Chapter 24: Newborn Nutrition and Feeding Perry: Maternal Child Nursing Care, 6th Edition, Chapter 23: Nursing Care of the Newborn and Family Perry: Maternal Child Nursing Care, 6th Edition, Chapter 22: Physiologic and Behavioral Adaptations of the N...

The physiologic changes that occur during the reversal of the processes of pregnancy are distinctive; however, they are normal. To provide care during this recovery period the nurse must synthesize knowledge regarding anticipated maternal changes and deviations from normal. Please match the vital signs finding that the after-birth nurse may encounter with the probable cause. a. Elevated temperature within the first 24 hours b. Rapid pulse c. Elevated temperature at 36 hours after birth d. Hypertension e. Hypoventilation 1. Puerperal sepsis 2. Unusually high epidural or spinal block 3. Dehydrating effects of labor 4. Hypovolemia resulting from hemorrhage 5. Excessive use of oxytocin

1. Puerperal sepsis-Elevated temperature at 36 hours after birth 2. Unusually high epidural or spinal block- Hypoventilation 3. Dehydrating effects of labor- Elevated temperature within the first 24 hours 4. Hypovolemia resulting from hemorrhage- Rapid pulse 5. Excessive use of oxytocin- Hypertension

PPH may be sudden and result in rapid blood loss. The nurse must be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss. Astute assessment of circulatory status can be done with noninvasive monitoring. Please match the type of noninvasive assessment that the RN would perform with the appropriate clinical manifestation or body system. a. Palpation b. Auscultation c. Inspection d. Observation e. Measurement 1. Pulse oximetry 2. Heart sounds 3. Arterial pulses 4. Skin color, temperature, turgor 5. Presence or absence of anxiety

1. Pulse oximetry- Measurement 2. Heart sounds- Auscultation 3. Arterial pulses- Palpation 4. Skin color, temperature, turgor- Inspection 5. Presence or absence of anxiety- Observation

The best way for the nurse to promote and support the maternal-infant bonding process is to: a. Help the mother identify her positive feelings toward the newborn. b. Encourage the mother to provide all newborn care. c. Assist the family with rooming-in. d. Return the newborn to the nursery during sleep periods.

c. Assist the family with rooming-in.

The nurse hears a primiparous woman talking to her son and telling him that his chin is just like his dad's chin. This woman's statement reflects: a. Mutuality. b. Synchrony. c. Claiming. d. Reciprocity.

c. Claiming.

Complicated bereavement occurs when, in multiple births, one child dies, and the other or others live. is a state in which the parents are ambivalent, as with abortion. is an extremely intense grief reaction that persists for a long time. is felt by the family of adolescent mothers who lose their babies.

is an extremely intense grief reaction that persists for a long time.

At 1 minute after birth, the nurse assesses the infant and notes a heart rate of 80 beats/min, some flexion of the extremities, a weak cry, grimacing, and a pink body with blue extremities. The nurse would calculate an Apgar score of _____________

5 Each of the five signs the nurse noted would score an Apgar of 1 for a total of 5. Signs include heart rate, respiratory effort, muscle tone, reflex irritability, and color. The highest possible Apgar score is 10.

Early after birth hemorrhage is defined as a blood loss greater than 500 mL in the first 24 hours after vaginal delivery. 750 mL in the first 24 hours after vaginal delivery. 1000 mL in the first 48 hours after cesarean delivery. 1500 mL in the first 48 hours after cesarean delivery.

500 mL in the first 24 hours after vaginal delivery.

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

A ("That's meconium, which is your baby's first stool. It's 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 initiation of feeding. "That means your baby is bleeding internally" is not accurate. "Oh, don't worry about that. It's okay" is not an appropriate statement. It is belittling to the father and does not educate him about the normal stool patterns of his daughter.)

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 the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is: a. "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." b. "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." c. "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." d. "Your baby will get cold stressed easily and needs to be bundled up at all times."

A ("Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him" is an accurate statement. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is 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, but 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.)

The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is: a. Vision. b. Hearing. c. Smell. d. Taste.

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

As related to the normal functioning of the renal system in newborns, nurses should be aware that: a. The pediatrician should be notified if the newborn has not voided in 24 hours. b. Breastfed infants likely will void more often during the first days after birth. c. "Brick dust" or blood on a diaper is always cause to notify the physician. d. Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.

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 void less during this time because the mother's breast milk has not come in yet. Brick dust may be uric acid crystals; blood spotting could be caused by withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if there is no apparent cause of bleeding. Weight loss from fluid loss may take 14 days to regain.)

A new mother states that her infant must be cold because the baby's hands and feet are blue. The nurse explains that this is a common and temporary condition called: a. Acrocyanosis. b. Erythema neonatorum. c. Harlequin color. d. Vernix caseosa.

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 appears intermittently over the first 7 to 10 days. Erythema toxicum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. Half of the body is pale, and the other half is ruddy or bluish red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering.)

The nurse should immediately alert the physician when: a. The infant is dusky and turns cyanotic when crying. b. Acrocyanosis is present at age 1 hour. c. The infant's blood glucose level is 45 mg/dL. d. The infant goes into a deep sleep at age 1 hour.

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. This is within normal range for a newborn. Infants enter the period of deep sleep when they are about 1 hour old.)

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

A (Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. 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 objects or surfaces.)

A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: a. May occur with spontaneous vaginal birth. b. Happens only as the result of a forceps or vacuum delivery. c. Is present immediately after birth. d. Will gradually absorb over the first few months of life.

A (Bleeding may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. The soft, irreducible fullness does not pulsate or bulge when the infant cries. Low forceps and other difficult extractions may result in bleeding. However, cephalhematomas can also occur spontaneously. The swelling may appear unilaterally or bilaterally and is usually minimal or absent at birth. It increases over the first 2 to 3 days of life. Cephalhematomas disappear gradually over 2 to 3 weeks. A less common condition results in calcification of the hematoma, which may persist for months.)

Part of the health assessment of a newborn is observing the infant's breathing pattern. A full-term newborn's breathing pattern is predominantly: a. Abdominal with synchronous chest movements. b. Chest breathing with nasal flaring. c. Diaphragmatic with chest retraction. d. Deep with a regular rhythm.

A (In normal infant respiration the chest and abdomen rise synchronously, and breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is a sign of respiratory distress. Infant breaths are not deep with a regular rhythm.)

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). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. Ability to respond to discrete stimuli while asleep a. Habituation b. Orientation c. Range of state d. Autonomic stability e. Regulation of state

A (NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.)

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

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.)

With regard to the respiratory development of the newborn, nurses should be aware that: a. The first gasping breath is an exaggerated respiratory reaction within 1 minute of birth. b. Newborns must expel the fluid from the respiratory system within a few minutes of birth. c. Newborns are instinctive mouth breathers. d. Seesaw respirations are no cause for concern in the first hour after birth.

A (The first breath produces a cry. Newborns continue to expel fluid for the first hour of life. Newborns are natural nose breathers; they may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.)

The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called: a. Vernix caseosa. b. Surfactant. c. Caput succedaneum. d. Acrocyanosis.

A (This protection, 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 that results in a blue coloring.)

The self-destruction of excess hypertrophied tissue in the uterus is called: a.Autolysis. c.Afterpain. b.Subinvolution. d.Diastasis.

A Autolysis is caused by a decrease in hormone levels. Subinvolution is failure of the uterus to return to a nonpregnant state. Afterpain is caused by uterine cramps 2 to 3 days after birth. Diastasis refers to the separation of muscles.

Which woman is at greatest risk for early postpartum hemorrhage (PPH)? A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress. A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor. A primigravida in spontaneous labor with preterm twins.

A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced.

RH0 immune globulin will be ordered after birth if which situation occurs? A. Mother Rh-, baby Rh + B. Mother Rh-, baby Rh- C. Mother Rh+, baby Rh+ D. Mother Rh +, baby Rh-

A. Mother Rh-, baby Rh +

The laboratory results for a after birth woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30% How would the nurse best interpret these data? A. Rubella vaccine should be given B. A blood transfusion is necessary C. Rh immune globulin is necessary within 72 hours of birth D. A Kleihauer- Betke test should be performed

A. Rubella vaccine should be given

Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins: A. at the time of admission to the nurse's unit B. when the infant is presented to the mother at birth C. during the first visit with the physician in the unit D. when the take- home information packet is given to the couple

A. at the time of admission to the nurse's unit

In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she: A. has recovered from epidural or spinal anesthesia B. has hidden bleeding underneath her. C. has regained some flexibility D. is a candidate to go home after 6 hours

A. has recovered from epidural or spinal anesthesia

A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to: a. Improve the accuracy of blood loss estimation, which usually is a subjective assessment. b. Determine which pad is best. c. Demonstrate that other nurses usually underestimate blood loss. d. Reveal to the nurse supervisor that one of them needs some time off.

A. improve the accuracy of blood loss estimation, which usually is a subjective assessment

In many hospitals, new mothers are routinely presented with gift bags containing samples of infant formula. This practice: A. is inconsistent with the Baby-Friendly Hospital Initiative. B. promotes longer periods of breastfeeding C. is perceived as supportive to both bottle-feeding and breastfeeding mothers D. Is associated with earlier cessation of breastfeeding

A. is inconsistent with the Baby- Friendly Hospital Initiative

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal, and the estimated blood loss (EBL) was approximately 1500 mL. When assessing the woman's vital signs, the nurse would be concerned to see: a. Temperature 37.9° C, heart rate 120, respirations 20, blood pressure (BP) 90/50. b. Temperature 37.4° C, heart rate 88, respirations 36, BP 126/68. c. temperature 38° C, heart rate 80, respirations 16, BP 110/80. d. Temperature 36.8° C, heart rate 60, respirations 18, BP 140/90.

ANS: A An EBL of 1500 mL with tachycardia and hypotension suggests hypovolemia caused by excessive blood loss. An increased respiratory rate of 36 may be secondary to pain from the birth. Temperature may increase to 38° C during the first 24 hours as a result of the dehydrating effects of labor. A BP of 140/90 is slightly elevated, which may be caused by the use of oxytocic medications.

Knowing that the condition of the new mother's breasts will be affected by whether she is breastfeeding, nurses should be able to tell their clients all the following statements except: a.Breast tenderness is likely to persist for about a week after the start of lactation. b.As lactation is established, a mass may form that can be distinguished from cancer by its position shift from day to day. c.In nonlactating mothers colostrum is present for the first few days after childbirth. d.If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

ANS: A Breast tenderness should persist for 24 to 48 hours after lactation begins. That movable, noncancerous mass is a filled milk sac. Colostrum is present for a few days whether the mother breastfeeds or not. A mother who does not want to breastfeed should also avoid stimulating her nipples.

Which finding 12 hours after birth requires further assessment? a.The fundus is palpable two fingerbreadths above the umbilicus. b.The fundus is palpable at the level of the umbilicus. c.The fundus is palpable one fingerbreadth below the umbilicus. d.The fundus is palpable two fingerbreadths below the umbilicus.

ANS: A The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. A fundus that is palpable at or below the level of the umbilicus is a normal finding for a patient who is 12 hours postpartum. Palpation of the fundus 2 fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate.

Several changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed? a.Nail brittleness b.Darker pigmentation of the areolae and linea nigra c.Striae gravidarum on the breasts, abdomen, and thighs d. Spider nevi

ANS: A The nails return to their prepregnancy consistency and strength. Some women have permanent darker pigmentation of the areolae and linea nigra. Striae gravidarum (stretch marks) usually do not completely disappear. For some women spider nevi persist indefinitely.

1. A woman gave birth to an infant boy 10 hours ago. Where would the nurse expect to locate this woman's fundus? a. One centimeter above the umbilicus b. Two centimeters below the umbilicus c. Midway between the umbilicus and the symphysis pubis d. Nonpalpable abdominally

ANS: A Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. The fundus descends about 1 to 2 cm every 24 hours. Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. By the sixth postpartum week the fundus normally is halfway between the symphysis pubis and the umbilicus. The fundus should be easily palpated using the maternal umbilicus as a reference point.

14. The best reason for recommending formula over breastfeeding is that: a. the mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. b. the mother lacks confidence in her ability to breastfeed. c. other family members or care providers also need to feed the baby. d. the mother sees bottle-feeding as more convenient.

ANS: A Breastfeeding is contraindicated when mothers have certain viruses, are undergoing chemotherapy, or are using/abusing illicit drugs. A lack of confidence, the need for others to feed the baby, and the convenience of bottle-feeding are all honest reasons for not breastfeeding, although further education concerning the ease of breastfeeding and its convenience, benefits, and adaptability (expressing milk into bottles) could change some minds. In any case the nurse must provide information in a nonjudgmental manner and respect the mother's decision. Nonetheless, breastfeeding is definitely contraindicated when the mother has medical or drug issues of her own.

10. According to the recommendations of the American Academy of Pediatrics on infant nutrition: 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, they should receive cow's milk, not formula. d. after 6 months mothers should shift from breast milk to cow's milk.

ANS: A Breastfeeding/human milk should also be the sole source of milk for the second 6 months. Infants start 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, they should receive iron-fortified formula, not cow's milk.

30. A new mother asks whether she should feed her newborn colostrum, because it is not "real milk." The nurse's most appropriate answer is: 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.

ANS: 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; it 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.

3. 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 is most accurate? Bottle-feeding using commercially prepared infant formulas: a. increases the risk that the infant will develop allergies. b. helps the infant sleep through the night. c. ensures that the infant is getting iron in a form that is easily absorbed. d. requires that multivitamin supplements be given to the infant.

ANS: A Exposure to cow's milk poses a risk of developing allergies, eczema, and asthma. "Bottle-feeding using commercially prepared infant formulas helps the infant sleep through the night" is a false statement. Iron is better absorbed from breast milk than from formula. Commercial formulas are designed to meet the nutritional needs of the infant and resemble breast milk.

29. 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 about pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? a. A premature infant more easily digests breast milk than formula. b. A glass of wine just before pumping will help reduce stress and anxiety. c. The mother should pump only as much as the infant can drink. d. The mother should pump every 2 to 3 hours, including during the night.

ANS: A Human milk is the ideal food for preterm infants, with benefits that are unique in addition to those received by 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 mother's milk ejection reflex. To establish an optimal milk supply, the mother should be instructed to pump 8 to 10 times a day for 10 to 15 minutes on each breast.

9. The nurse is discussing storage of breast milk with a mother whose infant is preterm and in the special care unit. What statement would indicate that the mother needs 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 8 hours." d. "I can store my breast milk in the refrigerator for 3 to 5 days."

ANS: A If the mother states that she can store her breast milk in the refrigerator for 3 months, she needs additional teaching about safe storage. Breast milk can be stored at room temperature for 8 hours, in the refrigerator for 3 to 5 days, in the freezer for 3 months, or in a deep freezer for 6 to 12 months. It is accurate and does not require additional teaching if the mother states that she can store her breast milk in the freezer for 3 months, at room temperature for 8 hours, and in the refrigerator for 3 to 5 days.

3. A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: a. are benign if they disappear within 48 hours of birth. b. result from increased blood volume. c. should always be further investigated. d. usually occur with forceps delivery.

ANS: A Petechiae, or pinpoint hemorrhagic areas, 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 situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

12. With regard to umbilical cord care, nurses should be aware that: a. the stump can easily become infected. b. a nurse noting bleeding from the vessels of the cord 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.

ANS: 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 the bleeding does not stop, the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

7. When preparing to administer a hepatitis B vaccine to a newborn, the nurse should: a. obtain a syringe with a 25-gauge, 5/8-inch needle. b. confirm that the newborn's mother has been infected with the hepatitis B virus. c. assess the dorsogluteal muscle as the preferred site for injection. d. confirm that the newborn is at least 24 hours old.

ANS: A The hepatitis B vaccine should be administered with a 25-gauge, 5/8-inch needle. Hepatitis B vaccination is recommended for all infants. If the infant is born to an infected mother who is a chronic carrier, hepatitis vaccine and hepatitis B immune globulin should be administered within 12 hours of birth. Hepatitis B vaccine should be given in the vastus lateralis muscle. Hepatitis B vaccine can be given at birth.

21. 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.

ANS: 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 home visits are expensive, they are not available in all geographic areas. 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.

16. Nurses providing nutritional instruction should be cognizant of the uniqueness of human milk. Which statement is correct? a. Frequent feedings during predictable growth spurts stimulate increased milk production. b. The milk of preterm mothers is the same as the milk of mothers who gave birth at term. c. The 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.

ANS: A These growth spurts (10 days, 3 weeks, 6 weeks, 3 months) usually last 24 to 48 hours, after which 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).

1. Examples of appropriate techniques to wake a sleepy infant for breastfeeding include: (Select all that apply.) a. unwrapping the infant. b. changing the diaper. c. talking to the infant. d. slapping the infant's hands and feet. e. applying a cold towel to the infant's abdomen.

ANS: 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. Slapping the infant's hand and feet and applying a cold towel to the infant's abdomen are not appropriate. The parent can rub the infant's hands or feet to wake the infant. Applying a cold towel to the infant's abdomen may lead to cold stress in the infant. The parent may want to apply a cool cloth to the infant's face to wake the infant.

1. Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain management techniques include: (Select all that apply.) a. swaddling. b. nonnutritive sucking. c. skin-to-skin contact with the mother. d. sucrose. e. acetaminophen.

ANS: 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.

2. A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion? (Select all that apply.) a. Breast tenderness b. Warmth in the breast c. An area of redness on the breast often resembling the shape of a pie wedge d. A small white blister on the tip of the nipple e. Fever and flu-like symptoms

ANS: A, B, C, E Breast tenderness, breast warmth, breast redness, and fever and flu-like symptoms are commonly associated with mastitis and should be included in the nurse's discussion of mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis. It is commonly seen in women who have a plugged milk duct.

2. 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 American Academy of Pediatrics. Reasons for having this testing performed include: (Select all that apply.) a. prevention or reduction of developmental delay. b. reassurance for concerned new parents. c. early identification and treatment. d. helping the child communicate better. e. recommendation by the Joint Committee on Infant Hearing.

ANS: A, C, D, E New parents are often anxious regarding this test and the impending results; however, it is not the reason for the screening to be performed. Auditory screening is usually done before hospital discharge. It is important for the nurse to ensure that the infant receives the appropriate testing and that the test is fully explained to the parents. For infants who are referred for further testing and follow-up, it is important for the nurse to provide further explanation and emotional support. 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 they still do not pass the test, they should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in early intervention by 6 months of age.

With regard to the postpartum uterus, nurses should be aware that: a.At the end of the third stage of labor it weighs approximately 500 g. b.After 2 weeks postpartum it should not be palpable abdominally. c.After 2 weeks postpartum it weighs 100 g. d.It returns to its original (prepregnancy) size by 6 weeks postpartum.

ANS: B After 2 weeks postpartum, the uterus should not be palpable abdominally; however, it has not yet returned to its original size. At the end of the third stage of labor, the uterus weighs approximately 1000 g. It takes 6 full weeks for the uterus to return to its original size. After 2 weeks postpartum the uterus weighs about 350 g, not its original size. The normal self-destruction of excess hypertrophied tissue accounts for the slight increase in uterine size after each pregnancy.

2. Which woman is most likely to experience strong afterpains? a. A woman who experienced oligohydramnios b. A woman who is a gravida 4, para 4-0-0-4 c. A woman who is bottle-feeding her infant d. A woman whose infant weighed 5 pounds, 3 ounces

ANS: B Afterpains are more common in multiparous women. Afterpains are more noticeable with births in which the uterus was greatly distended, as in a woman who experienced polyhydramnios or a woman who delivered a large infant. Breastfeeding may cause afterpains to intensify.

A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: a. Urinary tract infection. c. A ruptured bladder. b. Excessive uterine bleeding. d. Bladder wall atony.

ANS: B Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.

With regard to the postpartum changes and developments in a woman's cardiovascular system, nurses should be aware that: a.Cardiac output, the pulse rate, and stroke volume all return to prepregnancy normal values within a few hours of childbirth. b.Respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth. c.The lowered white blood cell count after pregnancy can lead to false-positive results on tests for infections. d.A hypercoagulable state protects the new mother from thromboembolism, especially after a cesarean birth.

ANS: B Respirations should decrease to within the woman's normal prepregnancy range by 6 to 8 weeks after birth. Stroke volume increases, and cardiac output remains high for a couple of days. However, the heart rate and blood pressure return to normal quickly. Leukocytosis increases 10 to 12 days after childbirth and can obscure the diagnosis of acute infections (false-negative results). The hypercoagulable state increases the risk of thromboembolism, especially after a cesarean birth.

Which description of postpartum restoration or healing times is accurate? a.The cervix shortens, becomes firm, and returns to form within a month postpartum. b.Vaginal rugae reappear by 3 weeks postpartum. c.Most episiotomies heal within a week. d.Hemorrhoids usually decrease in size within 2 weeks of childbirth.

ANS: B Vaginal rugae reappear by 3 weeks postpartum; however, they are never as prominent as in nulliparous women. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.

9. To prevent the abduction of newborns from the hospital, the nurse should: a. instruct the mother not to give her infant to anyone except the one nurse assigned to her that day. b. apply an electronic and identification bracelet to mother and infant. c. carry the infant when transporting him or her in the halls. d. restrict the amount of time infants are out of the nursery.

ANS: 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 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, so 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.

28. To prevent nipple trauma, the nurse should instruct the new mother to: 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.

ANS: B If the infant's 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. This 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.

20. The breastfeeding mother should be taught a safe method to remove the breast from the baby's mouth. Which suggestion by the nurse is most appropriate? a. Slowly remove the breast from the baby's 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 infant's mouth. c. A popping sound occurs when the breast is correctly removed from the infant's mouth. d. Elicit the Moro reflex to wake the baby and remove the breast when the baby cries.

ANS: B Inserting a finger into the corner of the baby's 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 baby's 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.

2. 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. The nurse can explain to him that beginning solid foods before 4 to 6 months may: a. decrease the infant's intake of sufficient calories. b. lead to early cessation of breastfeeding. c. help the infant sleep through the night. d. limit the infant's growth.

ANS: B Introduction of solid foods before the infant is 4 to 6 months of age may result in overfeeding and decreased intake of breast milk. It is not true that feeding of solids helps infants sleep through the night. The proper balance of carbohydrate, protein, and fat for an infant to grow properly is in the breast milk or formula.

10. The nurse's initial action when caring for an infant with a slightly decreased temperature is to: a. notify the physician immediately. b. place a cap on the infant's head. c. tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d. change the formula because this is a sign of formula intolerance.

ANS: B Keeping the head well covered with a cap will prevent further heat loss from the head, and having the mother place the infant skin to skin should increase the infant's temperature. Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary. A slightly decreased temperature can be treated in the mother's room. This would be an excellent time for parent teaching on prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days as the infant adapts to external life.

Which statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth? a."My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." b."My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." c. "I will not have a menstrual cycle for 6 months after childbirth." d."My first menstrual cycle will be heavier than normal and then will be light for several months after."

ANS: B My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles" is an accurate statement and indicates her understanding of her expected menstrual activity. She can expect her first menstrual cycle to be heavier than normal (which occurs by 3 months after childbirth), and the volume of her subsequent cycles will return to prepregnant levels within three or four cycles.

24. The hormone necessary for milk production is: a. estrogen. b. prolactin. c. progesterone. d. lactogen.

ANS: B Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Progesterone decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced.

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 her infant is crying frantically. On the basis of this information, this woman should feed her infant about every 2.5 to 3 hours when she: a. waves her arms in the air. b. makes sucking motions. c. has hiccups. d. stretches her legs out straight.

ANS: B Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding-readiness cues. Waving the arms in the air, hiccupping, and stretching the legs out straight are not typical feeding-readiness cues.

14. During the complete physical examination 24 hours after birth: a. the parents are excused to reduce their normal anxiety. b. the nurse can gauge the neonate's maturity level by assessing the infant's general appearance. c. once often neglected, blood pressure is now routinely checked. d. when the nurse listens to the heart, the S1 and S2 sounds can be heard; the first sound is somewhat higher in pitch and sharper than the second.

ANS: B The nurse will be looking at skin color, alertness, cry, head size, and other features. The parents' presence actively involves them in child care and gives the nurse a chance to observe interactions. Blood pressure is not usually taken unless cardiac problems are suspected. The second sound is higher and sharper than the first.

18. The process whereby parents awaken the infant to feed every 3 hours during the day and at least every 4 hours at night is: a. known as demand feeding. b. necessary during the first 24 to 48 hours after birth. c. used to set up the supply-meets-demand system. d. a way to control cluster feeding.

ANS: B The parents do this to make sure that the infant has at least eight feedings in 24 hours. Demand feeding is when the infant determines the frequency of feedings; this is appropriate once the infant is feeding well and gaining weight. The supply-meets-demand system is a milk production system that occurs naturally. Cluster feeding is not a problem if the baby has eight feedings in 24 hours.

15. As related to laboratory tests and diagnostic tests in the hospital after birth, nurses should be aware that: 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 done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. d. hearing screening is now mandated by federal law.

ANS: C If done very early, genetic screening should be repeated. States all test for PKU and hypothyroidism, but other genetic defects are not universally covered. Federal law mandates newborn genetic screening, but not screening for hearing problems (although more than half the states do mandate hearing screening).

2. A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the erythromycin ophthalmic ointment is to: a. destroy an infectious exudate caused by Staphylococcus that could make the infant blind. b. prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. c. prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. d. prevent the infant's eyelids from sticking together and help the infant see.

ANS: B The purpose of the erythromycin ophthalmic ointment is to prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial infection. Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems.

12. The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would be inaccurate and provide conflicting information to the patient? 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 after birth weight loss.

ANS: B Women who breastfeed have a decreased risk of breast cancer, an increase in bone density, and a possibility of quicker after birth weight loss. Breastfeeding delays the return of fertility; however, it is not an effective birth control method.

3. Late in pregnancy, the woman's breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Some nipple conditions make it necessary to provide intervention before birth. These include: (Select all that apply.) a. everted nipples. b. flat nipples. c. inverted nipples. d. nipples that contract when compressed. e. cracked nipples.

ANS: B, C, D Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling them between the fingers. Inverted nipples are retracted into the breast tissue. These nipples appear normal; however, they will draw inward when the areola is compressed by the infant's mouth. Dome-shaped devices known as breast shells can be worn during the last weeks of pregnancy and between feedings after birth. The shells are placed inside the bra with the opening over the nipple. The shells exert slight pressure against the areola to help the nipples protrude. The helpfulness of breast shells is debated. A breast pump can be used to draw the nipples out before feedings after delivery. Everted nipples protrude and are normal. No intervention will be required. Cracked, blistered, and bleeding nipples occur after breastfeeding has been initiated and are the result of improper latch. The infant should be repositioned during feeding. Application of colostrum and breast milk after feedings will aid in healing.

With regard to afterbirth pains, nurses should be aware that these pains are: a.Caused by mild, continuous contractions for the duration of the postpartum period. b.More common in first-time mothers. c.More noticeable in births in which the uterus was overdistended. d.Alleviated somewhat when the mother breastfeeds.

ANS: C A large baby or multiple babies overdistend the uterus. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations, which persist through the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. Breastfeeding intensifies afterbirth pain because it stimulates contractions.

If the patient's white blood cell (WBC) count is 25,000/mm on her second postpartum day, the nurse should: a.Tell the physician immediately. b.Have the laboratory draw blood for reanalysis. c.Recognize that this is an acceptable range at this point postpartum. d.Begin antibiotic therapy immediately.

ANS: C During the first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm are common. Because this is a normal finding there is no reason to alert the physician. There is no need for reassessment or antibiotics because it is expected for the WBCs to be elevated.

As relates to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: a.Kidney function returns to normal a few days after birth. b.Diastasis recti abdominis is a common condition that alters the voiding reflex. c.Fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium. d.With adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth.

ANS: C Excess fluid loss through other means occurs as well. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Bladder tone usually is restored 5 to 7 days after childbirth.

4. Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? a. Estrogen c. Prolactin b. Progesterone d. Human placental lactogen

ANS: C Prolactin levels in the blood increase progressively throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth. Estrogen and progesterone levels decrease markedly after expulsion of the placenta and reach their lowest levels 1 week into the postpartum period. Human placental lactogen levels decrease dramatically after expulsion of the placenta.

Which documentation on a woman's chart on postpartum day 14 indicates a normal involution process? a.Moderate bright red lochial flow b.Breasts firm and tender c.Fundus below the symphysis and not palpable d. Episiotomy slightly red and puffy

ANS: C The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. The lochia should be changed by this day to serosa. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage.

With regard to postpartum ovarian function, nurses should be aware that: a.Almost 75% of women who do not breastfeed resume menstruating within a month after birth. b.Ovulation occurs slightly earlier for breastfeeding women. c.Because of menstruation/ovulation schedules, contraception considerations can be postponed until after the puerperium. d.The first menstrual flow after childbirth usually is heavier than normal.

ANS: D The first flow is heavier, but within three or four cycles, it is back to normal. Ovulation can occur within the first month, but for 70% of nonlactating women, it returns within 12 weeks after birth. Breastfeeding women take longer to resume ovulation. Because many women ovulate before their first postpartum menstrual period, contraceptive options need to be discussed early in the puerperium.

5. Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is: a.Elevated temperature caused by postpartum infection. b.Increased basal metabolic rate after giving birth c. Loss of increased blood volume associated with pregnancy. d.Increased venous pressure in the lower extremities.

ANS: C Within 12 hours of birth women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid. An elevated temperature would cause chills and may cause dehydration, not diaphoresis and diuresis. Diaphoresis and diuresis sometimes are referred to as reversal of the water metabolism of pregnancy, not as the basal metabolic rate. Postpartal diuresis may be caused by the removal of increased venous pressure in the lower extremities.

13. While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the patient 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.

ANS: 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.

1. An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is 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 newborn's first hour after birth.

ANS: C Apgar scoring is performed at 1 minute and 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts

20. The nurse administers vitamin K to the newborn for which reason? a. Most mothers have a diet deficient in vitamin K, which results in the infant's being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.

ANS: C Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. 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.

26. As the nurse assists a new mother with breastfeeding, the patient asks, "If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?" The nurse's best response is that it contains: a. more calories. b. essential amino acids. c. important immunoglobulins. d. more calcium.

ANS: C Breast milk contains immunoglobulins that protect the newborn against infection. The calorie count of formula and breast milk is about 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. This higher level can cause an excessively high renal solute load if the formula is not diluted properly.

6. A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? 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. Cleanse the penis gently with water and put 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.

ANS: C Cleansing the penis gently with water and putting petroleum jelly around the glans after each diaper change are appropriate when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed off with warm water to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates cover the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudates should not be removed.

23. 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

ANS: 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.

9. As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is: a. to protect the baby from infection. b. that it is part of the Apgar protocol. c. to protect the nurse from contamination by the newborn. d. the nurse has primary responsibility for the baby during the first 2 hours.

ANS: C Gloves are worn to protect the nurse from infection until the blood and amniotic fluid are cleaned off the newborn.

15. With regard to the nutrient needs of breastfed and formula-fed infants, nurses should understand that: a. breastfed infants need extra water in hot climates. b. during the first 3 months breastfed infants consume more energy than do formula-fed infants. c. breastfeeding infants should receive oral vitamin D drops daily at least during the first 2 months. d. vitamin K injections at birth are not needed for infants fed on specially enriched formula.

ANS: C Human milk contains only small amounts of vitamin D. Neither breastfed nor formula-fed infants need to be given water, even in very hot climates. During the first 3 months formula-fed infants consume more energy than do 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 baby's stomach at birth.

19. With regard to basic care of the breastfeeding mother, nurses should be able to advise her that she: a. will need an extra 1000 calories a day to maintain energy and produce milk. b. can go back to prepregnancy consumption patterns of any drinks, as long as she ingests enough calcium. c. should avoid trying to lose large amounts of weight. d. must avoid exercising because it is too fatiguing.

ANS: C Large weight loss would release fat-stored contaminants into her breast milk. It would also likely involve eating too little and/or exercising too much. A breastfeeding mother need add only 200 to 500 extra calories to her diet to provide extra nutrients for the infant. The mother can go back to her consumption patterns of any drinks as long as she ingests enough calcium, only if she does not drink alcohol, limits coffee to no more than two cups (caffeine in chocolate, tea, and some sodas), and reads the herbal tea ingredients carefully. The mother needs her rest, but moderate exercise is healthy.

8. A new mother wants to be sure that she is meeting her daughter's needs while feeding her commercially prepared infant formula. The nurse should evaluate the mother's knowledge about appropriate infant care. The mother meets her child's needs when she: a. adds rice cereal to her formula at 2 weeks of age to ensure adequate nutrition. b. warms the bottles using a microwave oven. c. burps her infant during and after the feeding as needed. d. refrigerates any leftover formula for the next feeding.

ANS: C Most infants swallow air when fed from a bottle and should be given a chance to burp several times during a feeding 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, and this may pose a risk of burning the infant. Any formula left in the bottle after the feeding should be discarded because the infant's saliva has mixed with it.

25. To initiate the milk ejection reflex (MER), the mother should be advised to: a. wear a firm-fitting bra. b. drink plenty of fluids. c. place the infant to the breast. d. apply cool packs to her breast.

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

22. Which type of formula is not diluted before being administered to an infant? a. Powdered b. Concentrated c. Ready-to-use d. Modified cow's milk

ANS: C Ready-to-use formula can be poured directly from the can into baby's 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. Cow's milk is more difficult for the infant to digest and is not recommended, even if it is diluted.

13. In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would: a. fall between the 25th and 75th percentiles for the infant's age. b. depend on the infant's length and the size of the head. c. fall between the 10th and 90th percentiles for the infant's age. d. be modified to consider intrauterine growth restriction (IUGR).

ANS: C The AGA range is large: between the 10th and the 90th percentiles for the infant's age. The infant's length and size of the head are measured, but they do not affect the normal weight designation. IUGR applies to the fetus, not the newborn's weight.

17. In assisting the breastfeeding mother position the baby, nurses should keep in mind that: a. the cradle position usually is 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.

ANS: C The infant inevitably faces the mother, belly to belly. The football position usually is preferred after 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.

4. A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to: a. apply an oil-based lotion to the newborn's skin to prevent dying and cracking. b. limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea. c. place eye shields over the newborn's closed eyes. d. change the newborn's position every 4 hours.

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

6. A breastfeeding woman develops engorged breasts at 3 days' after birth. What action would help this woman achieve her goal of reducing the engorgement? The woman: a. skips feedings to let her sore breasts rest. b. avoids using a breast pump. c. breastfeeds her infant every 2 hours. d. reduces her fluid intake for 24 hours.

ANS: 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 feed adequately and empty the breast, the mother may pump to extract the milk and relieve some of the discomfort. Dehydration further irritates swollen breast tissue.

Plantar creases should be evaluated within a few hours of birth because: a. The 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.

B (As the infant's skin begins to dry, the creases will appear more prominent, and the infant's gestation could be misinterpreted. Footprinting will not interfere with the creases. Heel sticks will not interfere with the creases. The creases will appear more prominent after 24 hours.)

17. The normal term infant has little difficulty clearing the airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to: 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.

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

8. The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that this finding: a. is normal. b. indicates that the infant is hungry. c. may indicate that the infant has a tracheoesophageal fistula or esophageal atresia. d. may indicate that the infant has a diaphragmatic hernia.

ANS: C The presence of excessive saliva in a neonate should alert the nurse to the possibility of tracheoesophageal fistula or esophageal atresia

7. At a 2-month well-baby examination, it was discovered that a breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse agree that, to gain weight faster, the infant needs to: a. begin solid foods. b. have a bottle of formula after every feeding. c. add at least one extra breastfeeding session every 24 hours. d. start iron supplements.

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

Changes in blood volume after childbirth depend on several factors such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. A postpartum nurse anticipates blood loss of (Select all that apply): a. 100 mL b. 250 mL or less c. 300 to 500 mL d. 500 to 1000 mL e. 1500 mL or greater

ANS: C, D The average blood loss for a vaginal birth of a single fetus ranges from 300 to 500 mL (10% of blood volume). The typical blood loss for women who gave birth by cesarean is 500 to 1000 mL (15% to 30% of blood volume)

Postbirth uterine/vaginal discharge, called lochia: a.Is similar to a light menstrual period for the first 6 to 12 hours. b.Is usually greater after cesarean births. c.Will usually decrease with ambulation and breastfeeding. d.Should smell like normal menstrual flow unless an infection is present

ANS: D An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births and usually increases with ambulation and breastfeeding.

The nurse caring for the postpartum woman understands that breast engorgement is caused by: a. Overproduction of colostrum. b. Accumulation of milk in the lactiferous ducts. c. Hyperplasia of mammary tissue. d. Congestion of veins and lymphatics.

ANS: D Breast engorgement is caused by the temporary congestion of veins and lymphatics, not by overproduction of colostrum, overproduction of milk, or hyperplasia of mammary tissue.

Which maternal event is abnormal in the early postpartum period? a.Diuresis and diaphoresis b.Flatulence and constipation c.Extreme hunger and thirst d.Lochial color changes from rubra to alba

ANS: D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. Diuresis and diaphoresis are the methods by which the body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.

Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium? a.Varicosities of the legs b.Carpal tunnel syndrome c.Periodic numbness and tingling of the fingers d.Headaches

ANS: D Headaches in the postpartum period can have a number of causes, some of which deserve medical attention. Total or nearly total regression of varicosities is expected after childbirth. Carpal tunnel syndrome is relieved in childbirth when the compression on the median nerve is lessened. Periodic numbness of the fingers usually disappears after birth unless carrying the baby aggravates the condition.

3. A woman gave birth to a healthy infant boy 5 days ago. What type of lochia would the nurse expect to find when assessing this woman? a. Lochia rubra c. Lochia alba b. Lochia sangra d. Lochia serosa

ANS: D Lochia serosa, which consists of blood, serum, leukocytes, and tissue debris, generally occurs around day 3 or 4 after childbirth. Lochia rubra consists of blood and decidual and trophoblastic debris. The flow generally lasts 3 to 4 days and pales, becoming pink or brown. There is no such term as lochia sangra. Lochia alba occurs in most women after day 10 and can continue up to 6 weeks after childbirth.

A postpartum patient asks, "Will these stretch marks go away?" The nurse's best response is: a."They will continue to fade and should be gone by your 6-week checkup." b."No, never." c."Yes, eventually." d. "They will fade to silvery lines but won`t disappear completely."

ANS: D Stretch marks never disappear altogether; however, they gradually fade to silvery lines.

Infants in whom cephalhematomas develop are at increased risk for: a. Infection. b. Jaundice. c. Caput succedaneum. d. Erythema toxicum.

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

Childbirth may result in injuries to the vagina and uterus. Pelvic floor exercises also known as Kegel exercises will help to strengthen the perineal muscles and encourage healing. The nurse knows that the client understands the correct process for completing these conditioning exercises when she reports: a."I contract my thighs, buttocks, and abdomen." b."I do 10 of these exercises every day." c."I stand while practicing this new exercise routine." d."I pretend that I am trying to stop the flow of urine midstream."

ANS: D The woman can pretend that she is attempting to stop the passing of gas or the flow of urine midstream. This will replicate the sensation of the muscles drawing upward and inward. Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. Guidelines suggest that these exercises should be done 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. The best position to learn Kegel exercises is to lie supine with knees bent. A secondary position is on the hands and knees.

4. A after birth woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who: 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 6 to 8 wet diapers per day.

ANS: D After day 4, when the mother's milk comes in, the infant should have 6 to 8 wet diapers every 24 hours. Sleeping for 6 hours between feedings is not an indication of whether the infant is breastfeeding well. 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 infant should have a minimum of three bowel movements in a 24-hour period. Breastfed infants typically gain 15 to 30 g/day.

11. An Apgar score of 10 at 1 minute after birth would indicate a(n): a. infant having no difficulty adjusting to extrauterine life and needing no further testing. b. infant in severe distress who needs resuscitation. c. prediction of a future free of neurologic problems. d. infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.

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

11. Which statement concerning the benefits or limitations of breastfeeding is inaccurate? a. Breast milk changes over time to meet changing needs as infants grow. b. Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. c. Breast milk/breastfeeding may enhance cognitive development. d. Breastfeeding increases the risk of childhood obesity.

ANS: D Breastfeeding actually decreases the risk of childhood obesity. There are multiple benefits of breastfeeding. Breast milk changes over time to meet changing needs as infants grow. Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. Breast milk/breastfeeding may enhance cognitive development.

18. When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to: a. keep the state records updated. b. allow accurate statistical information. c. document the number of births. d. recognize and treat newborn disorders early.

ANS: D Early treatment of disorders will prevent morbidity associated with inborn errors of metabolism or other genetic conditions. Keeping records and reporting for statistical purposes are not the primary reason for the screening test. The number of births recorded is not reported from the newborn screening test.

27. When responding to the question "Will I produce enough milk for my baby as she grows and needs more milk at each feeding?" the nurse should explain that: a. the breast milk will gradually become richer to supply additional calories. b. as the infant requires more milk, feedings can be supplemented with cow's milk. c. early addition of baby food will meet the infant's needs. d. the mother's milk supply will increase as the infant demands more at each feeding.

ANS: D The amount of milk produced depends on the amount of stimulation of the breast. Increased demand with more frequent and longer breastfeeding sessions results in more milk available for the infant. Mature breast milk will stay the same. The amounts will increase as the infant feeds for longer times. Supplementation will decrease the amount of stimulation of the breast and decrease the milk production. Solids should not be added until about 4 to 6 months, when the infant's immune system is more mature. This will decrease the chance of allergy formations

16. As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Which statement is incorrect? 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.

ANS: D The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. Infants are vulnerable to respiratory infections; infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding, and 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.

5. Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after: a. the bleeding stops completely. b. yellow exudate forms over the glans. c. the PlastiBell rim falls off. d. the infant voids.

ANS: D The infant should be observed for urination after the circumcision. Bleeding is a common complication after circumcision. The nurse will check the penis for 12 hours after a circumcision to assess and provide appropriate interventions for prevention and treatment of bleeding. Yellow exudates cover the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The PlastiBell remains in place for about a week and falls off when healing has taken place.

5. A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. The nurse can facilitate the infant's correct latch-on by helping the woman hold the infant: a. with his arms folded together over his chest. b. curled up in a fetal position. c. with his head cupped in her hand. d. with his head and body in alignment.

ANS: D The infant's head and body should be in correct alignment with the mother and the breast during latch-on and feeding. Holding the infant with his arms folded together over his chest, curled up in a fetal position, or with his head cupped in her hand are not ideal positions to facilitate latch-on.

21. A newly delivered mother who intends to breastfeed tells her nurse, "I am so relieved that this pregnancy is over so I can start smoking again." The nurse encourages the patient to refrain from smoking. However, this new mother insists that she will resume smoking. The nurse will need to adapt her health teaching to ensure that the patient is aware that: a. smoking has little or no effect on milk production. b. there is no relation 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.

ANS: 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 immunologic properties of breast milk. Research supports that mothers should not smoke within 2 hours before a feeding. The effects of secondhand smoke on infants include sudden infant death syndrome.

Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? After birth depression After birth psychosis After birth bipolar disorder After birth blues

After birth blues

A woman delivered a 9-lb, 10-ounce baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she ―feels all wet underneath.‖ You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? a. Call for help. Assess the fundus for firmness. Take her blood pressure. Check the perineum for lacerations.

Assess the fundus for firmness.

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

B ("Infants can track their parent's eyes and distinguish patterns; they prefer complex 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. Infants prefer low illumination and withdraw from bright light.)

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.

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

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as: a. Enterohepatic circuit. b. Conjugation of bilirubin. c. Unconjugation of bilirubin. d. Albumin binding.

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

A newborn is placed under a radiant heat warmer, and the nurse evaluates the infant's body temperature every hour. Maintaining the newborn's body temperature is important for preventing: a. Respiratory depression. b. Cold stress. c. Tachycardia. d. Vasoconstriction.

B (Loss of heat must be controlled to protect the infant from the metabolic and physiologic effects of cold stress, and that is the primary reason for placing a newborn under a radiant heat warmer. Cold stress results in an increased respiratory rate and vasoconstriction.)

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). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. Ability to attend to visual and auditory stimuli while alert. a. Habituation b. Orientation c. Range of state d. Autonomic stability e. Regulation of state

B (NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.)

An examiner who discovers unequal movement or uneven gluteal skin folds during the Ortolani maneuver would then: a. Tell the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. b. Alert the physician that the infant has a dislocated hip. c. Inform the parents and physician that molding has not taken place. d. Suggest that, if the condition does not change, surgery to correct vision problems may be needed.

B (The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified.)

By knowing about variations in infants' blood count, nurses can explain to their clients that: a. A somewhat lower than expected red blood cell count could be the result of delay in clamping the umbilical cord. b. The early high white blood cell (WBC) count is normal at birth and should decrease rapidly. c. Platelet counts are higher than in adults for a few months. d. Even a modest vitamin K deficiency means a problem with the ability of the blood to clot properly.

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

A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the: a. Transition period. b. First period of reactivity. c. Organizational stage. d. Second period of reactivity.

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. There is no such phase as the organizational stage. The second period of reactivity occurs roughly between 4 and 8 hours after birth, after a period of prolonged sleep.)

Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of: a. Increased pressure in the right atrium. b. Increased pressure in the left atrium. c. Decreased blood flow to the left ventricle. d. Changes in the hepatic blood flow.

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. It is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes, but that is not the reason for the closure of the foramen ovale.)

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

B, C, D (Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Perspiration and urination are not modes of heat loss in newborns.)

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by: a. Running warm water on her breasts during a shower. b. Applying ice to the breasts for comfort. c. Expressing small amounts of milk from the breasts to relieve pressure. d. Wearing a loose-fitting bra to prevent nipple irritation.

B. Applying ice to the breasts for comfort

When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is: A. rectal suppositories B. early and frequent ambulation C. tightening and relaxing abdominal muscles D. carbonated beverages

B. early and frequent ambulation

As relates to rubella and Rh issues, nurses should be aware that: A. breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus B. Women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination. C. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant D. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

B. women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination

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

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. The nurse should: a. Notify the physician immediately. b. Move the newborn to an isolation nursery. c. Document the finding as erythema toxicum. d. Take the newborn's temperature and obtain a culture of one of the vesicles.

C (Erythema toxicum (or erythema neonatorum) is a newborn rash that resembles flea bites. This is a normal finding that does not require notification of the physician, isolation of the newborn, or any additional interventions.)

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is: a. Seen at age 3 days. b. The residue of a milk curd. c. Passed in the first 12 hours of life. d. Lighter in color and looser in consistency.

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, 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.)

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). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. Measure of general arousability. a. Habituation b. Orientation c. Range of state d. Autonomic stability e. Regulation of state

C (NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.)

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

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 fade gradually 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 is an appalling-looking rash, but 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 infant blood types. c. The bilirubin levels of physiologic jaundice peak between the second and fourth days of life. d. This condition is also known as "breast milk jaundice."

C (Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dL or greater, which occurs when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice occurs during the first 24 hours of life. Pathologic jaundice is caused by blood incompatibilities, causing excessive destruction of erythrocytes, and 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 skin folds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has: a. Polydactyly. b. Clubfoot. c. Hip dysplasia. d. Webbing

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.)

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: a. 80 to 100 beats/min. b. 100 to 120 beats/min. c. 120 to 160 beats/min. d. 150 to 180 beats/min.

C (The average infant heart rate while awake is 120 to 160 beats/min. The newborn's heart rate may be about 85 to 100 beats/min while sleeping. The infant's heart rate typically is a bit higher when alert but quiet. A heart rate of 150 to 180 beats/min is typical when the infant cries.)

In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is: a. Important in the production of red blood cells. b. Necessary in the production of platelets. c. Not initially synthesized because of a sterile bowel at birth. d. Responsible for the breakdown of bilirubin and prevention of jaundice.

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 clotting factors.)

With regard to the newborn's developing cardiovascular system, nurses should be aware that: a. The heart rate of a crying infant may rise to 120 beats/min. b. Heart murmurs heard after the first few hours are cause for concern. c. The point of maximal impulse (PMI) often is visible on the chest wall. d. Persistent bradycardia may indicate respiratory distress syndrome (RDS).

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

A after birth woman overhears the nurse tell the obstetrics clinician that she has a positive Homans' sign and asks what it means. The nurse's best response is: A. "You have pitting edema in your ankles." B. "You have deep tendon reflexes rated 2+ C. "You have calf pain when the nurse flexes your foot." D. "You have a "fleshy" odor to your vaginal drainage

C. "You have calf pain when the nurse flexes your foot."

Under the Newborns' and Mothers' Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of_______ hours after a normal vaginal birth and for _______ hours after a cesarean birth.

C. 48,96

Excessive blood loss after childbirth can have several causes; however, the most common is: a) Vaginal or vulvar hematomas b) Unrepaired lacerations of the vagina or cervix c) Failure of the uterine muscle to contract firmly d) Retained placental fragments

C. Failure of the uterine muscle to contract firmly

If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid? A. Putting the patient in antiembolic stockings (TED hose) and/ or sequential compression device (SCD) boots B. Having the patient flex, extend, and rotate her feet, ankles, and legs C. Having the patient sit in a chair D. Notifying the physician immediately if a positive Homans' sign occurs

C. Having the patient sit in a chair

A 25- year- old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9- Ib, 7 ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, "I'm bleeding a lot." The most likely cause of after birth hemorrhage in this woman is: A. retained placental fragments B. unrepaired vaginal lacerations C. uterine atony D. puerperal infection

C. Uterine Atony

A recently delivered mother and her baby are at the clinic for a 6- week after birth checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman: A. discusses her labor and birth experience excessively B. Believes that her baby is more attractive and clever than any others C. has not given the baby a name D. has a partner or family member who react very positively about the baby.

C. has not given the baby a name

An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called: a. Lanugo. b. Vascular nevi. c. Nevus flammeus. d. Mongolian spots.

D (A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair seen 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.)

During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is not one of these essential factors? a. Chemical b. Mechanical c. Thermal d. Psychologic

D (A psychologic factor is not one of the essential factors in the initiation of breathing; the fourth factor is sensory. The sensory factors include handling by the provider, drying by the nurse, lights, smells, and sounds. Chemical factors are essential for the initiation of 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. Prostaglandins are known to inhibit breathing, and clamping of the cord results in a drop in the level of prostaglandins. Mechanical factors also are necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. With 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. This also contributes to the initiation of breathing.)

Which statement describing physiologic jaundice is incorrect? a. Neonatal jaundice is common, but kernicterus is rare. b. The appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. c. Because jaundice may not appear before discharge, parents need instruction on how to assess it and when to call for medical help. d. Breastfed babies have a lower incidence of jaundice.

D (Breastfeeding is associated with an increased incidence of jaundice. Neonatal jaundice occurs in 60% of newborns; 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 know how to assess for jaundice in their newborn.)

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). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. Signs of stress related to homeostatic adjustment a. Habituation b. Orientation c. Range of state d. Autonomic stability e. Regulation of state

D (NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.)

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

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 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.)

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

D (The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. This is a particularly common condition for infants delivered by cesarean section. Surfactant is produced by the lungs, so aspiration is not a concern.)

Which statement describing the first phase of the transition period is inaccurate? a. It lasts no longer than 30 minutes. b. It is marked by spontaneous tremors, crying, and head movements. c. It includes the passage of meconium. d. It may involve the infant's suddenly sleeping briefly.

D (The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase. The first phase is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. In the first phase the newborn also produces saliva.)

The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is: a. Closure of fetal shunts in the circulatory system. b. Full function of the immune defense system at birth. c. Maintenance of a stable temperature. d. Initiation and maintenance of respirations.

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

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

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.)

One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the: a. Incompletely developed neuromuscular system. b. Primitive reflex system. c. Presence of various sleep-wake states. d. Cerebellum growth spurt.

D (The vulnerability of the brain likely is to the result of the cerebellum growth spurt. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant. The various sleep-wake states are not relevant.)

The interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state is called the: a.Involutionary period because of what happens to the uterus. b.Lochia period because of the nature of the vaginal discharge. c.Mini-tri period because it lasts only 3 to 6 weeks. d.Puerperium, or fourth trimester of pregnancy.

D The puerperium, also called the fourth trimester or the after birth period of pregnancy, lasts about 3 to 6 weeks. Involution marks the end of the puerperium, or the fourth trimester of pregnancy. Lochia refers to the various vaginal discharges during the puerperium, or fourth trimester of pregnancy.

If nonsurgical treatment for late after birth hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a. Hysterectomy b. Laparoscopy c. Laparotomy d. D&C

D&C

A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse's most appropriate response is to ask the woman: a. "Didn't you like your lunch?" b. "Does your doctor know that you are planning to eat that?" c. "What is that anyway?" d. "I'll warm the soup in the microwave for you."

D. "I'll warm the soup in the microwave for you

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action it to: A. begin an intravenous (IV) infusion of Ringer's lactate solution B. assess the woman's vital signs C. call the woman's primary health care provider D. massage the woman's fundus

D. Massage the woman's fundus

In a variation of rooming- in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with: A. the father of the infant B. the mother (grandmother of the infant) C. her eldest daughter (infant's sister) D. The nurse

D. The nurse

The nurse caring for the after birth woman understands that breast engorgement is caused by: A. overproduction of colostrum B. accumulation of milk in the laciferous ducts and glands. C. hyperplasia of mammary tissue D. congestion of veins and lymphatics

D. congestion of veins and lymphatics

Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to: A. formally initializing individualized care by confirming the woman's and infant's identification (ID) numbers on their respective wrist bands. B. teaching the mother to check the identity of any person who comes to remove the baby from the room C including other family members in the teaching of self- care and child care D. nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.

D. nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood

A woman gave birth vaginally to a 9-lb, 12 ounce girl yesterday. Her primary healthcare provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? A. the woman is a gravida 2, para 2 B. the woman had a vacuum- assisted birth C. the woman received epidural anesthesia D. the woman has an episiotomy

D. the woman has an episiotomy

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). Please match the cluster of neonatal behavior with the correct level on the NBAS scale. How the infant responds when aroused a. Habituation b. Orientation c. Range of state d. Autonomic stability e. Regulation of state

E (NOT: Other clusters of neonatal behavior include motor performance, quality of movement and tone and reflexes, and assessment of neonatal reflexes.)

What PPH conditions are considered medical emergencies that require immediate treatment? Inversion of the uterus and hypovolemic shock Hypotonic uterus and coagulopathies Subinvolution of the uterus and idiopathic thrombocytopenic purpura Uterine atony and disseminated intravascular coagulation

Inversion of the uterus and hypovolemic shock

What infection is contracted mostly by first-time mothers who are breastfeeding? Endometritis Wound infections Mastitis Urinary tract infections

Mastitis

Which instruction should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications? Palpate the fundus daily to ensure that it is soft. Notify the physician of any increase in the amount of lochia or a return to bright red bleeding. Report any decrease in the amount of brownish red lochia. The passage of clots as large as an orange can be expected.

Notify the physician of any increase in the amount of lochia or a return to bright red bleeding.

Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply.) Pitocin. Methergine. Terbutaline. Hemabate. magnesium sulfate

Pitocin. Methergine. Hemabate.

Postpartal overdistention of the bladder and urinary retention can lead to which complications? A. After birth hemorrhage and eclampsia B. Fever and increased blood pressure C. After birth hemorrhage and urinary tract infection D. Urinary tract infection and uterine rupture

c. After birth hemorrhage and urinary tract infection (UTI)

New parents express concern that, because of the mothers emergency cesarean birth under general anesthesia, they did not have the opportunity to hold and bond with their daughter immediately after her birth. The nurses response should convey to the parents that: a. Attachment, or bonding, is a process that occurs over time and does not require early contact. b. The time immediately after birth is a critical period for people. c. Early contact is essential for optimum parent-infant relationships. d. They should just be happy that the infant is healthy.

a. Attachment, or bonding, is a process that occurs over time and does not require early contact.

Which concerns about parenthood are often expressed by visually impaired mothers (Select all that apply)? a. Infant safety b. Transportation c. The ability to care for the infant d. Missing out visually e. Needing extra time for parenting activities to accommodate the visual limitations

a. Infant safety b. Transportation d. Missing out visually e. Needing extra time for parenting activities to accommodate the visual limitations

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting go b. Taking hold c. Taking in d. Taking on

a. Letting go

When the infants behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, this is called: a. Mutuality. b. Bonding. c. Claiming. d. Acquaintance.

a. Mutuality.

The nurse can help a father in his transition to parenthood by: a. Pointing out that the infant turned at the sound of his voice. b. Encouraging him to go home to get some sleep. c. Telling him to tape the infants diaper a different way. d. Suggesting that he let the infant sleep in the bassinet.

a. Pointing out that the infant turned at the sound of his voice.

The mother-baby nurse is able to recognize reciprocal attachment behavior. This refers to: a. The positive feedback an infant exhibits toward parents during the attachment process. b. Behavior during the sensitive period when the infant is in the quiet alert stage. c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact. d. Behavior by the infant during the sensitive period to elicit feelings of falling in love from the parents.

a. The positive feedback an infant exhibits toward parents during the attachment process.

A parent who has a hearing impairment is presented with a number of challenges in parenting. Which nursing approaches are appropriate for working with hearing-impaired new parents (Select all that apply)? a. Use devices that transform sound into light. b. Assume that the patient knows sign language. c. Speak quickly and loudly. d. Ascertain whether the patient can read lips before teaching. e. Written messages aid in communication.

a. Use devices that transform sound into light. d. Ascertain whether the patient can read lips before teaching. e. Written messages aid in communication.

In the United States the en face position is preferred immediately after birth. Nurses can facilitate this process by all of these actions except: a. Washing both the infants face and the mothers face. b. Placing the infant on the mothers abdomen or breast with their heads on the same plane. c. Dimming the lights. d. Delaying the instillation of prophylactic antibiotic ointment in the infants eyes.

a. Washing both the infants face and the mothers face.

The nurse notes that a Vietnamese woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In evaluating the woman's behavior with her infant, the nurse realizes that: a. What appears to be a lack of interest in the newborn is in fact the Vietnamese way of demonstrating intense love by attempting to ward off evil spirits. b. The woman is inexperienced in caring for newborns. c. The woman needs a referral to a social worker for further evaluation of her parenting behaviors once she goes home with the newborn. d. Extra time needs to be planned for assisting the woman in bonding with her newborn.

a. What appears to be a lack of interest in the newborn is in fact the Vietnamese way of demonstrating intense love by attempting to ward off evil spirits.

To promote bonding and attachment immediately after delivery, the most important nursing intervention is to: a. Allow the mother quiet time with her infant. b. Assist the mother in assuming an en face position with her newborn. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in feeding her baby.

b. Assist the mother in assuming an en face position with her newborn.

Many first-time parents do not plan on their parents help immediately after the newborn arrives. What statement by the nurse is the most appropriate when counseling new parents about the involvement of grandparents? a. You should tell your parents to leave you alone. b. Grandparents can help you with parenting skills and also help preserve family traditions. c. Grandparent involvement can be very disruptive to the family. d. They are getting old. You should let them be involved while they can.

b. Grandparents can help you with parenting skills and also help preserve family traditions.

Other early sensual contacts between infant and mother involve sound and smell. Nurses should be aware that, despite what folk wisdom may say: a. High-pitched voices irritate newborns. b. Infants can learn to distinguish their mothers voice from others soon after birth. c. All babies in the hospital smell alike. d. A mothers breast milk has no distinctive odor.

b. Infants can learn to distinguish their mothers voice from others soon after birth.

The postpartum woman who continually repeats the story of her labor, delivery, and recovery experience is: a. Providing others with her knowledge of events. b. Making the birth experience real. c. Taking hold of the events leading to her labor and delivery. d. Accepting her response to labor and delivery.

b. Making the birth experience real.

With regard to the adaptation of other family members, mainly siblings and grandparents, to the newborn, nurses should be aware that: a. Sibling rivalry cannot be dismissed as overblown psychobabble; negative feelings and behaviors can take a long time to blow over. b. Participation in preparation classes helps both siblings and grandparents. c. In the United States paternal and maternal grandparents consider themselves of equal importance and status. d. In the past few decades the number of grandparents providing permanent care to their grandchildren has been declining.

b. Participation in preparation classes helps both siblings and grandparents.

A man calls the nurses station and states that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, She was never like this before the baby was born. The nurses initial response could be to: a. Tell him to ignore the mood swings, as they will go away. b. Reassure him that this behavior is normal. c. Advise him to get immediate psychological help for her. d. Instruct him in the signs, symptoms, and duration of postpartum blues.

b. Reassure him that this behavior is normal.

The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, would the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? a. Talks and coos to her son b. Seldom makes eye contact with her son c. Cuddles her son close to her d. Tells visitors how well her son is feeding

b. Seldom makes eye contact with her son

The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to: a. Tell the mother she must pay attention to her infant. b. Show the mother how the infant initiates interaction and pays attention to her. c. Demonstrate for the mother different positions for holding her infant while feeding. d. Arrange for the mother to watch a video on parent-infant interaction.

b. Show the mother how the infant initiates interaction and pays attention to her.

In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. Which one is a facilitating behavior? a. The parents have difficulty naming the infant. b. The parents hover around the infant, directing attention to and pointing at the infant. c. The parents make no effort to interpret the actions or needs of the infant. d. The parents do not move from fingertip touch to palmar contact and holding.

b. The parents hover around the infant, directing attention to and pointing at the infant.

When working with parents who have some form of sensory impairment, nurses should understand that ________ is an inaccurate statement. a. One of the major difficulties visually impaired parents experience is the skepticism of health care professionals. b. Visually impaired mothers cannot overcome the infants need for eye-to-eye contact. c. The best approach for the nurse is to assess the parents capabilities rather than focusing on their disabilities. d. Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information.

b. Visually impaired mothers cannot overcome the infants need for eye-to-eye contact.

Of the many factors that influence parental responses, nurses should be conscious of negative stereotypes that apply to specific patient populations. Which response could be an inappropriate stereotype of adolescent mothers? a. An adolescent mothers egocentricity and unmet developmental needs interfere with her ability to parent effectively. b. An adolescent mother is likely to use less verbal instruction, be less responsive, and interact less positively than other mothers. c. Adolescent mothers have a higher documented incidence of child abuse. d. Mothers older than 35 often deal with more stress related to work and career issues and decreasing libido.

c. Adolescent mothers have a higher documented incidence of child abuse.

With regard to parents early and extended contact with their infant and the relationships built, nurses should be aware that: a. Immediate contact is essential for the parent-child relationship. b. Skin-to-skin contact is preferable to contact with the body totally wrapped in a blanket. c. Extended contact is especially important for adolescents and low-income women because they are at risk for parenting inadequacies. d. Mothers need to take precedence over their partners and other family matters.

c. Extended contact is especially important for adolescents and low-income women because they are at risk for parenting inadequacies.

On observing a woman on her first postpartum day sitting in bed while her newborn lies awake in the bassinet, the nurse should: a. Realize that this situation is perfectly acceptable. b. Offer to hand the baby to the woman. c. Hand the baby to the woman. d. Explain taking in to the woman.

c. Hand the baby to the woman.

The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, about one-half million women in America experience a more severe syndrome known as postpartum depression (PPD). Which statement regarding PPD is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis? a. PPD symptoms are consistently severe. b. This syndrome affects only new mothers. c. PPD can easily go undetected. d. Only mental health professionals should teach new parents about this condition.

c. PPD can easily go undetected.

During a phone follow-up conversation with a woman who is 4 days postpartum, the woman tells the nurse, I don't know what's wrong. I love my son, but I feel so let down. I seem to cry for no reason! The nurse would recognize that the woman is experiencing: a. Taking-in. b. Postpartum depression (PPD). c. Postpartum (PP) blues. d. Attachment difficulty.

c. Postpartum depression (PPD).

A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry. Your initial action should be to a. Assess her for pain. b. Point out how lucky she is to have a healthy baby. c. Explain that she is experiencing postpartum blues. d. Allow her time to express her feelings.

d. Allow her time to express her feelings.

Nursing activities that promote parent-infant attachment are many and varied. One activity that should not be overlooked is management of the environment. While providing routine mother-baby care, the nurse should ensure that: a. The baby is able to return to the nursery at night so that the new mother can sleep. b. Routine times for care are established to reassure the parents. c. The father should be encouraged to go home at night to prepare for mother-baby discharge. d. An environment that fosters as much privacy as possible should be created.

d. An environment that fosters as much privacy as possible should be created.

Which nursing action is appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? A. Notify the physician of an impending hemorrhage B. Assess the blood pressure and pulse C. Evaluate the lochia D. assist the patient in emptying her bladder

d. Assist the patient in emptying her bladder

After they are born, a crying infant may be soothed by being held in a position in which the newborn can hear the mothers heartbeat. This phenomenon is known as: a. Entrainment. b. Reciprocity. c. Synchrony. d. Biorhythmicity.

d. Biorhythmicity.

A new father states, I know nothing about babies, but he seems to be interested in learning. This is an ideal opportunity for the nurse to: a. Continue to observe his interaction with the newborn. b. Tell him when he does something wrong. c. Show no concern, as he will learn on his own. d. Include him in teaching sessions.

d. Include him in teaching sessions.

After giving birth to a healthy infant boy, a primiparous woman, 16 years old, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is Risk for impaired parenting related to deficient knowledge of newborn care. In planning for the woman's discharge, what should the nurse be certain to include in the plan of care? a. Instruct the patient how to feed and bathe her infant. b. Give the patient written information on bathing her infant. c. Advise the patient that all mothers instinctively know how to care for their infants. d. Provide time for the patient to bathe her infant after she views an infant bath demonstration.

d. Provide time for the patient to bathe her infant after she views an infant bath

A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old brother is punching his mother on the back. The nurse should: a. Report the incident to the social services department. b. Advise the parents that the toddler needs to be reprimanded. c. Report to oncoming staff that the mother is probably not a good disciplinarian. d. Realize that this is a normal family adjusting to family change.

d. Realize that this is a normal family adjusting to family change.

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is: A. pouring water from a squeeze bottle over the woman's perineum B. placing oil of peppermint in a bedpan under the woman C. asking the physician to prescribe analgesics D. inserting a sterile catheter

d. inserting a sterile catheter

Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for after birth hemorrhage from birth until 4 weeks after delivery as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the patient with von Willebrand disease who experiences a after birth hemorrhage is cryoprecipitate. factor VIII and vWf. desmopressin. hemabate.

desmopressin.

When a woman is diagnosed with postpartum depression (PPD) with psychotic features, one of the main concerns is that she may have outbursts of anger. neglect her hygiene. c. harm her infant. d. lose interest in her husband.

harm her infant.

To provide adequate after birth care, the nurse should be aware that postpartum depression (PPD) without psychotic features means that the woman is experiencing the baby blues. In addition, she has a visit with a counselor or psychologist. is more common among older, Caucasian women because they have higher expectations. is distinguished by irritability, severe anxiety, and panic attacks. will disappear on its own without outside help.

is distinguished by irritability, severe anxiety, and panic attacks.

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests uterine atony. lacerations of the genital tract. perineal hematoma. infection of the uterus.

lacerations of the genital tract.

To provide adequate after birth care, the nurse should be aware that postpartum depression (PPD) with psychotic features is more likely to occur in women with more than two children. is rarely delusional and then is usually about someone trying to harm her (the mother). although serious, is not likely to need psychiatric hospitalization. may include bipolar disorder (formerly called ―manic depression‖).

may include bipolar disorder (formerly called ―manic depression‖).

The first and most important nursing intervention when a nurse observes profuse after birth bleeding is to call the woman's primary health care provider. administer the standing order for an oxytocic. palpate the uterus and massage it if it is boggy. assess maternal blood pressure and pulse for signs of hypovolemic shock.

palpate the uterus and massage it if it is boggy.

A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to establish venous access. perform fundal massage. prepare the woman for surgical intervention. catheterize the bladder.

perform fundal massage.

Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is phobias. panic disorder. posttraumatic stress disorder (PTSD). obsessive-compulsive disorder (OCD).

posttraumatic stress disorder (PTSD).

With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or after birth depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent after birth depression. The most accurate statement as related to these activities is to stay home and avoid outside activities to ensure adequate rest. be certain that you are the only caregiver for your baby to facilitate infant attachment. keep feelings of sadness and adjustment to your new role to yourself. realize that this is a common occurrence that affects many women.

realize that this is a common occurrence that affects many women.

The perinatal nurse caring for the after-birth woman understands that late postpartum hemorrhage (PPH) is most likely caused by subinvolution of the placental site. defective vascularity of the decidua. cervical lacerations. coagulation disorders.

subinvolution of the placental site.

One of the first symptoms of puerperal infection to assess for in the after-birth woman is fatigue continuing for longer than 1 week. pain with voiding. profuse vaginal bleeding with ambulation. temperature of 38C (100.4F) or higher on two successive days starting 24 hours after birth.

temperature of 38C (100.4F) or higher on two successive days starting 24 hours after birth.

A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect and should confirm the diagnosis by . disseminated intravascular coagulation; asking for laboratory tests von Willebrand disease; noting whether bleeding times have been extended thrombophlebitis; using real-time and color Doppler ultrasound coagulopathies; drawing blood for laboratory analysis

thrombophlebitis; using real-time and color Doppler ultrasound

Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance PPH is easy to recognize early; after all, the woman is bleeding. traditionally it takes more than 1000 mL of blood after vaginal birth and 2500 mL after cesarean birth to define the condition as PPH. if anything, nurses and doctors tend to overestimate the amount of blood loss. traditionally PPH has been classified as early or late with respect to birth.

traditionally PPH has been classified as early or late with respect to birth.

When caring for a after birth woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is absence of cyanosis in the buccal mucosa. cool, dry skin. diminished restlessness. urinary output of at least 30 mL/hr.

urinary output of at least 30 mL/hr.

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is uterine atony. uterine inversion. vaginal hematoma. vaginal laceration.

uterine atony.