Exam II

A 6-month-old child is being seen in the pediatrician's office. The child was born preterm and remained in the neonatal intensive care unit for the first 5 months of life. The child is being monitored for 5 chronic problems. Which of the following problems are directly related to the prematurity? Select all that apply. A. Bronchopulmonary dysplasia. B. Cerebral palsy. C. Retinopathy. D. Hypothyroidism. E. Seizure disorders

A, B, C, and E are correct. A. Bronchopulmonary dysplasia often is a consequence of the respiratory therapy that preemies receive in the NICU. B. Cerebral palsy results from a hypoxic insult that likely occurred as a result of the baby's prematurity. C. Retinopathy of the premature is a disease resulting from the immaturity of the vascular system of the eye. D. Hypothyroidism is one of the diseases assessed for in the neonatal screen. It is very unlikely that this problem resulted from the baby's stay in the NICU. E. Seizure disorders can result either from a hypoxic insult to the brain or from a ventricular bleed. Both of these conditions likely occurred as a result of the prematurity.

A nurse remarks to a 38-week-gravid client, "It looks like your face and hands are swollen." The client responds, "Yes, you're right. Why do you ask?" The nurse's response is based on the fact that the changes may be caused by which of the following? A. Altered glomerular filtration. B. Cardiac failure. C. Hepatic insufficiency. D. Altered splenic circulation.

A. Altered glomerular filtration leads to protein loss and, subsequently, to fluid retention, which can lead to swelling in the face and hands. The hypertension associated with preeclampsia results in poor perfusion of the kidneys. When the kidneys are poorly perfused, the glomerlular filtration is altered, allowing large molecules, most notably the protein albumin, to be lost through the urine. With the loss of protein, the colloidal pressure drops in the vascular tree, allowing fluid to third space. The body gets the message to retain fluids, exacerbating the problem. One of the early signs of the third spacing is the swelling of a client's hands and face.

Four full-term babies were admitted to the neonatal nursery. The mothers of each of the babies had labors of 4 hours or less. The nursery nurse should carefully monitor which of the babies for hypothermia? A. The baby whose mother cultured positive for group B strep during her third trimester. B. The baby whose mother had gestational diabetes. C. The baby whose mother was hospitalized for 3 months with complete placenta previa. D. The baby whose mother previously had a stillbirth.

A. Group B streptococcus causes severe infections in the newborn. A sign of neonatal sepsis is hypothermia.

A baby is in the NICU whose mother was addicted to heroin during the pregnancy. Which of the following nursing actions would be appropriate? A. Tightly swaddle the baby. B. Place the baby prone in the crib. C. Provide needed stimulation to the baby. D. Feed the baby half-strength formula.

A. Tightly swaddling drug-addicted babies often helps to control the hyperreflexia that they may exhibit.

The nurse is evaluating the effectiveness of bed rest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? A. Weight loss. B. 2+ proteinuria. C. Decrease in plasma protein. D. 3+ patellar reflexes

A. Weight loss is a positive sign. Loss of protein is not a sign of resolution of the disease.

A baby has just been born to a type 1 diabetic mother with retinopathy and nephropathy. Which of the following neonatal findings would the nurse expect to see? A. Hyperalbuminemia. B. Polycythemia. C. Hypercalcemia. D. Hypoinsulinemia.

B. Because the placenta is likely to be functioning less than optimally, it is highly likely that the baby will be polycythemic. The increase in red blood cells would improve the baby's oxygenation in utero.

A newborn nursery nurse notes that a baby's body is jaundiced at 36 hours of life. Which of the following nursing interventions will be most therapeutic? A. Maintain a warm ambient environment. B. Have the mother feed the baby frequently. C. Have the mother hold the baby skin to skin. D. Place the baby naked by a closed sunlit window

B. Bilirubin is excreted through the bowel. The more the baby consumes, the more stools, and therefore the more bilirubin the baby will expel.

A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lbs 2 oz, 21 inches long, TPR: 96.6ºF, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following actions should the nurse perform first? A. Swaddle the baby to provide warmth. B. Assess the glucose level of the baby. C. Take the baby to the mother for feeding. D. Administer the neonatal medications

B. The test taker should note that this baby is macrosomic and hypothermic, both of which make the baby at high risk for hypoglycemia. Plus, jitters are a classic symptom in hypoglycemic babies. In order to make an accurate assessment of the problem, the baby's glucose level must be assessed.

85. The nurse administers Lanoxin (digoxin) to a baby in the NICU that has a cardiac defect. The baby vomits shortly after receiving the medication. Which of the following actions should the nurse perform next? A. Give a repeat dose. B. Notify the physician. C. Assess the apical and brachial pulses concurrently. D. Check the vomitus for streaks of blood.

B. Vomiting is a sign of digoxin toxicity. This baby needs to have a digoxin level drawn. Because the nurse needs an order for the test, the nurse must notify the doctor of the problem

A 42-week gravida is delivering her baby. A nurse and pediatrician are present at the bith. The amniotic fluid is green and thick. The baby fails to breathe spontaneously. Which of the following actions should the nurse take next? A. Stimulate the baby to breathe. B. Assess neonatal heart rate. C. Assist with intubation. D. Place the baby in the prone position.

C. Before breathing, the baby must be intubated so that the meconiumcontaminated fluid can be aspirated from the baby's airway.

A neonate has intrauterine growth restriction secondary to placental insufficiency. Which of the following signs/symptoms should the nurse expect to observe at delivery? A. Thrombocytopenia. B. Neutropenia. C. Polycythemia. D. Hyperglycemia

C. Even if the test taker were unfamiliar with the expected lab findings of a neonate that had been born after living with an aging placenta, deductive reasoning could assist the test taker to choose the correct response. Aging placentas function poorly, and therefore the fetuses receive less nutrition and oxygenation. The baby's body, therefore, must compensate for the losses by metabolizing glycogen stores in the liver and producing increased numbers of red blood cells. The neonate, therefore, is often polycythemic and hypoglycemic.

A neonate is in the warming crib for poor thermoregulation. Which of the following sites is appropriate for the placement of the skin thermal sensor? A. Xiphoid process. B. Forehead. C. Abdominal wall. D. Great toe.

C. It is essential that the test taker be prepared safely to perform relatively simple procedures for the premature infant. To monitor the temperature of the premature, the probes should be placed on a nonbony and wellperfused tissue site. The abdominal wall is the site of choice.

A gravid client, G6P5005, 24 weeks' gestation, has been admitted to the hospital for placenta previa. Which of the following is an appropriate long-term goal for this client? A. The client will state an understanding of need for complete bedrest. B. The client will have a reactive nonstress test on day 2 of hospitalization. C. The client will be symptom-free until at least 37 weeks' gestation. D. The client will call her children shortly after admission.

C. That the client be symptom-free until at least 37 weeks' gestation is a longterm goal. At that time, the baby will be full term. Each and every one of the goals is appropriate for a client with placenta previa. Only the statement that projects the client's response into the future is, however, a long-term goal.

Which of the following findings should the nurse expect when assessing a client, 8 weeks' gestation, with gestational trophoblastic disease (hydatiform mole)? A. Protracted pain. B. Variable fetal heart decelerations. C. Dark brown vaginal bleeding. D. Suicidal ideations

C. The condition is usually diagnosed after a client complains of brown vaginal discharge early in the "pregnancy."

The nurse must perform nasopharyngeal suctioning of a newborn with profuse secretions. Place the following nursing actions for nasopharyngeal suctioning in chronological order. 1. Slowly rotate and remove the suction catheter. 2. Place thumb over the suction control on the catheter. 3. Assess type and amount of secretions. 4. Insert free end of the tubing through the nose.

4, 2, 1, and 3 is the correct order. 1. Rotation and removal of the suction catheter should be done after the tubing has been inserted through the nose and a thumb placed over the suction control on the catheter. 2. The nurse should place a thumb over the suction control on the catheter after inserting the free end of the tubing through the nose—and before the other two steps are taken. 3. Assessing the type and amount of secretions in the last step in the process. 4. Inserting the free end of the tubing through the nose is the first step in nasopharyngeal suctioning process.

A client with 4+ protein and 4+ reflexes is admitted to the hospital with severe preeclampsia. The nurse must closely monitor the woman for which of the following? A. Grand mal seizure. B. High platelet count. C. Explosive diarrhea. D. Fractured pelvis.

A. A client who is diagnosed with severe preeclampsia is high risk for becoming eclamptic. Clients who become eclamptic have had at least one seizure.

An insulin-dependent diabetic, G3P0200, 38 weeks' gestation, is being seen in the labor and delivery suite in metabolic dysequillibrium. The nurse knows that which of the following maternal blood values is most high risk to her unborn baby? A. Glucose 150 mg/dL. B. pH 7.25. C. pCO2 34 mm Hg. D. Hemoglobin A1c 10%.

B Acidosis is life threatening to the fetus. It is essential that the nurse monitor clients for situations that would put the fetus in jeopardy of being in an acidotic environment, including maternal hypoxia and diabetic ketoacidosis.

A client with mild preeclampsia, who has been advised to be on bed rest at home, asks why it is necessary. Which of the following is the best response for the nurse to give the client? A. "Bed rest will help you to conserve energy for your labor." B. "Bed rest will help to relieve your nausea and anorexia." C. "Reclining will increase the amount of oxygen that your baby gets." D. "The position change will prevent the placenta from separating."

C. The vital organs of preeclamptic clients are being poorly perfused as a result of the abnormally high blood pressure. When a woman lies on her side, blood return to the heart is improved and the cardiac output is also improved. With improved cardiac output, perfusion to the placenta and other organs is improved.

An obese client is being seen by the nurse during her prenatal visit. Which of the following comments by the nurse is appropriate at this time? A. "We will want you to gain the same amount of weight we would encourage any pregnant woman to gain." B. "To have a healthy baby we suggest that you go on a weight reduction diet right away." C. "To prevent birth defects we suggest that you gain weight during the first trimester and then maintain your weight for the rest of the pregnancy." D. "We suggest that you gain weight throughout your pregnancy but not quite as much as other women."

D Obese clients are encouraged to gain about 15 to 25 lb during their pregnancies. Normal weight clients are encouraged to gain between 25 and 35 pounds.

32. A woman, 8 weeks pregnant, is admitted to the obstetric unit with a diagnosis of threatened abortion. Which of the following tests would help to determine whether the woman is carrying a viable or a nonviable pregnancy? A. Luteinizing hormone level. B. Endometrial biopsy. C. Hysterosalpinogram. D. Serum progesterone level.

D. One relatively easy way to determine the viability of the conceptus is by performing a serum progesterone test; high levels indicate a viable baby while low levels indicate a pregnancy loss. Ultrasonography to assess for a beating heart may also be performed.

A newborn in the nursery is exhibiting signs of neonatal abstinence syndrome. Which of the following signs/symptoms is the nurse observing? Select all that apply. A. Hyperphagia. B. Lethargy. C. Prolonged periods of sleep. D. Hyporeflexia. E. Persistent shrill cry.

A & E Babies with signs of neonatal abstinence syndrome repeatedly exhibit signs of hunger. Babies with signs of neonatal abstinence syndrome often have a shrill cry that may continue for prolonged periods.

A neonate is being assessed for necrotizing enterocolitis (NEC). Which of the following actions by the nurse is appropriate? Select all that apply. A. Perform hemoccult test on stools. B. Monitor for an increase in abdominal girth. C. Measure gastric contents before each feed. D. Assess bowel sounds before each feed. E. Assess for anal fissures daily.

A, B, C, and D are correct. A. Babies with necrotizing enterocolitis (NEC) have blood in their stools. B. The abdominal girth measurements of babies with NEC increase. C. When babies have NEC, they have increasingly larger undigested gastric contents after feeds. D. The neonates' bowel sounds are diminished with NEC. E. The presence of anal fissures is unrelated to NEC.

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? A. Type O negative. B. Type A negative. C. Type B positive. D. Type AB positive.

A. A mother whose blood type is O, the blood type that is antigen negative, will produce anti-A and/or antiB antibodies against blood types A and/or B, respectively. The anti-A (and/or anti-B) that passes into the baby's bloodstream via the placenta can attack the baby's red blood cells if he or she is type A or B. As a result of the blood cell destruction, the baby becomes jaundiced.

In anticipation of a complication that may develop in the second half of pregnancy, the nurse teaches an 18-week gravid client to call the office if she experiences which of the following? A. Headache and decreased output. B. Puffy feet. C. Hemorrhoids and vaginal discharge. D. Backache.

A. Headache and decreased output are signs of preeclampsia. It is important for the test taker to realize that, although some symptoms like puffy feet may seem significant, they are normal in pregnancy, while other symptoms like headache, which in a nonpregnant woman would be considered benign, may be potentially very important in a pregnant woman.

A baby was just born to a mother who had positive vaginal cultures for group B streptococcus. The mother was admitted to the labor room 2 hours before the birth. For which of the following should the nursery nurse closely observe this baby? A. Hypothermia. B. Mottling. C. Omphalocele. D. Stomatitis.

A. Hypothermia in a neonate may be indicative of sepsis. Group B streptococci can seriously adversely affect neonates. In fact, group B strep has been called "the baby killer." To prevent a severe infection from the bacteria, mothers are given intravenous antibiotics every 4 hours from admission, or from rupture of membranes, until delivery. A minimum of 2 doses is considered essential to protect the baby. Since this woman arrived only 2 hours prior to the delivery, there was not enough time for 2 doses to be administered.

Based on maternal history of alcohol addiction, a baby in the neonatal nursery is being monitored for signs of fetal alcohol syndrome (FAS). The nurse should assess this baby for which of the following? A. Poor suck reflex. B. Ambiguous genitalia. C. Webbed neck. D. Absent Moro reflex

A. The characteristic facial signs of fetal alcohol syndrome— shortened palpebral (eyelid) fissures, thin upper lip, and hypoplastic philtrum (median groove on the external surface of the upper lip)—are rarely evident in the neonatal period. They typically appear later in the child's life. Rather the behavioral characteristics of the FAS baby, such as weak suck, irritability, tremulousness, and seizures, are present at birth.

A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? A. Assess deep tendon reflexes. B. Obtain complete blood count. C. Assess baseline weight. D. Obtain routine urinalysis.

A. The nurse should check the client's patellar reflexes. The most common way to assess the deep tendon reflexes is to assess the patellar reflexes. Preeclampsia is a very serious complication of pregnancy. The nurse must assess for changes in the blood count, for evidence of marked weight gain, and for changes in the urinalysis. By assessing the patellar reflexes first, however, the nurse can make a preliminary assessment of the severity of the preeclampsia. For example, if the reflexes are 2, the client would be much less likely to become eclamptic than a client who has 4 reflexes with clonus.

A client is being taught fetal kick counting. Which of the following should be included in the patient teaching? A. The woman should choose a time when her baby is least active. B. The woman should lie on her side with her head elevated about 30º. C. The woman should report fetal kick counts of greater than 10 in an hour. D. The woman should refrain from eating immediately before counting.

B This is the best position for perfusing the placenta. Since the goal of fetal kick counting is to monitor fetal wellbeing, it is best to do the test when the baby is most active and is most likely to be well nourished and well oxygenated. Many women find that the best time for the assessment is immediately after a meal.

Which of the following pregnant clients is most high risk for preterm premature rupture of the membranes (PPROM)? A. 30-week gestation with prolapsed mitral valve (PMV). B. 32-week gestation with urinary tract infection (UTI). C. 34-week gestation with gestational diabetes (GDM). D. 36-week gestation with deep vein thrombosis (DVT).

B. Although the exact mechanism is not well understood, clients who have urinary tract infections are high risk for PPROM. This is particularly important since pregnant clients often have urinary tract infections that present either with no symptoms at all or only with urinary frequency, a complaint of many pregnant clients.

A baby is born with erythroblastosis fetalis. Which of the following signs/symptoms would the nurse expect to see? A. Ruddy complexion. B. Anasarca. C. Alopecia. D. Erythema toxicum.

B. Babies born with erythroblastosis fetalis often are in severe congestive heart failure and, therefore, exhibit anasarca.

A woman is recovering at the gynecologist's office following a late first-trimester spontaneous abortion. At this time, it is essential for the nurse to check which of the following? A. Maternal rubella titer. B. Past obstetric history. C. Maternal blood type. D. Cervical patency

C It is essential that the woman's blood type be assessed.

A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal factors would predispose the baby to this diagnosis? Select all that apply. A. Hyperopia. B. Gestational diabetes. C. Substance abuse. D. Chronic hypertension. E. Advanced maternal age.

C, D, and E are correct. A. Hyperopia, another name for farsightedness, is unrelated to placental function. B. If the mother had gestational diabetes, the nurse would expect the baby to be macrosomic, not to have IUGR. C. Placental function is affected by the vasoconstrictive properties of many illicit drugs, as well as by cigarette smoke. D. Placental function is diminished in women who have chronic hypertension. E. Placental function has been found to be diminished in women of advanced maternal age. Any condition that inhibits the flow of blood, including illicit drug use, hypertension, cigarette smoking, and the like, can lead to fetal IUGR—that is, a fetus smaller than expected for the gestational period.

A 6-month-old child developed kernicterus immediately after birth. Which of the following tests should be done to determine whether or not this child has developed any sequelae to the illness? A. Blood urea nitrogen and serum creatinine. B. Alkaline phosphotase and bilirubin. C. Hearing and vision assessments. D. Peak expiratory flow and blood gas assessments.

C. Because the central nervous system (CNS) may have been damaged by the high bilirubin levels, testing of the senses as well as motor and cognitive assessments are appropriate.

A neonate, whose mother is HIV positive, is admitted to the NICU. A nursing diagnosis: Risk for infection related to perinatal exposure to HIV/AIDS is made. Which of the following interventions should the nurse make in relation to the diagnosis? A. Monitor daily viral load laboratory reports. B. Check the baby's viral antibody status. C. Obtain an order for antiviral medication. D. Place the baby on strict precautions

C. The standard of care for neonates born to mothers with HIV/AIDS is to begin them on anti-AIDS medication in the nursery. The mother will be advised to continue to give the baby the medication after discharge.

Which finding should the nurse expect when assessing a client with placenta previa? A. Severe occipital headache. B. History of renal disease. C. Previous premature delivery. D. Painless vaginal bleeding.

D. Painless vaginal bleeding is often the only symptom of placenta previa.

A client has severe preeclampsia. The nurse would expect the primary health care practitioner to order tests to assess the fetus for which of the following? A. Severe anemia. B. Hypoprothrombinemia. C. Craniosynostosis. D. Intrauterine growth restriction.

D. Perfusion to the placenta drops when clients are preeclamptic because the client's hypertension impairs adequate blood flow. When the placenta is poorly perfused, the baby is poorly nourished. Without the nourishment provided by the mother through the umbilical vein, the fetus' growth is affected

A 12-week-gravid client presents in the emergency department with abdominal cramps and scant dark red bleeding. What should the nurse assess this client for? A. Shortness of breath. B. Enlarging abdominal girth. C. Hyperreflexia and clonus. D. Fetal heart dysrhythmias

D. This client is showing signs of spontaneous abortion. The nurse should check the fetal heart rate. It is essential that the test taker carefully read the weeks of gestation when answering this question. If the client were in the third trimester, it would be appropriate to check the fetal heart as well as to monitor for increasing abdominal girth measurements. At 12 weeks, however, the latter assessment is not appropriate.

The staff on the maternity unit is developing a protocol for nurses to follow after a baby is delivered who fails to breathe spontaneously. Which of the following should be included in the protocol as the first action for the nurse to take? A. Prepare epinephrine for administration. B. Provide positive pressure oxygen. C. Administer chest compressions. D. Rub the back and feet of the baby

D. When a neonate fails to breathe, the nurse should: dry the baby and provide tactile stimulation, place the child in the "sniff" position under a radiant warmer, and suction the mouth and nose of any mucus. Only after these initial actions fail—since the vast majority of the time the baby will respond—should further intervention be begun.

A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? A. Low serum creatinine. B. High serum protein. C. Bloody stools. D. Epigastric pain.

D. When the liver is deprived of sufficient blood supply, as can occur with severe preeclampsia, the organ becomes ischemic. The client experiences pain at the site of the liver as a result of the hypoxia in the liver.