Evolve: Adaptive Quiz - Newborn and Materal Assessment

A nurse is performing a newborn assessment. What characteristics cause the nurse to suspect that the newborn has Down syndrome? Select all that apply. 1 - Webbed neck 2 - Protruding tongue 3 - Epicanthal eye folds 4 - Widely spaced nipples 5 - One transverse palmar crease

Protruding tongue Epicanthal eye folds One transverse palmar crease

Which component of postpartum care is most important for the nurse to provide when helping a new mother on the postpartum unit develop her role as a parent? 1 - Teaching her how to care for the baby 2 - Providing time for her and her baby to be together 3 - Responding to any questions she has about her baby's behavior 4 - Demonstrating baby care and evaluating her return demonstration

Providing time for her and her baby to be together

The nurse is assigned to care for an infant in the newborn nursery who is 24 hours old. During assessment the nurse becomes concerned that the baby is jaundiced. The nurse knows that jaundice first becomes visible in a newborn when serum bilirubin reaches what level? 1 - 1 to 3 mg/dL (17.1 to 51.3 µmol/L) 2 - 2 to 4 mg/dL (34.2 to 68.4 µmol/L) 3 - 5 to 7 mg/dL (85.5 to 119.7 µmol/L) 4 - 8 to 10 mg/dL (136.8 to 171 µmol/L)

5 to 7 mg/dL (85.5 to 119.7 µmol/L)

The nurse is admitting a pregnant client who has mitral valve stenosis to the high-risk unit. Which prophylactic medication does the nurse anticipate administering during the intrapartum period? 1 - Diuretic 2 - Antibiotic 3 - Cardiotonic 4 - Anticoagulant

Antibiotic

The nurse is caring for preterm infants with respiratory distress in the neonatal intensive care unit. What is the priority nursing action? 1 - Limiting caloric intake to decrease metabolic rate 2 - Maintaining the prone position to prevent aspiration 3 - Limiting oxygen concentration to prevent eye damage 4 - Maintaining a high-humidity environment to promote gas exchange

Maintaining a high-humidity environment to promote gas exchange

A nurse is teaching a postpartum client the characteristics of lochia and any deviations that should be reported immediately. Which client statement indicates that the teaching was effective? 1 - "If I pass any clots, I'll notify the clinic." 2 - "I'll call the clinic if my lochia changes from red to pink." Correct3 "I'll notify the clinic if my lochia starts to smell bad." 4 "If my vaginal discharge continues for 3 weeks, I'll call the clinic."

"I'll notify the clinic if my lochia starts to smell bad."

A woman in labor with no known complications rings the call bell to say she has had a "gush" from her vagina. The nurse identifies a large amount of bright-red blood. In what order should the nurse perform the necessary interventions? Call the primary healthcare provider Call for help Start oxygen at 8 L via mask Increase the maintenance intravenous (IV) infusion rate Check fetal heart tones

1. Call for help 2. Check fetal heart tones 3. Increase the maintenance intravenous (IV) infusion rate 4. Start oxygen at 8 L via mask 5. Call the primary healthcare provider

A nurse has inserted a nasogastric tube to intermittently gavage feed a preterm newborn. Place in order the steps the nurse will take to perform the gavage. Pour the prescribed amount of formula into the syringe. Add 1 to 2 ml of sterile water to the syringe. Encourage the infant's parent to hold the newborn during feeding. Connect the barrel of the syringe to the gavage tube. Allow the feeding to flow slowly to gravity (approximately 1 ml/min). Ensure that the tube is properly placed into the stomach.

1. Ensure that the tube is properly placed into the stomach. 2. Encourage the infant's parent to hold the newborn during feeding 3. Connect the barrel of the syringe to the gavage tube. 4. Pour the prescribed amount of formula into the syringe. 5. Allow the feeding to flow slowly to gravity (approximately 1 ml/min)

The nurse gently performs Leopold maneuvers on a client with a suspected placenta previa. What does the nurse expect to find during this assessment? 1 - Firm engagement of the fetal head 2 - Difficulty palpating small fetal parts 3 - A high, floating fetal presenting part 4 - A hard and tetanically contracted uterus

A high, floating fetal presenting part

A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing? 1 - Placenta previa 2 - Precipitous birth 3 - Abruptio placentae 4 - Breech presentation

Abruptio placentae

After hyperbilirubinemia develops in a neonate, phototherapy is prescribed. What should the plan of care for an infant undergoing phototherapy include? 1 - Taking vital signs every hour 2 - Keeping the eye shields on continuously 3 - Administering additional fluids every 2 hours 4 - Covering the neonate with a lightweight blanket

Administering additional fluids every 2 hours

After a difficult vaginal birth, assessment of a full-term newborn reveals an unequal Moro reflex on one side and a flaccid arm in adduction. Which problem does the nurse suspect? 1 - Brachial palsy 2 - Supratentorial tear 3 - Fracture of the clavicle 4 - Developmental dysplasia of the hip

Brachial palsy

A woman is being seen in the prenatal clinic at 36 weeks' gestation. The nurse is reviewing signs and symptoms that should be reported to the primary healthcare provider with the mother. Which signs and symptoms require further evaluation by the primary healthcare provider? Select all that apply. 1 - Decreased urine output 2 - Blurred vision with spots 3 - Urinary frequency without dysuria 4 - Heartburn after eating a fatty meal 5 - Contractions that are regular and 5 minutes apart 6 - Shortness of breath after climbing a flight of stairs

Decreased urine output Blurred vision with spots Contractions that are regular and 5 minutes apart

What action should the nurse take to assist parents with bonding immediately after birth? 1 - Assess for typical parenting techniques 2 - Demonstrate desired behaviors to the parents 3 - Delay applying the antibiotic to the newborn's eyes 4 - Postpone footprinting the newborn until later in the day

Delay applying the antibiotic to the newborn's eyes

A nurse who is observing a sleeping newborn at 2 hours of age identifies periods of irregular breathing and occasional twitching movements of the arms and legs. The neonate's heart rate is 150 beats/min; the respiratory rate is 50 breaths/min; and the glucose strip reading is 60 mg/dL (3.3 mmol/L). What does the nurse conclude that these findings indicate? 1 - Hypoglycemia 2 - Seizure activity 3 - Expected adaptations 4 - Respiratory distress syndrome

Expected adaptations

A primary healthcare provider prescribes carboprost to be administered to a postpartum client with intractable vaginal bleeding. Which prior condition noted in the client's history should alert the nurse to question this prescription? 1 - History of asthma 2 - Homan sign 3 - Increased blood pressure 4 - Absence of the Babinski reflex

History of asthma

A client at term is admitted in active labor. She has tested positive for human immunodeficiency virus (HIV). Which intervention in the standard prescriptions should the nurse question? 1 - Sonogram 2 - Nonstress test 3 - Sterile vaginal examination 4 - Internal fetal scalp electrode

Internal fetal scalp electrode

The nurse must meet the hydration needs of a preterm infant. What should the nurse consider carefully regarding the preterm infant's kidney function? 1 - Large amounts of urine are excreted. 2 - It is the same as in a full-term newborn. 3 - Urine is concentrated, with an increased specific gravity. 4 - Acid-base and electrolyte balance are adequately maintained

Large amounts of urine are excreted.

What should the nurse discuss with new parents to assist them in preparing for infant care? 1 - Allowing crying time to help the lungs develop 2 - Establishing a set feeding schedule to promote steady weight gain 3 - Counting the number of stool diapers daily to confirm adequate hydration 4 - Learning specific behaviors involving states of wakefulness to promote positive interactions

Learning specific behaviors involving states of wakefulness to promote positive interactions

When calculating the Apgar score for a newborn, what does the nurse assess in addition to the heart rate? 1 - Muscle tone 2 - Amount of mucus 3 - Degree of head lag 4 - Depth of respirations

Muscle tone

The nurse determines that a postpartum client is gravida 1, para 1. Her blood type is B negative, and her baby's blood type is O positive. What should the nurse include in the plan of care? 1 - Obtaining a prescription for Rho (D) immune globulin 2 - Determining the father's blood type 3 - Checking for signs of ABO incompatibility 4 - Obtaining blood for type and cross-matching

Obtaining a prescription for Rho (D) immune globulin

What is the priority nursing intervention for a client who has just given birth to her fifth child? 1 - Palpating her fundus frequently, because she is at increased risk for uterine atony 2 - Offering her fluids, because multiparas generally lose more fluid during labor 3 - Assessing her bladder tone, because she is at increased risk for urinary tract infection 4 - Performing passive range-of-motion exercises on her extremities, because she is at risk for thrombophlebitis

Palpating her fundus frequently, because she is at increased risk for uterine atony

Which clinical finding should the nurse evaluate before continuing the administration of intravenous (IV) magnesium sulfate therapy? 1 - Temperature and respirations 2 - Patellar reflexes and urinary output 3 - Urinary glucose and specific gravity 4 - Level of consciousness and funduscopic appearance

Patellar reflexes and urinary output

A pregnant client experiences an episode of painless vaginal bleeding during the last trimester. What does the nurse suspect is the cause of this bleeding? 1 - Placenta previa 2 - Abruptio placentae 3 - Frequent sexual intercourse 4 - Excessive alcohol ingestion

Placenta previa

What are the primary nursing interventions when a client is receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply. 1 - Restricting visitors 2 - Limiting fluid intake 3 - Preparing for a precipitate birth 4 - Maintaining a quiet environment 5 - Keeping magnesium gluconate at the bedside

Restricting visitors Maintaining a quiet environment

A client being prepared for surgery because of a ruptured tubal pregnancy complains that she feels lightheaded. Her pulse is rapid, and her color is pale. Which condition does the nurse anticipate as a common complication of a ruptured tubal pregnancy? 1 - Shock 2 - Anxiety 3 - Infection 4 - Hyperoxygenation

Shock

A newborn is being treated with phototherapy for hyperbilirubinemia. What is the nurse's role when providing phototherapy? 1 - Turning the infant every 2 hours 2 - Measuring the bilirubin level every 2 hours 3 - Maintaining the infant on daily 24-hour phototherapy 4 - Applying a sterile gauze pad to the infant's umbilical stump

Turning the infant every 2 hours

The nurse is caring for a client whose contraction stress test result (CST) is positive. The nurse remains with the client and continues to assess the fetal and maternal monitor strips. Which complication does the nurse anticipate? 1 - Preeclampsia 2 - Placenta previa 3 - Fetal prematurity 4 - Uteroplacental insufficiency

Uteroplacental insufficiency

An infant born at 40 weeks' gestation weighs 6 lb 13 oz (3090 g). What is the nurse's assessment of the neonate? 1 - Small for gestational age (SGA) and term 2 - SGA and preterm 3 - Appropriate for gestational age (AGA) and term 4 - AGA and preterm

Appropriate for gestational age (AGA) and term

The nurse is admitting a client to the unit after fetal death was confirmed by ultrasound. While initiating intravenous (IV) therapy the nurse notes blood continually oozing from the puncture site. What is the nurse's next action? 1 - Restarting the line distal to the initial site 2 - Informing the primary healthcare provider of this finding 3 - Starting the prescribed infusion of oxytocin 4 - Placing an oxygen mask on the client and setting the flow rate at 8 L/min

Informing the primary healthcare provider of this finding

A newborn with acquired herpes simplex virus infection is being discharged. Which facet of development should the nurse instruct the parents to monitor closely? 1 - Visual clarity 2 - Renal function 3 - Long bone growth 4 - Responses to sounds

Visual clarity

Which criterion should a nurse use when assessing the gestational age of a preterm infant? 1 - Reflex stability 2 - Simian creases 3 - Breast bud size 4 - Fingernail length

Breast bud size

A client asks about the difference between cow's milk and breast milk. The nurse should respond that cow's milk differs from human milk in that it contains what? 1 - Less protein, less calcium, and more carbohydrates 2 - More protein, less calcium, and fewer carbohydrates 3 - Less protein, more calcium, and more carbohydrates 4 - More protein, more calcium, and fewer carbohydrates

More protein, more calcium, and fewer carbohydrates

A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70 mm Hg, pulse of 90 beats/min, respiratory rate of 22 breaths/min, and fetal heart rate of 132 beats/min. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, what problem does the nurse suspect? 1 - Preterm labor 2 - Uterine inertia 3 - Placenta previa 4 - Abruptio placentae

Placenta previa

The nurse is testing newborns' heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? Select all that apply. 1 - Preterm infant 2 - Infant with Down syndrome 3 - Small-for-gestational-age infant 4 - Large-for-gestational-age infant 5 - Appropriate-for-gestational-age infant

Preterm infant Small-for-gestational-age infant Large-for-gestational-age infant

A new father tells the nurse that he is anxious about not feeling like a father. What is the priority nursing action to meet this father's needs? 1 - Encouraging the father's participation in a parenting class 2 - Providing time for the father to be alone with and get to know the baby 3 - Offering the father a demonstration on newborn diapering, feeding, and bathing 4 - Allowing time for the father to ask questions after viewing a film about a new baby

Providing time for the father to be alone with and get to know the baby