intake of milk to prevent nausea, vomiting, and diarrhea c. Placing eye shields over the newborns closed eyes d. Changing the newborns position every 4 hours

C (The infants eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should completely cover the eyes but not occlude the nares. Lotions and ointments should not be applied to the infant because they absorb heat and can cause burns. The lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration. Therefore, adequate hydration is important for the infant. The infant should be turned every 2 hours to expose all body surfaces to the light.)

19. As part of the infant discharge instructions, the nurse is reviewing the use of the infant car safety seat. Which information is the highest priority for the nurse to share? a. Infant carriers are okay to use until an infant car safety seat can be purchased. b. For traveling on airplanes, buses, and trains, infant carriers are satisfactory. c. Infant car safety seats are used for infants only from birth to 15 pounds. d. Infant car seats should be rear facing and placed in the back seat of the car.

D (An infant placed in the front seat could be severely injured by an air bag that deploys during an automobile accident. Infants should travel only in federally approved, rear-facing safety seats secured in the rear seat and only in federally approved safety seats even when traveling on a commercial vehicle. Infants should use a rear-facing car seat from birth to 20 pounds and to age 1 year.)

24. How should the nurse interpret an Apgar score of 10 at 1 minute after birth? a. The infant is having no difficulty adjusting to extrauterine life and needs no further testing. b. The infant is in severe distress and needs resuscitation. c. The nurse predicts a future free of neurologic problems. d. The infant is having no difficulty adjusting to extrauterine life but should be assessed again at 5 minutes after birth.

D (An initial Apgar score of 10 is a good sign of healthy adaptation; however, the test must be repeated at the 5-minute mark.)

29. Screening for critical congenital heart disease (CCHD) was added to the uniform screening panel in 2011. The nurse has explained this testing to the new mother. Which action by the nurse related to this test is correct? a. Screening is performed when the infant is 12 hours of age. b. Testing is performed with an electrocardiogram. c. Oxygen (O2) is measured in both hands and in the right foot. d. A passing result is an O2 saturation of 95%.

D (Screening is performed when the infant is between 24 and 48 hours of age. The test is performed using pulse oximetry technology. O2 is measured in the right hand and one foot. A passing result is an O2 saturation of 95% with a 3% absolute difference between upper and lower extremity readings.)

26. As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Based on the most recent evidence, which information is incorrect and should be discussed with parents? a. Prevent exposure to people with upper respiratory tract infections. b. Keep the infant away from secondhand smoke. c. Avoid loose bedding, water beds, and beanbag chairs. d. Place the infant on his or her abdomen to sleep.

D (The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome (SIDS). Grandmothers may encourage the new parents to place the infant on the abdomen; however, evidence shows back to sleep reduces SIDS. Infants are vulnerable to respiratory infections; therefore, infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding and in furniture that can trap them. Per AAP guidelines, infants should always be placed back to sleep and allowed tummy time to play to prevent plagiocephaly.)

3. A postpartum woman telephones the provider regarding her 5-day-old infant. The client is not scheduled for another weight check until the infant is 14 days old. The new mother is worried about whether breastfeeding is going well. Which statement indicates that breastfeeding is effective for meeting the infants nutritional needs? a.Sleeps for 6 hours at a time between feedings b.Has at least one breast milk stool every 24 hours c.Gains 1 to 2 ounces per week d.Has at least six to eight wet diapers per day

D (After day 4, when the mothers milk comes in, the infant should have six to eight wet diapers every 24 hours. Typically, infants sleep 2 to 4 hours between feedings, depending on whether they are being fed on a 2- to 3-hour schedule or cluster-fed. The infants sleep pattern is not an indication whether the infant is breastfeeding well. The infant should have a minimum of three bowel movements in a 24-hour period. Breastfed infants typically gain 15 to 30 g/day.)

20. A nurse is responsible for teaching new parents regarding the hygienic care of their newborn. Which instruction should the nurse provide regarding bathing? a. Avoid washing the head for at least 1 week to prevent heat loss. b. Sponge bathe the newborn for the first month of life. c. Cleanse the ears and nose with cotton-tipped swabs, such as Q-tips. d. Create a draft-free environment of at least 24 C (75 F) when bathing the infant.

D (The temperature of the room should be 24 C (75 F), and the bathing area should be free of drafts. To prevent heat loss, the infants head should be bathed before unwrapping and undressing. Tub baths may be initiated from birth. Ensure that the infant is fully immersed. Q-tips should not be used; they may cause injury. A corner of a moistened washcloth should be twisted into shape so that it can be used to cleanse the ears and nose.)

In providing counseling to pregnant women, the nurse can include information on the components of weight gain during pregnancy and the amount of weight that will be lost after the birth. Match the tissues contributing to maternal weight gain at 40 weeks of gestation with the approximate amount of weight gain in kilograms. a.0.5 to 1.8 b.1.8 to 2.3 c.3.2 to 3.9 d.0.9 e.0.9 to 1.1 1. Fetus 2. Placenta 3. Breast tissue 4. Amniotic fluid 5. Blood volume

1. ANS: C DIF: Cognitive Level: Analyze REF: p. 349 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Other components of tissue that contribute to weight gain include: an increase in uterine tissue (0.9), increased tissue fluid (1.4 to 2.3), and increased fat stores (1.8 to 2.7). Because lactation can help gradually reduce maternal energy stores, it also provides an opportunity to promote breastfeeding. 2. ANS: E DIF: Cognitive Level: Analyze REF: p. 349 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Other components of tissue that contribute to weight gain include: an increase in uterine tissue (0.9), increased tissue fluid (1.4 to 2.3), and increased fat stores (1.8 to 2.7). Because lactation can help gradually reduce maternal energy stores, it also provides an opportunity to promote breastfeeding. 3. ANS: A DIF: Cognitive Level: Analyze REF: p. 349 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Other components of tissue that contribute to weight gain include: an increase in uterine tissue (0.9), increased tissue fluid (1.4 to 2.3), and increased fat stores (1.8 to 2.7). Because lactation can help gradually reduce maternal energy stores, it also provides an opportunity to promote breastfeeding. 4. ANS: D DIF: Cognitive Level: Analyze REF: p. 349 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Other components of tissue that contribute to weight gain include: an increase in uterine tissue (0.9), increased tissue fluid (1.4 to 2.3), and increased fat stores (1.8 to 2.7). Because lactation can help gradually reduce maternal energy stores, it also provides an opportunity to promote breastfeeding. 5. ANS: B DIF: Cognitive Level: Analyze REF: p. 349 TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity NOT: Other components of tissue that contribute to weight gain include: an increase in uterine tissue (0.9), increased tissue fluid (1.4 to 2.3), and increased fat stores (1.8 to 2.7). Because lactation can help gradually reduce maternal energy stores, it also provides an opportunity to promote breastfeeding.

The BMI for a woman who is 51 kg before pregnancy and 1.57 m tall is _________.

20.7 A commonly used method of evaluating the appropriateness of weight for height is the BMI, which is calculated by the following formula. BMI = Weight in kg divided by the height in meters squared BMI = 51 kg ¸ (1.57 m)2 51 ¸ 2.47 = 20.69

9. A nurse is discussing the storage of breast milk with a mother whose infant is preterm and in the special care nursery. Which statement indicates that the mother requires additional teaching? a.I can store my breast milk in the refrigerator for 3 months. b.I can store my breast milk in the freezer for 3 months. c.I can store my breast milk at room temperature for 4 hours. d.I can store my breast milk in the refrigerator for 3 to 5 days.

A (Breast milk for the hospitalized infant can be stored in the refrigerator for only 8 days, not for 3 months. Breast milk can be stored in the freezer for 3 months, in a deep freezer for 6 months, or at room temperature for 4 hours. Human milk for the healthy or preterm hospitalized infant can be kept in the refrigerator for up to 8 days or in the freezer for up to 3 months, but only for 4 hours or less at room temperature.)

10. A new mother asks the nurse what the experts say about the best way to feed her infant. Which recommendation of the American Academy of Pediatrics (AAP) regarding infant nutrition should be shared with this client? a.Infants should be given only human milk for the first 6 months of life. b.Infants fed on formula should be started on solid food sooner than breastfed infants. c.If infants are weaned from breast milk before 12 months, then they should receive cows milk, not formula. d.After 6 months, mothers should shift from breast milk to cows milk.

A (Breastfeeding and human milk should also be the sole source of milk for the first 12 months, not for only the first 6 months. Infants should be started on solids when they are ready, usually at 6 months, whether they start on formula or breast milk. If infants are weaned from breast milk before 12 months, then they should receive iron-fortified formula, not cows milk.)

11. Which statement is the best rationale for recommending formula over breastfeeding? a.Mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. b.Mother lacks confidence in her ability to breastfeed. c.Other family members or care providers also need to feed the baby. d.Mother sees bottle feeding as more convenient.

A (Breastfeeding is contraindicated when mothers have certain viruses, tuberculosis, are undergoing chemotherapy, or are using or abusing drugs. Some women lack confidence in their ability to produce breast milk of adequate quantity or quality. The key to encouraging these mothers to breastfeed is anticipatory guidance beginning as early as possible during the pregnancy. A major barrier for many women is the influence of family and friends. She may view formula feeding as a way to ensure that the father and other family members can participate. Each encounter with the family is an opportunity for the nurse to educate, dispel myths, and clarify information regarding the benefits of breastfeeding. Many women see bottle feeding as more convenient and less embarrassing than breastfeeding. They may also see breastfeeding as incompatible with an active social life. Although modesty issues related to feeding the infant in public may exist, these concerns are not legitimate reasons to formula-feed an infant. Often, the decision to formula feed rather than breastfeed is made without complete information regarding the benefits of breastfeeding.)

29. A new mother asks whether she should feed her newborn colostrum, because it is not real milk. What is the nurses most appropriate answer? a.Colostrum is high in antibodies, protein, vitamins, and minerals. b.Colostrum is lower in calories than milk and should be supplemented by formula. c.Giving colostrum is important in helping the mother learn how to breastfeed before she goes home. d.Colostrum is unnecessary for newborns.

A (Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Supplementation is not necessary and will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge; however, the importance of the colostrum to the infant is the top priority. Colostrum provides immunities and enzymes necessary to cleanse the gastrointestinal system, among other things.)

2. A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle feeding. Which statement regarding bottle feeding using commercially prepared infant formulas might influence their choice? a.Bottle feeding using a commercially prepared formula increases the risk that the infant will develop allergies. b.Bottle feeding helps the infant sleep through the night. c.Commercially prepared formula ensures that the infant is getting iron in a form that is easily absorbed. d.Bottle feeding requires that multivitamin supplements be given to the infant.

A (Exposure to cows milk poses a risk of developing allergies, eczema, and asthma. Newborns should be fed during the night, regardless of the feeding method. Iron is better absorbed from breast milk than from formula. Commercial formulas are designed to meet the nutritional needs of the infant and to resemble breast milk. No supplements are necessary.)

13. The nurse should be cognizant of which statement regarding the unique qualities of human breast milk? a.Frequent feedings during predictable growth spurts stimulate increased milk production. b.Milk of preterm mothers is the same as the milk of mothers who gave birth at term. c.Milk at the beginning of the feeding is the same as the milk at the end of the feeding. d.Colostrum is an early, less concentrated, less rich version of mature milk.

A (Growth spurts (at 10 days, 3 weeks, 6 weeks, and 3 months) usually last 24 to 48 hours, after which the infants resume normal feeding. The milk of mothers of preterm infants is different from that of mothers of full-term infants to meet the needs of these newborns. Milk changes composition during feeding. The fat content of the milk increases as the infant feeds. Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals (but not fat).)

7. Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them regarding pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? a.Premature infants more easily digest breast milk than formula. b.A glass of wine just before pumping will help reduce stress and anxiety. c.The mother should only pump as much milk as the infant can drink. d.The mother should pump every 2 to 3 hours, including during the night.

A (Human milk is the ideal food for preterm infants, with benefits that are unique, in addition to those benefits received by full-term, healthy infants. Greater physiologic stability occurs with breastfeeding, compared with formula feeding. Consumption of alcohol during lactation is approached with caution. Excessive amounts can have serious effects on the infant and can adversely affect the mothers milk ejection reflex. To establish an optimal milk supply, the most appropriate instruction for the mother should be to pump 8 to 10 times a day for 10 to 15 minutes on each breast.)

14. A nurse providing couplet care should understand the issue of nipple confusion. In which situation might this condition occur? a.Breastfeeding babies receive supplementary bottle feedings. b.Baby is too abruptly weaned. c.Pacifiers are used before breastfeeding is established. d.Twins are breastfed together.

A (Nipple confusion can result when babies go back and forth between bottles and breasts, especially before breastfeeding is established in 3 to 4 weeks; bottle feeding and breastfeeding require different skills. Abrupt weaning can be distressing to the mother and/or baby but should not lead to nipple confusion. Pacifiers used before breastfeeding is established can be disruptive but do not lead to nipple confusion. Breastfeeding twins require some logistical adaptations but should not lead to nipple confusion.)

3. The Baby Friendly Hospital Initiative endorsed by the World Health Organization (WHO) and the United Nations Childrens Fund (UNICEF) was founded to encourage institutions to offer optimal levels of care for lactating mothers. Which actions are included in the Ten Steps to Successful Breastfeeding for Hospitals? (Select all that apply.) a.Give newborns no food or drink other than breast milk. b.Have a written breastfeeding policy that is communicated to all staff members. c.Help mothers initiate breastfeeding within hour of childbirth. d.Give artificial teats or pacifiers as necessary. e.Return infants to the nursery at night.

A, B, C (No artificial teats or pacifiers (also called dummies or soothers) should be given to breastfeeding infants. Although pacifiers have been linked to a reduction in SIDs, they should not be introduced until the infant is 3 to 4 weeks old and breastfeeding is well established. No other food or drink should be given to the newborn unless medically indicated. The breastfeeding policy should be routinely communicated to all health care staff members. All staff should be trained in the skills necessary to maintain this policy. Breastfeeding should be initiated within hour of childbirth, and all mothers need to be shown how to maintain lactation even if separated from their babies. The facility should practice rooming in and keep mothers and babies together 24 hours a day.)

1. Which actions are examples of appropriate techniques to wake a sleepy infant for breastfeeding? (Select all that apply.) a.Unwrapping the infant b.Changing the diaper c.Talking to the infant d.Slapping the infants hands and feet e.Applying a cold towel to the infants abdomen

A, B, C (Unwrapping the infant, changing the diaper, and talking to the infant are appropriate techniques to use when trying to wake a sleepy infant. The parent can rub, never slap, the infants hands or feet to wake the infant. Applying a cold towel to the infants abdomen may lead to cold stress in the infant. The parent may want to apply a cool cloth to the infants face to wake the infant.)

2. A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. Which findings should the nurse include in the discussion? (Select all that apply.) a.Breast tenderness b.Warmth in the breast c.Area of redness on the breast often resembling the shape of a pie wedge d.Small white blister on the tip of the nipple e.Fever and flulike symptoms

A, B, C, E (Breast tenderness, warmth in the breast, redness on the breast, and fever and flulike symptoms are commonly associated with mastitis and should be included in the nurses discussion of mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis but is commonly seen in women who have a plugged milk duct.)

5. The AAP recommends pasteurized donor milk for preterm infants if the mothers own milk in not available. Which statements regarding donor milk and milk banking are important for the nurse to understand and communicate to her client? (Select all that apply.) a.All milk bank donors are screened for communicable diseases. b.Internet milk sharing is an acceptable source for donor milk. c.Donor milk may be given to transplant clients. d.Donor milk is used in neonatal intensive care units (NICUs) for severely low-birth-weight infants only. e.Donor milk may be used for children with immunoglobulin A (IgA) deficiencies.

A, C, E (Because of the antiinfective and growth promotion properties for donor milk, donor milk is highly recommended for preterm and sick infants, as well as for term newborns. Human donor milk has also been used for older children with short gut syndrome, immunodeficiencies, metabolic disorders, or congenital anomalies. Human donor milk has also been used in the adult populationposttransplant clients and for those with colitis, ulcers, or cirrhosis of the liver. Some mothers acquire milk through Internet-based or community-based milk sharing. The U.S. Food and Drug Administration (FDA) has issued a warning regarding this practice. Samples of milk from these sources are higher in contaminants and infectious disease. A milk bank that belongs to the Human Milk Banking Association of North America should always be used for donor milk. All donors are scrupulously screened, and the milk is tested to determine its safety for use.)

The nurse has formulated a diagnosis of Imbalanced nutrition: Less than body requirements for the client. Which goal is most appropriate for this client to obtain? a.Gain a total of 30 pounds. b.Consistently take daily supplements. c.Decrease her intake of snack foods. d.Increase her intake of complex carbohydrates.

ANS: A A weight gain of 30 pounds is one indication that the client has gained a sufficient amount for the nutritional needs of pregnancy. A daily supplement is not the best goal for this client and does not meet the basic need of proper nutrition during pregnancy. Decreasing snack foods may be needed and should be assessed; however, assessing weight gain is the best method of monitoring nutritional intake for this pregnant client. Although increasing the intake of complex carbohydrates is important for this client, monitoring the weight gain should be the end goal.

Which alteration in the FHR pattern would indicate the potential need for an amnioinfusion? a.Variable decelerations b.Late decelerations c.Fetal bradycardia d.Fetal tachycardia

ANS: A Amnioinfusion is used during labor to either dilute meconium-stained amniotic fluid or supplement the amount of amniotic fluid to reduce the severity of variable FHR decelerations caused by cord compression. Late decelerations are unresponsive to amnioinfusion. Amnioinfusion is not appropriate for the treatment of fetal bradycardia and has no bearing on fetal tachycardia.

What is the most likely cause for early decelerations in the fetal heart rate (FHR) pattern? a.Altered fetal cerebral blood flow b.Umbilical cord compression c.Uteroplacental insufficiency d.Spontaneous rupture of membranes

ANS: A Early decelerations are the fetus' response to fetal head compression; these are considered benign, and interventions are not necessary. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the FHR unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.

Which clinical finding or intervention might be considered the rationale for fetal tachycardia to occur? a.Maternal fever b.Umbilical cord prolapse c.Regional anesthesia d.Magnesium sulfate administration

ANS: A Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result from maternal or fetal infection. Umbilical cord prolapse, regional anesthesia, and the administration of magnesium sulfate will each more likely result in fetal bradycardia, not tachycardia.

Which client would not be a suitable candidate for internal EFM? a.Client who still has intact membranes b.Woman whose fetus is well engaged in the pelvis c.Pregnant woman who has a comorbidity of obesity d.Client whose cervix is dilated to 4 to 5 cm

ANS: A For internal EFM, the membranes must have ruptured and the cervix must be dilated at least 2 to 3 cm. The presenting part must be low enough to allow placement of the spiral electrode necessary for internal EFM. The accuracy of EFM is not affected by maternal size. However, evaluating fetal well-being using external EFM may be more difficult on an obese client. The client whose cervix is dilated to 4 to 5 cm is indeed a candidate for internal monitoring.

Which information regarding protein in the diet of a pregnant woman is most helpful to the client? a.Many protein-rich foods are also good sources of calcium, iron, and B vitamins. b.Many women need to increase their protein intake during pregnancy. c.As with carbohydrates and fat, no specific recommendations exist for the amount of protein in the diet. d.High-protein supplements can be used without risk by women on macrobiotic diets.

ANS: A Good sources for protein, such as meat, milk, eggs, and cheese, have a lot of calcium and iron. Most women already eat a high-protein diet and do not need to increase their intake. Protein is sufficiently important that specific servings of meat and dairy are recommended. High-protein supplements are not recommended because they have been associated with an increased incidence of preterm births.

A pregnant woman reports that she is still playing tennis at 32 weeks of gestation. Which recommendation would the nurse make for this particular client after a tennis match? a.Drink several glasses of fluid. b.Eat extra protein sources such as peanut butter. c.Enjoy salty foods to replace lost sodium. d.Consume easily digested sources of carbohydrate.

ANS: A If no medical or obstetric problems contraindicate physical activity, then pregnant women should get 30 minutes of moderate physical exercise daily. Liberal amounts of fluid should be consumed before, during, and after exercise because dehydration can trigger premature labor. The woman's caloric intake should be sufficient to meet the increased needs of pregnancy and the demands of exercise.

Which guidance might the nurse provide for a client with severe morning sickness? a.Trying lemonade and potato chips b.Drinking plenty of fluids early in the day c.Immediately brushing her teeth after eating d.Never snacking before bedtime

ANS: A Interestingly, some women can tolerate tart or salty foods when they are nauseated. Lemonade and potato chips are an ideal combination. The woman should avoid drinking too much when nausea is most likely, but she should increase her fluid levels later in the day when she feels better. The woman should avoid brushing her teeth immediately after eating. A small snack of cereal and milk or yogurt before bedtime may help the stomach in the morning.

While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the FHR for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. What is the nurse's first priority? a.Change the woman's position. b.Notify the health care provider. c.Assist with amnioinfusion d.Insert a scalp electrode.

ANS: A Late FHR decelerations may be caused by maternal supine hypotension syndrome. These decelerations are usually corrected when the woman turns onto her side to displace the weight of the gravid uterus from the vena cava. If the fetus does not respond to primary nursing interventions for late decelerations, then the nurse should continue with subsequent intrauterine resuscitation measures and notify the health care provider. An amnioinfusion may be used to relieve pressure on an umbilical cord that has not prolapsed. The FHR pattern associated with this situation most likely will reveal variable decelerations. Although a fetal scalp electrode will provide accurate data for evaluating the well-being of the fetus, it is not a nursing intervention that will alleviate late decelerations nor is it the nurse's first priority.

Which nursing intervention would result in an increase in maternal cardiac output? a.Change in position b.Oxytocin administration c.Regional anesthesia d.IV analgesic

ANS: A Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This position reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and to avoid the supine position. Oxytocin administration, regional anesthesia, and IV analgesic may reduce maternal cardiac output.

What are the legal responsibilities of the perinatal nurses? a.Correctly interpreting FHR patterns, initiating appropriate nursing interventions, and documenting the outcomes b.Greeting the client on arrival, assessing her status, and starting an IV line c.Applying the external fetal monitor and notifying the health care provider d.Ensuring that the woman is comfortable

ANS: A Nurses who care for women during childbirth are legally responsible for correctly interpreting FHR patterns, initiating appropriate nursing interventions based on those patterns, and documenting the outcomes of those interventions. Greeting the client on arrival, assessing her, and starting an IV line are activities that should be performed when any client arrives to the maternity unit. The nurse is not the only one legally responsible for performing these functions. Applying the external fetal monitor and notifying the health care provider is a nursing function that is part of the standard of care for all obstetric clients and falls within the registered nurse's scope of practice. Everyone caring for the pregnant woman should ensure that both she and her support partner are comfortable.

Which nutrient's recommended dietary allowance (RDA) is higher during lactation than during pregnancy? a.Energy (kcal) b.Iron c.Vitamin A d.Folic acid

ANS: A Nutrient needs for energy—protein, calcium, iodine, zinc, B vitamins, and vitamin C—remain higher during lactation than during pregnancy. The need for iron is not higher during lactation than during pregnancy. A lactating woman does not have a greater requirement for vitamin A than a nonpregnant woman. Folic acid requirements are the highest during the first trimester of pregnancy.

Which statement best describes a normal uterine activity pattern in labor? a.Contractions every 2 to 5 minutes b.Contractions lasting approximately 2 minutes c.Contractions approximately 1 minute apart d.Contraction intensity of approximately 500 mm Hg with relaxation at 50 mm Hg

ANS: A Overall contraction frequency generally ranges from two to five contractions per 10 minutes of labor, with lower frequencies during the first stage and higher frequencies observed during the second stage. Contraction duration remains fairly stable throughout the first and second stages, ranging from 45 to 80 seconds, generally not exceeding 90 seconds. Contractions 1 minute apart are occurring too often and would be considered an abnormal labor pattern. The intensity of uterine contractions generally ranges from 25 to 50 mm Hg in the first stage of labor and may rise to more than 80 mm Hg in the second stage.

After the nurse completes nutritional counseling for a pregnant woman, she asks the client to repeat the instructions to assess the client's understanding. Which statement indicates that the client understands the role of protein in her pregnancy? a."Protein will help my baby grow." b."Eating protein will prevent me from becoming anemic." c."Eating protein will make my baby have strong teeth after he is born." d."Eating protein will prevent me from being diabetic."

ANS: A Protein is the nutritional element basic to growth. An adequate protein intake is essential to meeting the increasing demands of pregnancy. These demands arise from the rapid growth of the fetus; the enlargement of the uterus, mammary glands, and placenta; the increase in the maternal blood volume; and the formation of the amniotic fluid. Iron intake prevents anemia. Calcium intake is needed for fetal bone and tooth development. Glycemic control is needed in those with diabetes; protein is one nutritional factor to consider for glycemic control but not the primary role of protein intake.

Which nutritional recommendation regarding fluids is accurate? a.A woman's daily intake should be six to eight glasses of water, milk, and/or juice. b.Coffee should be limited to no more than 2 cups, but tea and cocoa can be consumed without worry. c.Of the artificial sweeteners, only aspartame has not been associated with any maternity health concerns. d.Water with fluoride is especially encouraged because it reduces the child's risk of tooth decay.

ANS: A Six to eight glasses is still the standard for fluids; however, they should be the right fluids. All beverages containing caffeine, including tea, cocoa, and some soft drinks, should be avoided or should be consumed only in limited amounts. Artificial sweeteners, including aspartame, have no ill effects on the normal mother or fetus. However, mothers with phenylketonuria (PKU) should avoid aspartame. Although no evidence indicates that prenatal fluoride consumption reduces childhood tooth decay, fluoride still helps the mother.

What is the correct placement of the tocotransducer for effective EFM? a.Over the uterine fundus b.On the fetal scalp c.Inside the uterus d.Over the mother's lower abdomen

ANS: A The tocotransducer monitors uterine activity and should be placed over the fundus, where the most intensive uterine contractions occur. The tocotransducer is for external use.

Part of the nurse's role is assisting with pushing and positioning. Which guidance should the nurse provide to her client in active labor? a.Encourage the woman's cooperation in avoiding the supine position. b.Advise the woman to avoid the semi-Fowler position. c.Encourage the woman to hold her breath and tighten her abdominal muscles to produce a vaginal response. d.Instruct the woman to open her mouth and close her glottis, letting air escape after the push.

ANS: A The woman should maintain a side-lying position. The semi-Fowler position is the recommended side-lying position with a lateral tilt to the uterus. Encouraging the woman to hold her breath and tighten her abdominal muscles is the Valsalva maneuver, which should be avoided. Both the mouth and glottis should be open, allowing air to escape during the push.

The client has delivered by urgent caesarean birth for fetal compromise. Umbilical cord gases were obtained for acid-base determination. The pH is 6.9, partial pressure of carbon dioxide (PCO2) is elevated, and the base deficit is 11 mmol/L. What type of acidemia is displayed by the infant? a.Respiratory b.Metabolic c.Mixed d.Turbulent

ANS: A These findings are evidence of respiratory acidemia. Metabolic acidemia is expressed by a pH <7.20, normal carbon dioxide pressure, and a base excess of 12 mmol/L. Mixed acidemia is evidenced by a pH <7.20, elevated carbon dioxide pressure, and a base excess of 12 mmol/L. There is no such finding as turbulent acidemia.

A nurse caring for a woman in labor should understand that absent or minimal variability is classified as either abnormal or indeterminate. Which condition related to decreased variability is considered benign? a.Periodic fetal sleep state b.Extreme prematurity c.Fetal hypoxemia d.Preexisting neurologic injury

ANS: A When the fetus is temporarily in a sleep state, minimal variability is present. Periodic fetal sleep states usually last no longer than 30 minutes. A woman in labor with extreme prematurity may display a FHR pattern of minimal or absent variability. Abnormal variability may also be related to fetal hypoxemia and metabolic acidemia. Congenital anomalies or a preexisting neurologic injury may also result in absent or minimal variability. Other possible causes might be central nervous system (CNS) depressant medications, narcotics, or general anesthesia.

In assessing the immediate condition of the newborn after birth, a sample of cord blood may be a useful adjunct to the Apgar score. Cord blood is then tested for pH, carbon dioxide, oxygen, and base deficit or excess. Which clinical situation warrants this additional testing? (Select all that apply.) a.Low 5-minute Apgar score b.Intrauterine growth restriction (IUGR) c.Maternal thyroid disease d.Intrapartum fever e.Vacuum extraction

ANS: A, B, C, D The American College of Obstetricians and Gynecologists (ACOG) suggests obtaining cord blood values in all of these clinical situations except for vacuum extractions deliveries. Cord blood gases should also be performed for multifetal pregnancies or abnormal FHR tracings. Samples can be drawn from both the umbilical artery and the umbilical vein. Results may indicate that fetal compromise has occurred.

Most women with uncomplicated pregnancies can use the nurse as their primary source for nutritional information. However, the nurse or midwife may need to refer a client to a registered dietitian for in-depth nutritional counseling. Which conditions would require such a consultation? (Select all that apply.) a.Preexisting or gestational illness such as diabetes b.Ethnic or cultural food patterns c.Obesity d.Vegetarian diets e.Multifetal pregnancy

ANS: A, B, C, D The nurse should be especially aware that conditions such as diabetes can require in-depth dietary planning and evaluation. To prevent issues with hypoglycemia and hyperglycemia, as well as an increased risk for perinatal morbidity and mortality, the client with a preexisting or gestational illness would benefit from a referral to a dietitian. Consultation with a dietitian may ensure that cultural food beliefs are congruent with modern knowledge of fetal development and that adjustments can be made to ensure that all nutritional needs are met. The obese pregnant client may be under the misapprehension that, because of her excess weight, little or no weight gain is necessary. According to the Institute of Medicine, a client with a BMI in the obese range should gain at least 7 kg to ensure a healthy outcome. This client may require in-depth counseling on the optimal food choices. The vegetarian client needs to have her dietary intake carefully assessed to ensure that the optimal combination of amino acids and protein intake is achieved. Very strict vegetarians (vegans) who consume only plant products may also require vitamin B and mineral supplementation. A multifetal pregnancy can be managed by increasing the number of servings of complex carbohydrates and proteins.

A client states that she plans to breastfeed her newborn infant. What guidance would be useful for this new mother? a.The mother's intake of vitamin C, zinc, and protein can now be lower than during pregnancy. b.Caffeine consumed by the mother accumulates in the infant, who may be unusually active and wakeful. c.Critical iron and folic acid levels must be maintained. d.Lactating women can go back to their prepregnant caloric intake.

ANS: B A lactating woman needs to avoid consuming too much caffeine. Vitamin C, zinc, and protein levels need to be moderately higher during lactation than during pregnancy. The recommendations for iron and folic acid are lower during lactation. Lactating women should consume approximately 500 kcal more than their prepregnancy intake, at least 1800 kcal daily overall.

Assessment of a woman's nutritional status includes a diet history, medication regimen, physical examination, and relevant laboratory tests. Which finding might require consultation to a higher level of care? a.Oral contraceptive use may interfere with the absorption of iron. b.Illnesses that have created nutritional deficits, such as PKU, may require nutritional care before conception. c.The woman's socioeconomic status and educational level are not relevant to her examination; they are the province of the social worker. d.Testing for diabetes is the only nutrition-related laboratory test most pregnant women need.

ANS: B A registered dietitian can help with therapeutic diets. Oral contraceptive use may interfere with the absorption of folic acid. Iron deficiency can appear if placement of an intrauterine device (IUD) results in blood loss. A woman's finances can affect her access to good nutrition; her education (or lack thereof) can influence the nurse's teaching decisions. The nutrition-related laboratory test that pregnant women usually need is a screen for anemia.

Which action is the highest priority for the nurse when educating a pregnant adolescent? a.Emphasize the need to eliminate common teenage snack foods because they are high in fat and sodium. b.Determine the weight gain needed to meet adolescent growth, and add 35 pounds. c.Suggest that she not eat at fast-food restaurants to avoid foods of poor nutritional value. d.Realize that most adolescents are unwilling to make dietary changes during pregnancy.

ANS: B Adolescents should gain in the upper range of the recommended weight gain. They also need to gain weight that would be expected for their own normal growth. Changes in the diet should be kept at a minimum. Snack foods can be included in moderation, and other foods can be added to make up for lost nutrients. Eliminating fast foods would make the adolescent appear different to her peers. The client should be taught to choose foods that add needed nutrients. Adolescents are willing to make changes; however, they still have the need to be similar to their peers.

Many clients are concerned about the increased levels of mercury in fish and may be reluctant to include this source of nutrients in their diet. What is the best advice for the nurse to provide? a.Canned white tuna is a preferred choice. b.Shark, swordfish, and mackerel should be avoided. c.Fish caught in local waterways is the safest. d.Salmon and shrimp contain high levels of mercury.

ANS: B As a precaution, the pregnant client should avoid eating shark, swordfish, and mackerel, as well as the less common tilefish. High levels of mercury can harm the developing nervous system of the fetus. Assisting the client in understanding the differences between numerous sources of mercury is essential for the nurse. A pregnant client may eat as much as 12 ounces a week of canned light tuna; however, canned white, albacore, or tuna steaks contain higher levels of mercury and should be limited to no more than 6 ounces per week. Pregnant women and mothers of young children should check with local advisories about the safety of fish caught by families and friends in nearby bodies of water. If no information is available, then these fish sources should be avoided, limited to less than 6 ounces per week, or the only fish consumed that week. Commercially caught fish that is low in mercury includes salmon, shrimp, pollock, or catfish. The pregnant client may eat up to 12 ounces of commercially caught fish per week. Additional information on levels of mercury in commercially caught fish is available at www.cfsan.fda.gov.

What three measures should the nurse implement to provide intrauterine resuscitation? a.Call the provider, reposition the mother, and perform a vaginal examination. b.Turn the client onto her side, provide oxygen (O2) via face mask, and increase intravenous (IV) fluids. c.Administer O2 to the mother, increase IV fluids, and notify the health care provider. d.Perform a vaginal examination, reposition the mother, and provide O2 via face mask.

ANS: B Basic interventions for the management of any abnormal FHR pattern include administering O2 via a nonrebreather face mask at a rate of 8 to 10 L/min, assisting the woman onto a side-lying (lateral) position, and increasing blood volume by increasing the rate of the primary IV infusion. The purpose of these interventions is to improve uterine blood flow and intervillous space blood flow and to increase maternal oxygenation and cardiac output. The term intrauterine resuscitation is sometimes used to refer to these interventions. If these interventions do not quickly resolve the abnormal FHR issue, then the primary provider should be immediately notified.

A new client and her partner arrive on the labor, delivery, recovery, and postpartum (LDRP) unit for the birth of their first child. The nurse applies the electronic fetal monitor (EFM) to the woman. Her partner asks you to explain what is printing on the graph, referring to the EFM strip. He wants to know what the baby's heart rate should be. What is the nurse's best response? a."Don't worry about that machine; that's my job." b."The baby's heart rate will fluctuate in response to what is happening during labor." c."The top line graphs the baby's heart rate, and the bottom line lets me know how strong the contractions are." d."Your physician will explain all of that later."

ANS: B Explaining what indicates a normal FHR teaches the partner about fetal monitoring and provides support and information to alleviate his fears. Telling the partner not to worry discredits his feelings and does not provide the teaching he is requesting. Telling the partner that the graph indicates how strong the contractions are provides inaccurate information and does not address the partner's concerns about the FHR. The EFM graphs the frequency and duration of the contractions, not their intensity. Nurses should take every opportunity to provide teaching to the client and her family, especially when information is requested.

To prevent gastrointestinal (GI) upset, when should a pregnant client be instructed to take the recommended iron supplements? a.On a full stomach b.At bedtime c.After eating a meal d.With milk

ANS: B Iron supplements taken at bedtime may reduce GI upset and should be taken at bedtime if abdominal discomfort occurs when iron supplements are taken between meals. Iron supplements are best absorbed if they are taken when the stomach is empty. Bran, tea, coffee, milk, and eggs may reduce absorption.

Which statement made by a lactating woman leads the nurse to believe that the client might have lactose intolerance? a."I always have heartburn after I drink milk." b."If I drink more than a cup of milk, I usually have abdominal cramps and bloating." c."Drinking milk usually makes me break out in hives." d."Sometimes I notice that I have bad breath after I drink a cup of milk."

ANS: B Lactose intolerance, which is an inability to digest milk sugar because of a lack of the enzyme lactose in the small intestine, is a problem that interferes with milk consumption. Milk consumption may cause abdominal cramping, bloating, and diarrhea in such people, although many lactose-intolerant individuals can tolerate small amounts of milk without symptoms. A woman with lactose intolerance is more likely to experience bloating and cramping, not heartburn. A client who breaks out in hives after consuming milk is more likely to have a milk allergy and should be advised to simply brush her teeth after consuming dairy products.

Which characteristic correctly matches the type of deceleration with its likely cause? a.Early deceleration—umbilical cord compression b.Late deceleration—uteroplacental insufficiency c.Variable deceleration—head compression d.Prolonged deceleration—unknown cause

ANS: B Late deceleration is caused by uteroplacental insufficiency. Early deceleration is caused by head compression. Variable deceleration is caused by umbilical cord compression. Prolonged deceleration has a variety of either benign or critical causes.

Maternal nutritional status is an especially significant factor of the many that influence the outcome of pregnancy. Why is this the case? a.Maternal nutritional status is extremely difficult to adjust because of an individual's ingrained eating habits. b.Adequate nutrition is an important preventive measure for a variety of problems. c.Women love obsessing about their weight and diets. d.A woman's preconception weight becomes irrelevant.

ANS: B Nutritional status draws so much attention not only for its effect on a healthy pregnancy and birth but also because significant changes are within relatively easy reach. Pregnancy is a time when many women are motivated to learn about adequate nutrition and make changes to their diet that will benefit their baby. Pregnancy is not the time to begin a weight loss diet. Clients and their caregivers should still be concerned with appropriate weight gain.

During labor a fetus displays an average FHR of 135 beats per minute over a 10-minute period. Which statement best describes the status of this fetus? a.Bradycardia b.Normal baseline heart rate c.Tachycardia d.Hypoxia

ANS: B The baseline FHR is measured over 10 minutes; a normal range is 110 to 160 beats per minute. Bradycardia is a FHR less than 110 beats per minute for 10 minutes or longer. Tachycardia is a FHR higher than 160 beats per minutes for 10 minutes or longer. Hypoxia is an inadequate supply of oxygen; no indication of hypoxia exists with a baseline FHR in the normal range.

What is the most likely cause for variable FHR decelerations? a.Altered fetal cerebral blood flow b.Umbilical cord compression c.Uteroplacental insufficiency d.Fetal hypoxemia

ANS: B Variable FHR decelerations can occur at any time during the uterine contracting phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow results in early decelerations in the FHR. Uteroplacental insufficiency results in late decelerations in the FHR. Fetal hypoxemia initially results in tachycardia and then bradycardia if hypoxia continues.

Foodborne illnesses can cause adverse effects for both mother and fetus. The nurse is in an ideal position to evaluate the client's knowledge regarding steps to prevent a foodborne illness. The nurse asks the client to "teach back" the fours simple steps of food preparation. What are they? (Select all that apply.) a.Purchase b.Clean c.Separate d.Cook e.Chill

ANS: B, C, D, E According to the U.S. Food and Drug Administration (2013), the "four simple steps" are: • Clean: Frequently cleanse hands, food preparation surfaces, and utensils. • Separate: Avoid contact among raw meat, fish, or poultry and other foods that will not be cooked before consumption. • Cook: Cook foods to the proper temperature. • Chill: Properly store foods, and promptly refrigerate. DIF: Cognitive Level: Apply REF: p. 361 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

A pregnant woman's diet consists almost entirely of whole grain breads and cereals, fruits, and vegetables. Which dietary requirement is the nurse most concerned about? a.Calcium b.Protein c.Vitamin B12 d.Folic acid

ANS: C A pregnant woman's diet is consistent with that followed by a strict vegetarian (vegan). Vegans consume only plant products. Because vitamin B12 is found in foods of animal origin, this diet is deficient in vitamin B12. Depending on the woman's food choices, a pregnant woman's diet may be adequate in calcium. Protein needs can be sufficiently met by a vegetarian diet. The nurse should be more concerned with the woman's intake of vitamin B12 attributable to her dietary restrictions. Folic acid needs can be met by enriched bread products.

Pregnant adolescents are at greater risk for decreased BMI and "fad" dieting with which condition? a.Obesity b.Gestational diabetes c.Low-birth-weight babies d.High-birth-weight babies

ANS: C Adolescents tend to have lower BMIs. In addition, the fetus and the still-growing mother appear to compete for nutrients. These factors, along with inadequate weight gain, lend themselves to a higher incidence of low-birth-weight babies. Obesity is associated with a higher-than-normal BMI. Unless the teenager has type 1 diabetes, an adolescent with a low BMI is less likely to develop gestational diabetes. High-birth-weight or large-for-gestational age (LGA) babies are most often associated with gestational diabetes.

In which clinical situation would the nurse most likely anticipate a fetal bradycardia? a.Intraamniotic infection b.Fetal anemia c.Prolonged umbilical cord compression d.Tocolytic treatment using terbutaline

ANS: C Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension. Intraamniotic infection, fetal anemia, and tocolytic treatment using terbutaline would most likely result in fetal tachycardia.

With regard to weight gain during pregnancy, the nurse should be aware of which important information? a.In pregnancy, the woman's height is not a factor in determining her target weight. b.Obese women may have their health concerns, but their risk of giving birth to a child with major congenital defects is the same as with women of normal weight. c.Women with inadequate weight gain have an increased risk of delivering a preterm infant with intrauterine growth restriction (IUGR). d.Greater than expected weight gain during pregnancy is almost always attributable to old-fashioned overeating.

ANS: C IUGR is associated with women with inadequate weight gain. The primary factor in making a weight gain recommendation is the appropriateness of the prepregnancy weight for the woman's height. Obese women are twice as likely as women of normal weight to give birth to a child with major congenital defects. Overeating is only one of several likely causes.

Which minerals and vitamins are usually recommended as a supplement in a pregnant client's diet? a.Fat-soluble vitamins A and D b.Water-soluble vitamins C and B6 c.Iron and folate d.Calcium and zinc

ANS: C Iron should generally be supplemented, and folic acid supplements are often needed because folate is so important in pregnancy. Fat-soluble vitamins should be supplemented as a medical prescription, as vitamin D might be for lactose-intolerant women. Water-soluble vitamin C is sometimes naturally consumed in excess; vitamin B6 is prescribed only if the woman has a very poor diet; and zinc is sometimes supplemented. Most women get enough calcium.

The nurse who provides care to clients in labor must have a thorough understanding of the physiologic processes of maternal hypotension. Which outcome might occur if the interventions for maternal hypotension are inadequate? a.Early FHR decelerations b.Fetal arrhythmias c.Uteroplacental insufficiency d.Spontaneous rupture of membranes

ANS: C Low maternal blood pressure reduces placental blood flow during uterine contractions, resulting in fetal hypoxemia. Maternal hypotension does not result in early FHR decelerations nor is it associated with fetal arrhythmias. Spontaneous rupture of membranes is not a result of maternal hypotension.

The nurse observes a sudden increase in variability on the ERM tracing. Which class of medications may cause this finding? a.Narcotics b.Barbiturates c.Methamphetamines d.Tranquilizers

ANS: C Narcotics, barbiturates, and tranquilizers may be causes of decreased variability; whereas methamphetamines may cause increased variability.

The labor and delivery nurse is preparing a client who is severely obese (bariatric) for an elective cesarean birth. Which piece of specialized equipment will not likely be needed when providing care for this pregnant woman? a.Extra-long surgical instruments b.Wide surgical table c.Temporal thermometer d.Increased diameter blood pressure cuff

ANS: C Obstetricians today are seeing an increasing number of morbidly obese pregnant women weighing 400, 500, and 600 pounds. To manage their conditions and to meet their logistical needs, a new medical subspecialty,bariatric obstetrics, has arisen. Extra-wide blood pressure cuffs, scales that can accommodate up to 880 pounds, and extra-wide surgical tables designed to hold the weight of these women are used. Special techniques for ultrasound examination and longer surgical instruments for cesarean birth are also required. A temporal thermometer can be used for a pregnant client of any size.

Which information related to a prolonged deceleration is important for the labor nurse to understand? a.Prolonged decelerations present a continuing pattern of benign decelerations that do not require intervention. b.Prolonged decelerations constitute a baseline change when they last longer than 5 minutes. c.A disruption to the fetal oxygen supply causes prolonged decelerations. d.Prolonged decelerations require the customary fetal monitoring by the nurse.

ANS: C Prolonged decelerations are caused by a disruption in the fetal oxygen supply. They usually begin as a reflex response to hypoxia. If the disruption continues, then the fetal cardiac tissue, itself, will become hypoxic, resulting in direct myocardial depression of the FHR. Prolonged decelerations can be caused by prolonged cord compression, uteroplacental insufficiency, or perhaps sustained head compression. Prolonged decelerations lasting longer than 10 minutes are considered a baseline change that may require intervention. A prolonged deceleration is a visually apparent decrease (may be either gradual or abrupt) in the FHR of at least 15 beats per minute below the baseline and lasting longer than 2 minutes but shorter than 10 minutes. Nurses should immediately notify the physician or nurse-midwife and initiate appropriate treatment of abnormal patterns when they see prolonged decelerations.

While obtaining a diet history, the nurse might be told that the expectant mother has cravings for ice chips, cornstarch, and baking soda. Which nutritional problem does this behavior indicate? a.Preeclampsia b.Pyrosis c.Pica d.Purging

ANS: C The consumption of foods low in nutritional value or of nonfood substances (e.g., dirt, laundry starch) is called pica. Preeclampsia is a vasospastic disease process encountered after 20 weeks of gestation. Characteristics of preeclampsia include increasing hypertension, proteinuria, and hemoconcentration. Pyrosis is a burning sensation in the epigastric region, otherwise known as heartburn. Purging refers to self-induced vomiting after consuming large quantities of food.

If a client's normal prepregnancy diet contains 45 g of protein daily, how many more grams of protein should she consume per day during pregnancy? a.5 b.10 c.25 d.30

ANS: C The recommended intake of protein for the pregnant woman is 70 g. Therefore, additional protein intakes of 5, 10, or 15 g would be inadequate to meet protein needs during pregnancy. A protein intake of 30 g is more than would be necessary and would add extra calories.

What is a distinct advantage of external EFM? a.The ultrasound transducer can accurately measure short-term variability and beat-to-beat changes in the FHR. b.The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions. c.The tocotransducer is especially valuable for measuring uterine activity during the first stage of labor. d.Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions.

ANS: C The tocotransducer is valuable for measuring uterine activity during the first stage of labor and is especially true when the membranes are intact. Short-term variability and beat-to-beat changes cannot be measured with this technology. The tocotransducer cannot measure and record the intensity of uterine contractions. The transducer must be repositioned when the woman or the fetus changes position.

A 27-year-old pregnant woman had a preconceptual body mass index (BMI) of 19. What is this client's total recommended weight gain during pregnancy? a.20 kg (44 lb) b.16 kg (35 lb) c.12.5 kg (27.5 lb) d.10 kg (22 lb)

ANS: C This woman has a normal BMI and should gain 11.5 to 16 kg during her pregnancy. A weight gain of 20 kg (44 lb) is unhealthy for most women; a weight gain of 16 kg (35 lb) is at the high end of the range of weight this woman should gain in her pregnancy; and a weight gain of 10 kg (22 lb) is appropriate for an obese woman. This woman has a normal BMI, which indicates that her weight is average.

The nurse providing care for a high-risk laboring woman is alert for late FHR decelerations. Which clinical finding might be the cause for these late decelerations? a.Altered cerebral blood flow b.Umbilical cord compression c.Uteroplacental insufficiency d.Meconium fluid

ANS: C Uteroplacental insufficiency results in late FHR decelerations. Altered fetal cerebral blood flow results in early FHR decelerations. Umbilical cord compression results in variable FHR decelerations. Meconium-stained fluid may or may not produce changes in the FHR, depending on the gestational age of the fetus and whether other causative factors associated with fetal distress are present.

A woman has come to the clinic for preconception counseling because she wants to start trying to get pregnant. Which guidance should she expect to receive? a."Discontinue all contraception now." b."Lose weight so that you can gain more during pregnancy." c."You may take any medications you have been regularly taking." d."Make sure you include adequate folic acid in your diet."

ANS: D A healthy diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. A woman's folate or folic acid intake is of particular concern in the periconception period. Neural tube defects are more common in infants of women with a poor folic acid intake. Depending on the type of contraception that she has been using, discontinuing all contraception at this time may not be appropriate. Advising this client to lose weight now so that she can gain more during pregnancy is also not appropriate advice. Depending on the type of medications the woman is taking, continuing to take them regularly may not be appropriate.

Which pregnant woman should strictly follow weight gain recommendations during pregnancy? a.Pregnant with twins b.In early adolescence c.Shorter than 62 inches or 157 cm d.Was 20 pounds overweight before pregnancy

ANS: D A weight gain of 5 to 9 kg will provide sufficient nutrients for the fetus. Overweight and obese women should be advised to lose weight before conception to achieve the best pregnancy outcomes. A higher weight gain in twin gestations may help prevent low birth weights. Adolescents need to gain weight toward the higher acceptable range, which provides for their own growth, as well as for fetal growth. In the past, women of short stature were advised to restrict their weight gain; however, evidence to support these guidelines has not been found.

Which definition of an acceleration in the fetal heart rate (FHR) is accurate? a.FHR accelerations are indications of fetal well-being when they are periodic. b.FHR accelerations are greater and longer in preterm gestations. c.FHR accelerations are usually observed with breech presentations when they are episodic. d.An acceleration in the FHR presents a visually apparent and abrupt peak.

ANS: D Acceleration of the FHR is defined as a visually apparent abrupt (only to peak 30 seconds) increase in the FHR above the baseline rate. Periodic accelerations occur with uterine contractions and are usually observed with breech presentations. Episodic accelerations occur during fetal movement and are indications of fetal well-being. Preterm accelerations peak at 10 beats per minute above the baseline and last for at least 10 seconds.

The major source of nutrients in the diet of a pregnant woman should be composed of what? a.Simple sugars b.Fats c.Fiber d.Complex carbohydrates

ANS: D Complex carbohydrates supply the pregnant woman with vitamins, minerals, and fiber. The most common simple carbohydrate is table sugar, which is a source of energy but does not provide any nutrients. Fats provide 9 kcal in each gram, in contrast to carbohydrates and proteins, which provide only 4 kcal in each gram. Fiber is primarily supplied by complex carbohydrates.

A woman in the 34th week of pregnancy reports that she is very uncomfortable because of heartburn. Which recommendation would be appropriate for this client? a.Substitute other calcium sources for milk in her diet. b.Lie down after each meal. c.Reduce the amount of fiber she consumes. d.Eat five small meals daily.

ANS: D Eating small, frequent meals may help with heartburn, nausea, and vomiting. Substituting other calcium sources for milk, lying down after eating, and reducing fiber intake are inappropriate dietary suggestions for all pregnant women and do not alleviate heartburn.

What physiologic change occurs as the result of increasing the infusion rate of nonadditive IV fluids? a.Maintaining normal maternal temperature b.Preventing normal maternal hypoglycemia c.Increasing the oxygen-carrying capacity of the maternal blood d.Expanding maternal blood volume

ANS: D Filling the mother's vascular system increases the amount of blood available to perfuse the placenta and may correct hypotension. Increasing fluid volume may alter the maternal temperature only if she is dehydrated. Most IV fluids for laboring women are isotonic and do not provide extra glucose. Oxygen-carrying capacity is increased by adding more red blood cells.

Which vitamins or minerals may lead to congenital malformations of the fetus if taken in excess by the mother? a.Zinc b.Vitamin D c.Folic acid d.Vitamin A

ANS: D If taken in excess, vitamin A causes a number of problems. An analog of vitamin A appears in prescribed acne medications, which must not be taken during pregnancy. Zinc, vitamin D, and folic acid are all vital to good maternity and fetal health and are highly unlikely to be consumed in excess.

Which FHR finding is the most concerning to the nurse who is providing care to a laboring client? a.Accelerations with fetal movement b.Early decelerations c.Average FHR of 126 beats per minute d.Late decelerations

ANS: D Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. Late FHR decelerations are considered ominous if they are persistent and left uncorrected. Accelerations with fetal movement are an indication of fetal well-being. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet; they are not generally a concern during normal labor. An FHR finding of 126 beats per minute is normal and not a concern.

The nurse is using intermittent auscultation (IA) to locate the fetal heartbeat. Which statement regarding this method of surveillance is accurate? a.The nurse can be expected to cover only two or three clients when IA is the primary method of fetal assessment. b.The best course is to use the descriptive terms associated with EFM when documenting results. c.If the heartbeat cannot be immediately found, then a shift must be made to EFM. d.Ultrasound can be used to find the FHR and to reassure the mother if the initial difficulty is a factor.

ANS: D Locating fetal heartbeats often takes time. Mothers can be verbally reassured and reassured by viewing the ultrasound pictures if that device is used to help locate the heartbeat. When used as the primary method of fetal assessment, IA requires a nurse-to-client ratio of one to one. Documentation should use only terms that can be numerically defined; the usual visual descriptions of EFM are inappropriate

The perinatal nurse realizes that an FHR that is tachycardic, bradycardic, has late decelerations, or loss of variability is nonreassuring and is associated with which condition? a.Hypotension b.Cord compression c.Maternal drug use d.Hypoxemia

ANS: D Nonreassuring FHR patterns are associated with fetal hypoxemia. Fetal bradycardia may be associated with maternal hypotension. Variable FHR decelerations are associated with cord compression. Maternal drug use is associated with fetal tachycardia.

A pregnant woman's diet may not meet her increased need for folates. Which food is a rich source of this nutrient? a.Chicken b.Cheese c.Potatoes d.Green leafy vegetables

ANS: D Sources of folates include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Chicken and cheese are excellent sources of protein but are poor sources for folates. Potatoes contain carbohydrates and vitamins and minerals but are poor sources for folates.

Nutrition is an alterable and important preventive measure for a variety of potential problems such as low birth weight and prematurity. While completing the physical assessment of the pregnant client, the nurse is able to evaluate the client's nutritional status by observing a number of physical signs. Which physical sign indicates to the nurse that the client has unmet nutritional needs? a.Normal heart rate, rhythm, and blood pressure b.Bright, clear, and shiny eyes c.Alert and responsive with good endurance d.Edema, tender calves, and tingling

ANS: D The physiologic changes of pregnancy may complicate the interpretation of physical findings. Lower extremity edema often occurs when caloric and protein deficiencies are present; however, edema in the lower extremities may also be a common physical finding during the third trimester. Completing a thorough health history and physical assessment and requesting further laboratory testing, if indicated, are essential for the nurse. The malnourished pregnant client may display rapid heart rate, abnormal rhythm, enlarged heart, and elevated blood pressure. A client receiving adequate nutrition will have bright, shiny eyes with no sores and moist, pink membranes. Pale or red membranes, dryness, infection, dull appearance of the cornea, or blue sclerae are signs of poor nutrition. A client who is alert and responsive with good endurance is well nourished. A listless, cachectic, easily fatigued, and tired presentation would be an indication of a poor nutritional status.

In which situation would the nurse be called on to stimulate the fetal scalp? a.As part of fetal scalp blood sampling b.In response to tocolysis c.In preparation for fetal oxygen saturation monitoring d.To elicit an acceleration in the FHR

ANS: D The scalp can be stimulated using digital pressure during a vaginal examination. Fetal scalp blood sampling involves swabbing the scalp with disinfectant before a sample is collected. The nurse stimulates the fetal scalp to elicit an acceleration of the FHR. Tocolysis is relaxation of the uterus. Fetal oxygen saturation monitoring involves the insertion of a sensor.

The nurse is evaluating the EFM tracing of the client who is in active labor. Suddenly, the FHR drops from its baseline of 125 down to 80 beats per minute. The mother is repositioned, and the nurse provides oxygen, increased IV fluids, and performs a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should the nurse take next? a.Call for help. b.Insert a Foley catheter. c.Start administering Pitocin. d.Immediately notify the care provider.

ANS: D To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluids, and provide oxygen. If oxytocin is infusing, then it should be discontinued. If the FHR does not resolve, then the primary care provider should be immediately notified. Inserting a Foley catheter is an inappropriate nursing action. If the FHR were to continue in a nonreassuring pattern, then a cesarean section could be warranted, which would require a Foley catheter. However, the physician must make that determination. The administration of Pitocin may place additional stress on the fetus.

Which action is the first priority for the nurse who is assessing the influence of culture on a client's diet? a.Evaluate the client's weight gain during pregnancy. b.Assess the socioeconomic status of the client. c.Discuss the four food groups with the client. d.Identify the food preferences and methods of food preparation common to the client's culture.

ANS: D Understanding the client's food preferences and how she prepares food will assist the nurse in determining whether the client's culture is adversely affecting her nutritional intake. An evaluation of a client's weight gain during pregnancy should be included for all clients, not only for clients from different cultural backgrounds. The socioeconomic status of the client may alter the nutritional intake but not the cultural influence. Teaching the food groups to the client should come after assessing her food preferences.

19. The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would provide conflicting information to the client? a.Women who breastfeed have a decreased risk of breast cancer. b.Breastfeeding is an effective method of birth control. c.Breastfeeding increases bone density. d.Breastfeeding may enhance postpartum weight loss.

B (Although breastfeeding delays the return of fertility, it is not an effective birth control method. Women who breastfeed have a decreased risk of breast cancer, an increase in bone density, and a possibility of faster postpartum weight loss.)

28. Which instruction should the nurse provide to reduce the risk of nipple trauma? a.Limit the feeding time to less than 5 minutes. b.Position the infant so the nipple is far back in the mouth. c.Assess the nipples before each feeding. d.Wash the nipples daily with mild soap and water.

B (If the infants mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, thus causing trauma to the area. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need and will also limit access to the higher-fat hindmilk. Assessing the nipples for trauma is important; however, this action alone will not prevent sore nipples. Soap can be drying to the nipples and should be avoided during breastfeeding.)

23. The breastfeeding mother should be taught a safe method to remove the breast from the babys mouth. Which suggestion by the nurse is most appropriate? a.Slowly remove the breast from the babys mouth when the infant has fallen asleep and the jaws are relaxed. b.Break the suction by inserting your finger into the corner of the infants mouth. c.A popping sound occurs when the breast is correctly removed from the infants mouth. d.Elicit the Moro reflex to wake the baby and remove the breast when the baby cries.

B (Inserting a finger into the corner of the babys mouth between the gums to break the suction avoids trauma to the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple that makes it sore. A popping sound indicates improper removal of the breast from the babys mouth and may cause cracks or fissures in the breast. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended.)

17. A new father is ready to take his wife and newborn son home. He proudly tells the nurse who is discharging them that within the next week he plans to start feeding the infant cereal between breastfeeding sessions. Which information should the nurse provide regarding this feeding plan? a.Feeding solid foods before your son is 4 to 6 months old may decrease your sons intake of sufficient calories. b.Feeding solid foods between breastfeeding sessions before your son is 4 to 6 months old will lead to an early cessation of breastfeeding. c.Your feeding plan will help your son sleep through the night. d.Feeding solid foods before your son is 4 to 6 months old will limit his growth.

B (The introduction of solid foods before the infant is 4 to 6 months of age may result in overfeeding and decreased intake of breast milk. The belief that feeding solid foods helps infants sleep through the night is untrue. The proper balance of carbohydrate, protein, and fat for an infant to grow properly is in the breast milk or formula.)

20. While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the client accordingly. Which statement as part of this discussion would be incorrect? a.Breastfeeding requires fewer supplies and less cumbersome equipment. b.Breastfeeding saves families money. c.Breastfeeding costs employers in terms of time lost from work. d.Breastfeeding benefits the environment.

C (Actually, less time is lost to work by breastfeeding mothers, in part because infants are healthier. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment. It saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal.)

27. As the nurse assists a new mother with breastfeeding, the client asks, If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better? What is the nurses best response? a.More calories b.Essential amino acids c.Important immunoglobulins d.More calcium

C (Breast milk contains immunoglobulins that protect the newborn against infection. The calorie count of formula and breast milk is approximately the same. All the essential amino acids are in both formula and breast milk; however, the concentrations may differ. Calcium levels are higher in formula than in breast milk, which can cause an excessively high renal solute load if the formula is not properly diluted.)

25. How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day? a.50 to 65 b.75 to 90 c.95 to 110 d.150 to 200

C (For the first 3 months, the infant needs 110 kcal/kg/day. At ages 3 to 6 months, the requirement is 100 kcal/kg/day. This level decreases slightly to 95 kcal/kg/day from 6 to 9 months and increases again to 100 kcal/kg/day until the baby reaches 12 months.)

12. Which statement regarding the nutrient needs of breastfed infants is correct? a.Breastfed infants need extra water in hot climates. b.During the first 3 months, breastfed infants consume more energy than formula-fed infants. c.Breastfeeding infants should receive oral vitamin D drops daily during at least the first 2 months. d.Vitamin K injections at birth are not necessary for breastfed infants.

C (Human milk contains only small amounts of vitamin D. All infants who are breastfed should receive 400 International Units of vitamin D each day. Neither breastfed nor formula-fed infants need to be fed water, not even in very hot climates. During the first 3 months, formula-fed infants consume more energy than breastfed infants and therefore tend to grow more rapidly. Vitamin K shots are required for all infants because the bacteria that produce it are absent from the babys stomach at birth.)

15. Which information should the nurse provide to a breastfeeding mother regarding optimal self-care? a.She will need an extra 1000 calories a day to maintain energy and produce milk. b.She can return to prepregnancy consumption patterns of any drinks as long as she gets enough calcium. c.She should avoid trying to lose large amounts of weight. d.She must avoid exercising because it is too fatiguing.

C (Large weight loss releases fat-stored contaminants into her breast milk, and it also involves eating too little and/or exercising too much. A breastfeeding mother needs to add only 200 to 500 extra calories to her diet to provide the extra nutrients for her infant. However, this is true only if she does not drink alcohol, limits coffee to no more than two cups (including caffeine in chocolate, tea, and some sodas, too), and carefully reads the herbal tea ingredients. Although she needs her rest, moderate exercise is healthy.)

8. A new mother wants to be sure that she is meeting her daughters needs while feeding the baby commercially prepared infant formula. The nurse should evaluate the mothers knowledge about appropriate infant feeding techniques. Which statement by the client reassures the nurse that correct learning has taken place? a.Since reaching 2 weeks of age, I add rice cereal to my daughters formula to ensure adequate nutrition. b.I warm the bottle in my microwave oven. c.I burp my daughter during and after the feeding as needed. d.I refrigerate any leftover formula for the next feeding.

C (Most infants swallow air when fed from a bottle and should be given a chance to burp several times during and after the feeding. Solid food should not be introduced to the infant for at least 4 to 6 months after birth. A microwave should never be used to warm any food to be given to an infant. The heat is not distributed evenly, which may pose a risk of burning the infant. Any formula left in the bottle after the feeding should be discarded because the infants saliva has mixed with it.)

26. Which action by the mother will initiate the milk ejection reflex (MER)? a.Wearing a firm-fitting bra b.Drinking plenty of fluids c.Placing the infant to the breast d.Applying cool packs to her breast

C (Oxytocin, which causes the MER reflex, increases in response to nipple stimulation. A firm bra is important to support the breast; however, it will not initiate the MER reflex. Drinking plenty of fluids is necessary for adequate milk production, but adequate intake of water alone will not initiate the MER reflex. Cool packs to the breast will decrease the MER reflex.)

24. Which type of formula is not diluted with water, before being administered to an infant? a.Powdered b.Concentrated c.Ready-to-use d.Modified cows milk

C (Ready-to-use formula can be poured directly from the can into the babys bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform in consistency. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cows milk is more difficult for the infant to digest and is not recommended, even if it is diluted.)

21. In assisting the breastfeeding mother to position the baby, which information regarding positioning is important for the nurse to keep in mind? a.The cradle position is usually preferred by mothers who had a cesarean birth. b.Women with perineal pain and swelling prefer the modified cradle position. c.Whatever the position used, the infant is belly to belly with the mother. d.While supporting the head, the mother should push gently on the occiput.

C (The infant naturally faces the mother, belly to belly. The football position is usually preferred after a cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.)

5. A breastfeeding woman develops engorged breasts at 3 days postpartum. What action will help this client achieve her goal of reducing the engorgement? a.Skip feedings to enable her sore breasts to rest. b.Avoid using a breast pump. c.Breastfeed her infant every 2 hours. d.Reduce her fluid intake for 24 hours.

C (The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. Skipping feedings may cause further swelling and discomfort. If the infant does not adequately feed and empty the breast, then the mother may pump to extract the milk and relieve some of the discomfort. Dehydration further irritates swollen breast tissue.)

6. At a 2-month well-baby examination, it was discovered that an exclusively breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse develop a feeding plan for the infant to increase his weight gain. Which change in dietary management will assist the client in meeting this goal? a.Begin solid foods. b.Have a bottle of formula after every feeding. c.Have one extra breastfeeding session every 24 hours. d.Start iron supplements.

C (Usually the solution to slow weight gain is to improve the feeding technique. Position and the latch-on technique are evaluated, and adjustments are made. Adding a feeding or two within a 24-hour period might help. Solid foods should not be introduced to an infant for at least 4 to 6 months. Bottle feeding may cause nipple confusion and may limit the supply of milk. Iron supplements have no bearing on weight gain.)

18. According to demographic research, which woman is least likely to breastfeed and therefore most likely to need education regarding the benefits and proper techniques of breastfeeding? a.Between 30 and 35 years of age, Caucasian, and employed part time outside the home b.Younger than 25 years of age, Hispanic, and unemployed c.Younger than 25 years of age, African-American, and employed full time outside the home d.35 years of age or older, Caucasian, and employed full time at home

C (Women least likely to breastfeed are typically younger than 25 years of age, have a lower income, are less educated, are employed full time outside the home, and are African-American.)

22. Nurses should be able to teach breastfeeding mothers the signs that the infant has correctly latched on. Which client statement indicates a poor latch? a.I feel a firm tugging sensation on my nipples but not pinching or pain. b.My baby sucks with cheeks rounded, not dimpled. c.My babys jaw glides smoothly with sucking. d.I hear a clicking or smacking sound.

D (The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. The tugging sensation without pinching is a good sign. Rounded cheeks are a positive indicator of a good latch. A smoothly gliding jaw also is a good sign.)

4. A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. How should the client be instructed to position the infant to facilitate correct latch-on? a.The infant should be positioned with his or her arms folded together over the chest. b.The infant should be curled up in a fetal position. c.The woman should cup the infants head in her hand. d.The infants head and body should be in alignment with the mother.

D (The infants head and body should be in correct alignment with the mother and the breast during latch-on and feeding. The infant should be facing the mother with his arms hugging the breast. The babys body should be held in correct alignment (i.e., ears, shoulder, and hips in a straight line) during feedings. The mother should support the babys neck and shoulders with her hand and not push on the occiput.)

16. A newly delivered mother who intends to breastfeed tells her nurse, I am so relieved that this pregnancy is over so that I can start smoking again. The nurse encourages the client to refrain from smoking. However, this new mother is insistent that she will resume smoking. How will the nurse adapt her health teaching with this new information? a.Smoking has little-to-no effect on milk production. b.No relationship exists between smoking and the time of feedings. c.The effects of secondhand smoke on infants are less significant than for adults. d.The mother should always smoke in another room.

D (The new mother should be encouraged not to smoke. If she continues to smoke, she should be encouraged to always smoke in another room, removed from the baby. Smoking may impair milk production. When the products of tobacco are broken down, they cross over into the breast milk. Tobacco also results in a reduction of the antiinfective properties of breast milk. Research supports the conclusion that mothers should not smoke within 2 hours before a feeding (AAP Committee on Drugs, 2001). The effects of secondhand smoke on infants include excessive crying, colic, upper respiratory infections, and an increased risk of sudden infant death syndrome (SIDS).)