Maternity chapter 32 Questions

The client with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse? 1. "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." 2. "Your body has made antibodies against the baby's blood that are destroying her red blood cells." 3. "The red blood cells of your baby are breaking down because you both have type O blood." 4. "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."

"Your body has made antibodies against the baby's blood that are destroying her red blood cells."

The nurse caring for a newborn with anemia would expect which initial laboratory data to be included in the initial assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Hemoglobin 2. Hematocrit 3. Reticulocyte count 4. Direct Coombs' test 5. Cord serum OgM

- Hemoglobin -Hematocrit - Reticulocyte count -Direct Coombs' test

A newborn is receiving phototherapy. Which intervention by the nurse would be most important? 1. Measurement of head circumference 2. Encouraging the mother to stop breastfeeding 3. Stool blood testing 4. Assessment of hydration status

-. Assessment of hydration status

Which nursing interventions are appropriate when caring for the newborn undergoing phototherapy? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cover the newborn's eyes at all times, even when not under the lights. 2. Close the newborn's eyelids before applying eye patches. 3. Inspect the eyes each shift for conjunctivitis. 4. Keep the baby swaddled in a blanket to prevent heat loss. 5. Reposition the baby every 2 hours.

-Close the newborn's eyelids before applying eye patches. -Inspect the eyes each shift for conjunctivitis. -Reposition the baby every 2 hours.

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following signs and symptoms would not be characteristic of RDS? 1. Grunting respirations 2. Nasal flaring 3. Respiratory rate of 40 during sleep 4. Chest retractions

-Respiratory rate of 40 during sleep

What indications would lead the nurse to suspect sepsis in a newborn? 1. Respiratory distress syndrome developing 48 hours after birth 2. Temperature of 97.0°F 2 hours after warming the infant from 97.4°F 3. Irritability and flushing of the skin at 8 hours of age 4. Bradycardia and tachypnea developing when the infant is 36 hours old

-Temperature of 97.0°F 2 hours after warming the infant from 97.4°F

The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Lights can stay on all the time. 2. The eyes do not need to be covered. 3. The lights will need to be removed for feedings. 4. Newborns do not get overheated. 5. Weight loss is not a complication of this system.

1. Lights can stay on all the time. 2. The eyes do not need to be covered. 4. Newborns do not get overheated. 5. Weight loss is not a complication of this system.

Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Obtain skin cultures. 2. Restrict parental visits. 3. Evaluate bilirubin levels. 4. Administer oxygen as ordered. 5. Observe for signs of hypoglycemia.

1. Obtain skin cultures. 3.Evaluate bilirubin levels. 4. Administer oxygen as ordered. 5. Observe for signs of hypoglycemia.

Which findings would the nurse expect when assessing a newborn infected with syphilis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Rhinitis 2. Fissures on mouth corners 3. Red rash around anus 4. Lethargy 5. Large for gestational age

1. Rhinitis 2. Fissures on mouth corners 3. Red rash around anus

13) Which nursing intervention is appropriate in the management of the preterm infant with hypothermia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Warm the baby rapidly to reverse the hypothermia. 2. Monitor skin temperature every 2 hours to determine whether the infant's temperature is increasing. 3. Keep IV fluids at room temperature. 4. Initiate efforts to maintain the newborn in a neutral thermal environment. 5. Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment.

4. Initiate efforts to maintain the newborn in a neutral thermal environment. 5. Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment.

The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse expect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Jaundice present within the first 24 hours of life 2. Appearance of jaundice symptoms after 24 hours of life 3. Yellowish coloration of the sclera of the eyes 4. Cephalohematoma or excessive bruising 5. Cyanosis

Appearance of jaundice symptoms after 24 hours of life Yellowish coloration of the sclera of the eyes

The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? 1. Eyes are covered, no clothing on, diaper in place 2. Axillary temperature 99.7°F 3. Infant removed from the isolette for breastfeeding 4. Loose bowel movement

Axillary temperature 99.7°F

A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best? 1. Begin chest compressions. 2. Begin direct tracheal suctioning. 3. Begin bag-and-mask ventilation. 4. Obtain a blood pressure reading.

Begin bag-and-mask ventilation.

The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dL to 16.6 mg/dL in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn? 1. Continue to observe 2. Begin phototherapy 3. Begin blood exchange transfusion 4. Stop breastfeeding

Begin phototherapy

The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following? 1. A history of obsessive-compulsive disorder (OCD) 2. Chlamydia 3. Delivered six other children by cesarean section 4. A urinary tract infection (UTI)

Chlamydia

A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse anticipate? 1. Delivery of the neonate on its side with head up, to facilitate drainage of secretions. 2. Direct tracheal suctioning by specially trained personnel. 3. Preparation for the immediate use of positive pressure to expand the lungs. 4. Suctioning of the oropharynx when the newborn's head is delivered.

Direct tracheal suctioning by specially trained personnel.

1) The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require which of the following? 1. Initial resuscitation 2. Vigorous stimulation at birth 3. Phototherapy immediately 4. An initial feeding of iron-enriched formula

Initial resuscitation

One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate? 1. Meticulous hand washing and antibiotic eye ointment administration. 2. Intravenous acyclovir (Zovirax) and contact precautions. 3. Cultures of blood and CSF and serial chest x-rays every 12 hours. 4. Parental rooming-in and four intramuscular injections of penicillin.

Intravenous acyclovir (Zovirax) and contact precautions.

Mild or chronic anemia in an infant may be treated adequately which of the following? 1. Transfusions with O-negative or typed and cross-matched packed red cells 2. Iron supplements or iron-fortified formulas 3. Steroid therapy 4. Antibiotics or antivirals

Iron supplements or iron-fortified formulas

What content should the nurse include in this presentation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Physiologic jaundice occurs after 24 hours of age. 2. Pathologic jaundice occurs after 24 hours of age. 3. Phototherapy increases serum bilirubin levels. 4. The need for phototherapy depends on the bilirubin level and age of the infant. 5. Kernicterus causes irreversible neurological damage.

Physiologic jaundice occurs after 24 hours of age. Kernicterus causes irreversible neurological damage

Which of the following are considered risk factors for development of severe hyperbilirubinemia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Northern European descent 2. Previous sibling received phototherapy 3. Gestational age 27 to 30 weeks 4. Exclusive breastfeeding 5. Infection

Previous sibling received phototherapy Exclusive breastfeeding Infection

The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Increased pulse 2. High blood pressure 3. Tachycardia 4. Bradycardia 5. Capillary filling time greater than 3 seconds

Tachycardia Capillary filling time greater than 3 seconds

The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? 1. The newborn maintains a normal temperature 2. An increase of serum bilirubin levels 3. Weight loss 4. Skin blanching yellow

The newborn maintains a normal temperature

During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations? 1. The rise and fall of the chest 2. Sudden wakefulness 3. Urinary output 4. Adequate thermoregulation

The rise and fall of the chest

The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition? 1. Meconium aspiration syndrome 2. Transient tachypnea of the newborn 3. Respiratory distress syndrome 4. Prematurity of the neonate

Transient tachypnea of the newborn

The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? 1. Urine specific gravity is assessed each voiding. 2. Eye coverings are left off to help keep the baby calm. 3. Temperature is checked every 6 hours. 4. The infant is taken out of the isolette for diaper changes.

Urine specific gravity is assessed each voiding.

Which fetal/neonatal risk factors would lead the nurse to anticipate a potential need to resuscitate a newborn? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Nonreassuring fetal heart rate pattern/sustained bradycardia 2. Fetal scalp/capillary blood sample pH greater than 7.25 3. History of meconium in amniotic fluid 4. Prematurity 5. Significant intrapartum bleeding

_Nonreassuring fetal heart rate pattern/sustained bradycardia - History of meconium in amniotic fluid -Prematurity -Significant intrapartum bleeding