Maternal Exam 2 Study Guide
hypoglycemia in a mature newborn is denied as a blood glucose level below which amount?
40
a nurse is caring for a client who has delivered her first newborn less than 24 hours ago. The newborn has been diagnosed with hyperbilirubinemia. While providing education to the client on this condition, the nurse should include what has potential causes of this condition? (SATA)
1. biliary atresia 2. abo incompatibility 3. Rh isoimmunization (blood group incompatibility)
when assessing a newborn, the apgar score determines the ability of the newborn to transition to extrauterine life. What does the Apgar score assess? (SATA)
1. color 2. heart rate 3. respiration
in caring for a postpartum client, the nurse will include assessment and observation for signs of postpartum hemorrhage. What would indicate an increased risk for postpartum hemorrhage? (SATA)
1. macrocosmic infant 2. dysfunctional or prolonged labor 3. multiparty
after delivery, a client is diagnosed with postpartum preeclampsia. What care will the nurse provide to this client? (SATA)
1. maintain on bed rest with bathroom privileges 2. monitor urine output and daily weight 3. administer magnesium sulfate as prescribed 4. administer antihypertensive medication as prescribed
a nurse is assessing a newborn for congenital hip dysplasia. Which signs or symptoms should be brought to the attention of the health care provider for further assessment? (SATA)
1. newborn has one leg that appears longer than the other 2. newborn who has extra skin folds on the inner thigh of one leg 3. newborn who has a click in the hip joint when one hip is maneuvered
the nurse is evaluating a new mother's ability to effectively breastfeed her newborn. What criteria indicates that the mother should be breastfeeding?
1. nipples are everted 2. breast are soft and nontender 3. mother holds the newborn close to her breast (holds newborn like a football) 4. newborn swallows spontaneously and frequently
in providing care to the postpartum client, the nurse recognizes that women are hypercoagulable during the third trimester of pregnancy and that assessment of this client should include evaluation for the development of venous thromboembolism. Which of the following should be included in this evaluation? (SATA)
1. observe the lower extremities for symmetry 2. auscultation of lung sounds 3. observation of respiratory rate and effort
the nurse in the pediatric clinic is providing education to the parents of a child newly diagnosed with autism. Which of the following would be included in the lifestyle implementation? (SATA)
1. social skills training 2. speech and language therapy 3. structured and predictable environment
during a home visit, the nurse determines that a toddler has a difficult temperament. What did the nurse observe in this visit? (SATA)
1. withdrawing 2. intense mood/negative mood 3. menial adaptability
the nurse is teaching new parents how to calculate the amount of formula to feed their newborn each day. The baby weighs 8 lbs. How much formula should the nurse teach the parents to provide?
16-24 oz
the nurse is preparing formula for a preterm newborn. Which type of formula will most likely be prescribed for this client?
24 calorie per ounce infant formula
when caring for a newborn several hours after birth, what would the nurse assess as a normal newborns respiratory rate?
30-60 breaths per minute
while assessing the newborn's 5 minute apgar score, the nurse notes the following: heart rate 154, respiratory effort lusty cry, muscle tone well flexed with active movement, reflex irritability crying vigorously with stimulation, color hands and feet are blue. What score would she assign to this newborn?
9
the nurse provides discharge instructions to a postpartum client who had a vaginal birth. What client statement indicates that teaching has been effective?
I can return to my full-time job after 6 weeks
a new mother asks the nurse how soon she can try to breastfeed after delivery. Which of the following would be the nurse's best response?
as soon as possible or as soon as the newborn shows feeding cues
a newborn goes through many changes at the time of delivery when transitioning to extrauterine life. What changes are normal?
acrocyanosis
a postpartum woman has a fourth-degree perineal laceration. Which of the following physician orders would the nurse anticipate?
administer of acetaminophen/oxycodone for pain
a newborn is prescribed to receive vitamin k 0.5 mg intramuscularly. What should the nurse do to administer this medication to the newborn?
administer the medication into the vests lateralis
what actions should the nurse take to prepare the preschool aged child for a physical examination?
allow the child to role play
a nurse is caring for a newborn with myelomeningocele. What actions should the nurse include in their care?
apply a sterile, moist dressing on the sac
the nurse is called to the room of a client who had a term delivery of a 9 lb, 8 oz. newborn 24 hours ago. The client is noted to have lost consciousness on her way to the bathroom, what is the nurses first priority?
assess and massage the fundus
the nurse is providing discharge teaching to the postpartum client regarding mood changes to report. In differentiating between the baby blues and postpartum depression, what statements would be accurate?
baby blues may present in the first few days after birth and resolves prior to the second postpartum week
which of the following is an advantage of breastfeeding for the newborn?
breast milk contains antibodies and decreases the possibility of gastrointestinal disorders and obesity
a newborn has loose, yellow stools. The newborn appears healthy, but his mother is concerned that this means he is allergic to breast milk. What is the nurses response?
breastfed newborns stools are normally loose
the nurse is preparing a seminar on breastfeeding for a group of pregnant clients. Which information should the nurse include during the seminar?
breastfeeding enhances bonding with the newborn
an infant develops hydrocephalus at 2 weeks of age. What finding would the nurse expect to assess?
bulging fontanels
which assessment finding indicates to the nurse that a newborn has hip sublimation?
inability for the hip to abduct
while inspecting a newborn's head, the nurse identifies a swelling of the scalp on the right posterior side of the head, what is this expected finding?
cephalohematoma
a newborn was delivered 2 hours ago is being assessed in the nursery. Upon exam, the nurse notes a flattened nasal bridge, wide cat eyes, what would the nurse expect the physician to order?
chromosomal blood testing
the nurse is assessing a term newborn. Which finding should the nurse expect when assessing the pattern of sole creases?
creases on two thirds of the foot
when assessing a newborn, what techniques should the nurse use to elicit the stepping reflex?
hold the newborn upright with their feet touching a flat surface
why are postpartum women prone to urinary retention?
decreased bladder sensation results from edema because of pressure from birth
a woman who delivered a term neonate 3 days ago is complaining of fever, fatigue, and heavy vaginal discharge. On assessment, the nurse expects what diagnosis?
endometritis
a nurse at a well-baby clinic is collecting data about a nine-month-old infant. The nurse understands that what occurs at this stage of development?
fear of strangers
the parents of a newborn are concerned that something is wrong with their newborn eyesight. What should the nurse reassure the parents as being an expected finding in the newborn?
follows a light to the midline
the nurse is assessing the fundus on a client on postpartum day 2. What should the nurse expect when palpating the fundus?
funds two finger breadths below the umbilicus and firm
a nurse is caring for a 9-month-old with influenza. What would be a toy that could be used to interact, play, or distract them from the discomfort?
graduated size wooden rings on a solid platform or large plastic blocks
the nurse on the postpartum unit is reviewing uterotonic (oxytocic) medications with a group of nursing students. What medication is oxytocic?
hemabate
a nurse is assessing a newborn that was admitted to the newborn nursery 28 hours ago. Mother's history includes addiction to recreational drugs. Which finding would the nurse expect?
incessant crying
by the time children reach their twelfth birthday, they should have learned to trust others and should have developed a sense of...
industry
a preterm newborn is placed in a radiant heat warmer immediately after birth. What nursing diagnoses would this be?
ineffective thermoregulation related to immaturity
according to erickson, which stage of development has the developmental task, trust vs mistrust?
infancy
the nurse is assessing a child who has been diagnosed with mononucleosis for splenomegaly. which area of the abdomen would be palpated to identify the abnormality?
left upper quadrant (LUQ)
the nurse assesses a postpartum client's discharge as being moderate in amount and red in color. How should the nurse document the appearance of the lochia?
lochia rubra
the nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful, inflamed area on one breast. Upon assessment, the nurse notes a wedged-shaped area on one breast to be red and warm to touch. Clients temperature is 101.8. What should the nurse consider is the potential diagnosis?
mastitis
the nurse is caring to a postpartum woman 18 hours after the primary cesarean section for preeclampsia. The client is noted to have a boggy uterus and a moderate to large amount of vaginal bleeding. The nurse notifies the physician of these findings and expects an order for what?
misoprostol
which action by the mother relates to the nurse that she is accepting her child?
mom turns her face to meet the newborn's eyes when she holds her newborn
the nurse instructs the parents of a newborn on actions to prevent sudden infant death syndrome. What observation indicates that teaching has been effective?
newborn is placed on the back to sleep
according to piaget, which basic concept will the child learn during the first year of life?
newborns are not an extension of their parents
during the assessment of a 7-year-old male the nurse notes an abnormal depression of the lower portion of the sternum. The child is alert and orientated and in no apparent distress. what should the nurse expect?
pectus exacavatum
a client recently delivered a newborn and her legs are still numb from the epidural . The nurse assessed the fundus and found it to be at 1 fingerbreadth above the umbilicus and deviated to the right. What is the priority nursing action?
perform a straight cauterization to receive bladder distention
a newborn has jaundice and receiving phototherapy. Which of the following is an appropriate intervention when caring for a newborn with hyperbilirubinemia?
place eye shields over the newborns closed eyes
which technique is used to palpate the fundal height on a postpartum client?
placing one hand at the base of the uterus and one on the fungus
during a home visit, a postpartum client reports fullness and tenderness on the outer side of her right breast. with light palpation, the nurse feels a small lump with engorgement. what is the expected finding?
plugged milk duct
the nurse is assisting a new mother to begin breastfeeding. Which action is the most appropriate for the nurse to take?
positioning the newborn near her breast and stroking newborn cheek to encourage him to latch
the nurse is assessing a client at her 6-week postpartum appointment. The client states that she feels tired all the time, has trouble falling and staying asleep, the nurse would expect that the client has?
postpartum depression
at birth the newborn has dry, cracked skin, absence of vernix, lack of subcutaneous fat, and fingernails extending beyond the fingertips. Based on these findings what term would the nurse expect the newborn?
postterm
according to erickson, which stage of development has the developmental task, initiative vs guilt?
preschool toddler
a nurse is caring for an adolescent whose mother expresses concern about the child sleeping such long hours. What is associated with the long sleeping hours?
rapid growth
a nurse is caring for a 4-year-old female. What action is expected of a preschool aged child?
relating fears to magical thinking
when planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection?
reproductive tract
the nurse is inspecting a male newborn genitalia. Which action should the nurse avoid?
retracting the foreskin over the glans to assess for secretions
a newborn has just returned from surgery to place a gastrostomy tube. Which nursing diagnosis will the nurse use?
risk for impaired skin integrity or risk for thermoregulation
a postpartum women (gravida1, para 1) asks the nurse immediately after delivery if she should request rooming-in with her newborn. what would be the best response from the nurse?
rooming-in allows increases maternal-newborn contact
the nurse is concerned that a new mother is not showing interest in the newborn and does not participate in newborn care. What action should the nurse take to help both the mother and newborn during initial change and growth period?
schedule home visits for mother, newborn, and support person
a postpartum woman is prescribed an antibiotic because of endometritis. Her breast-fed newborn should be observed for...
signs of thrush and easy bruising
the nurse in the pediatric clinic is recording anthropometric data in the 12-month-old child's chart. The father asks, is my son growing the way that he should?" Which of the following nurses response?
the child's weight will triple the birth weight by one year of age
a nurse is helping her postpartum client up to the bathroom for the first time after delivery. Which finding indicates her lochia is normal or expected?
the color of the flow is red
the nurse had instructed a mother on the importance of providing a toddler with a balanced diet. What observation during a home visit indicates that the mother understands the education?
the mother prepares a scrambled egg for the toddlers breakfast
a new mother asks the nurse how to determine if the baby is receiving enough breast milk. How should the nurse respond to the mother?
the newborn should gain weight and have six wet diapers daily
during a home visit, a new mother is concerned that after three meconium stools her newborn is now starting to have yellow seedy stools. What should the nurse explain?
this is a normal finding
according to erickson, which stage of development has the developmental task, autonomy vs shame?
toddler
the nurse observes a mother telling a toddler that pasta and potatoes will make the child fat. What should the nurse instruct the mother about these food items?
toddlers need carbohydrates for brain function
