Maternity Test 3, High/Low Risk Newborn, Reflexes, Drug Withdrawal, Contraception and Sexual Adaptation

Which term describes placement of the sperm and ova into the fallopian tube? A. Embryo transfer (ET) B. In vitro fertilization (IVF) C. Gamete intrafallopian transfer (GIFT) D. Assisted reproductive technologies (ART)

C. Gamete intrafallopian transfer (GIFT)

A 22-year-old patient has presented to her primary care provider for her scheduled Pap smear. Abnormal results of this diagnostic test may imply infection with: a) human papillomavirus (HPV). b) Chlamydia trachomatis. c) Candida albicans. d) Trichomonas vaginalis.

A) human papillomavirus (HPV)Although a Pap smear does not test directly for HPV, dysplasia of cervical cells is strongly associated with HPV infection. An abnormal Pap smear is not indicative of chlamydial infection, trichomoniasis, or candidiasis.

A nurse is conducting a head to toe assessment on a preterm infant that was just delivered. Which of the following are characteristics of a preterm infant that the nurse would expect to find? (select all that apply) a. small size and increased muscle tone b. small size and poor muscle tone c. wrinkled skin d. thin and tacky skin e. red skintone f. peeling skin g. no SQ fat

b. small size and poor muscle tone d. thin and tacky skin e. red skintone g. no SQ fat

The nurse is educating a mother who has recently given birth to an infant at 36 weeks gestation. The nurse explains that one of the best ways to promote adequate thermoregulation of her infant is to: a. swaddle the infant and rock the infant back and forth in a vertical motion b. leave the infant uninterrupted under the warmer throughout the day to ensure adequate thermoregulation is maintained c. participate in skin to skin kangaroo care which promotes thermoregulation of her infant and improves their oxygenation levels

c. participate in skin to skin kangaroo care which promotes thermoregulation of her infant and improves their oxygenation levels

A nurse is caring for an infant that exhibits extremely quiet behavior with no use of energy. The infant is easily exhausted from the noise of the nursery and sleeps for a long span of hours. Based on these findings, the nurse knows that this infant is a: a. post-term infant b. infant of a diabetic mom c. preterm infant d. infant of a drug using mom

c. preterm infant

he nurse is preparing to instruct a client in how to bathe a newborn. Which statement should the nurse include in the instruction? 1."Begin with the eyes and face." 2."Begin with the feet and work upward." 3."Do the back side first, and then the front side." 4."Start with the chest, move to the face, and then finish the rest of the body."

1 Bathing should start at the eyes and face, usually the cleanest area. Next the external ear and the area behind the ears are cleansed. The newborn's neck should be washed because formula, lint, or breast milk will often accumulate in the folds of the neck. Hands and arms are then washed. The newborn's legs are washed next, and the diaper area is washed last.

The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which would the nurse expect to note in the neonate? 1.Tremors 2.Bradycardia 3.Flaccid muscles 4.Extreme lethargy

1 Clinical symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea.

The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions? 1.The mother bathes the newborn infant after a feeding. 2.The mother states that she would gather all supplies before the bath is started. 3.The mother states that she would never leave the newborn infant in the tub of water alone. 4.The mother fills a clean basin or sink with 2 to 3 inches of water and then checks the temperature with her wrist.

1 It is not advisable to bathe a newborn infant after a feeding because handling may cause regurgitation. Because bathing is thought to be relaxing to the infant, bathing before feeding may be the best time. All other options are appropriate interventions in teaching the mother how to bathe a newborn.

The nurse is preparing to bathe a 1-day-old newborn. Which action should the nurse avoid when performing the procedure? 1.Immersing the newborn in water 2.Supporting the newborn's body during the bath 3.Ensuring that the water temperature is warm 4.Ensuring that the water temperature does not exceed 100° F

1 Newborn infants may be immersed in water after the umbilical stump has healed. The infant's body must be supported at all times during the bath. Water should be warm, not hot. A bath thermometer may be used to check the temperature of the water, which should not exceed 100° F. If a thermometer is not available, water that is comfortable when tested on the inside of the wrist or elbow is appropriate.

On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? 1.At 1 minute after birth and 5 minutes after birth 2.Immediately at birth, 3 minutes after birth, and 10 minutes after birth 3.At 1 minute after birth, 5 minutes after birth, and 10 minutes after birth 4.At 1 minute after birth, after the cord is cut, and after the mother delivers the placenta

1 One of the earliest indicators of successful adaptation of the newborn is the Apgar score. This test is performed 1 minute after birth and again 5 minutes after birth.

Which of the following signs and symptoms would indicate to the nurse that an infant is experiencing respiratory distress syndrome? Select all that apply 1) intercostal and subcostal retractions 2) bradypnea 3) tachypnea 4) nasal flaring 5) cyanosis

1, 3, 4, 52) Bradypnea is not listed

The nurse conducts a neurological assessment of the newborn. Which findings indicate the need for further evaluation? SELECT ALL THAT APPLY 1. Asymmetrical fine jumping movements of the leg and arm muscles 2. Fanning and hyperextension of toes when the sole is stroked upward from the heel 3. Grasping a finger placed in the neonate's palm 4. Muscle flaciddity not relieved by holding the newborn 5. Weak and ineffective sucking movements

1, 4, 5. The usual position of the infant is partially flexed and all movements should by symmetrical. Any weak, absent, asymmetrical, or fine jumping movements suggest nervous system disorders and indicate the need for further evaluation. Common reflexes found in the normal newborn include the Babinski (or plantar), which is fanning, and hyperextension of the toes when the sole is stroked upward from the heel toward the ball of the foot and the grasping reflex, elicited by stimulating the newborn to grasp on an object by touching the palm of the hand.

A mother was diagnosed with gonorrhea immediately after delivery. When providing nursing care for the infant, what is an important goal of the nurse? 1. Prevent the development of ophthalmia neonatorum. 2. Lubricate the eyes. 3. Prevent the development of thrush. 4. Teach the danger of breastfeeding with gonorrhea.

1. A newborn can become infected with gonorrhea as he or she passes through the birth canal. Gonorrhea can cause permanent blindness in the newborn, called ophthalmia neonatorum. All babies' eyes are treated with an antibiotic prophylactically after birth. The eyes require antibiotic prophylaxis, not lubrication. Thrush would result from a yeast infection rather than gonorrhea. There is no risk for breastfeeding because of gonorrhea.

When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? 1. Bradycardia 2. Hyperglycemia 3. Metabolic alkalosis 4. Shivering

1. Bradycardia. Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.

A mother asks, "Is it true that breast milk will prevent my baby from catching colds and other infections?" The nurse should make which reply based on current research findings? 1. "Your baby will have increased resistance to illness caused by bacteria and viruses, but may still contract infections." 2. "You shouldn't have to worry about your baby's exposure to contagious diseases until the breastfeeding period of time is over." 3. "Breast milk offers no greater protection to your baby than formula feedings." 4. "Breast milk will give your baby protection from all illnesses to which you are immune."

1. Breast milk will not protect the baby from all illnesses. Lactoferrin (a whey protein in human milk) inhibits the growth of iron-dependent bacteria in the GI tract together with secretory IgA (another whey protein in human milk), which protects against respiratory and GI bacteria, viral organisms, and allergies. Breast milk does have other enzymes and proteins that protect the infant from illness.

A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: 1. Connect the resuscitation bag to the oxygen outlet 2. Turn on the apnea and cardiorespiratory monitors 3. Set up the intravenous line with 5% dextrose in water 4. Set the radiant warmer control temperature at 36.5 C (97.6F)

1. Connect the resuscitation bag to the oxygen outlet. The highest priority on admission to the nursery for a newborn with low Apgar scores is AIRWAY, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.

A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as: 1. Milia 2. Lanugo 3. Whiteheads 4. Mongolian spots

1. Milia occur commonly, are not indicative of any illness, and eventually disappear.

To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: 1. Monitoring for the passage of meconium each shift 2. Instituting phototherapy for 30 minutes every 6 hours 3. Substituting breastfeeding for formula during the 2nd day after birth 4. Supplementing breastfeeding with glucose water during the first 24 hours

1. Monitoring for the passage of meconium each shift - Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.

A postpartal client has decided to bottle-feed her infant. The nurse would teach the client that which of the following is an acceptable guideline for the use and storage of canned formula? 1. Powdered formulas are the least expensive but must be refrigerated. 2. Tap water in cities is clean and need not be sterilized for preparing infant formula. 3. Refrigerating unused portions of the infant's formula after feeding is a good practice. 4. Unused formula in an opened can should be discarded after 48 hours.

1. Opened cans of formula must be used within a 24-hour period. There are no nutrients in whole milk that can enhance formula. The least expensive option is powdered formula but it must be properly prepared and stored. Tap water is not always safe. Any formula not taken by the infant should be disposed of as bacteria from the infant's mouth can enter the bottle and contaminate the remaining formula.

The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should most appropriately document which Apgar score for the newborn? 1.3 2.5 3.7 4.10

2 One of the earliest indicators of successful adaptation of the newborn is the Apgar score. Scores range from 0 to 10. Five criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 = 1; greater than 100 = 2. Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0; some extremity flexion = 1; active, moving, and well flexed = 2. Irritability or reflexes (measured by bulb suctioning): no response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of extremities = 1; pink = 2. Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more vigorous resuscitation.

A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL. The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn? 1.Applying lotions to exposed newborn skin 2.Assessing skin integrity and fluid status of the newborn 3.Having minimal contact with the newborn to prevent stimulation 4.Advising the mother to limit the newborn's oral intake during phototherapy

2 Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Assessing skin integrity and fluid status of the newborn infant is an essential component of phototherapy. Lotions are not used to ensure the therapeutic effect of light exposure in subcutaneous tissue. Contact with the newborn infant is important. Adequate oral fluids are essential to prevent dehydration because diarrhea is a common side effect of therapy. In addition, safe care for the newborn infant during phototherapy requires shielding the eyes with a soft eye shield to prevent retinal damage, keeping the newborn's skin exposed except for the wearing of a diaper, and changing the newborn's position frequently.

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely finding? 1.A depressed anterior fontanel 2.A soft and flat anterior fontanel 3.An anterior fontanel measuring 1 cm 4.An anterior fontanel measuring 7 cm

2 The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat and may range in size from almost nonexistent to 4 to 5 cm across. It normally closes by 18 to 24 months of age. A depressed fontanel may indicate dehydration.

While changing the diaper of an 8 hr. old infant, the Mom notices blood in the stool and notifies the nurse. Upon assessment, the nurse notices mild abdominal distention, lethargy, and that the baby's temperature is 95.1F. Which of the following complications does the nurse suspect? 1) High levels of phenylalanine 2) Necrotizing enterocolitis 3) Fetal drug withdrawal 4) Hyperbilirubinemia

2) Necrotizing enterocolitisOther s/s include: feeding intolerance, bile-colored vomiting

The nurse is admitting a neonate two hours after delivery. Which assessment data should the nurse be concerned about? SELECT ALL THAT APPLY 1. Hands and feet blue with otherwise pink color 2. Bilateral nasal flaring 3. Minimal response to verbal stimulation 4. Apical heart rate 140-1565. Chest retractions

2, 5. Nasal flaring and chest retraction could be signs of respiratory distress and require immediate intervention. Blue hands and feet, a minimal response to verbal stimulation and apical heart rate of 140-156 are normal findings for a neonate at two hours of age.

A baby's mother is HIV-positive. Which intervention is most important for the nurse to include when planning care for this newborn? 1. Encourage the mother to breastfeed. 2. Administer zidovudine (ZDV) after delivery. 3. Cuddle the baby as much as possible. 4. Place the baby's crib in a quiet corner of the nursery.

2. Administering zidovudine (ZDV, formerly AZT) to the mother prenatally and intrapartally, as well as to the infant immediately after delivery, decreases the prenatal risk of transmission of HIV by decreasing the prenatal risk of transmission of HIV by 60-70%. Breastfeeding is contraindicated in an HIV-positive mother because the virus can be passed through breast milk. Cuddling the infant is important, but not the highest priority in this situation. Decreasing environmental stimulation is not indicated.

By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? 1. Conduction 2. Convection 3. Evaporation 4. Radiation

2. Convection heat loss is the flow of heat from the body surface to the cooler air. Conduction is a loss of heat via direct contact with cold surface like the scales. Evaporation is a loss of heat when the baby's wet skin is exposed to air. Radiation is transfer of heat from body surface to cooler surfaces & objects not in direct contact with the body (incubator).

While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? 1. Activate the code blue or emergency system. 2. Do nothing because acrocyanosis is normal in the neonate 3. Immediately take the newborn's temperature according to hospital policy 4. Notify the physician of the need for a cardiac consult

2. Do nothing because acrocyanosis is normal in the neonate. Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.

The nurse is aware that a healthy newborns respirations are: 1. Regular, abdominal, 40-50 per minute, deep 2. Irregular, abdominal, 30-60 per minute, shallow 3. Irregular, initiated by chest wall, 30-60 per minute, deep 4. Regular, initiated by the chest wall, 40-60 per minute, shallow

2. Irregular, abdominal, 30-60 per minute, shallow - Normally the newborn's breathing is abdominal and irregular in depth and rhythm; the rate ranges from 30-60 breaths per minute.

The nurse would take which action as part of nursing care of the infant experiencing neonatal abstinence syndrome? 1. Place stuffed animals and mobiles in the crib to provide visual stimulation. 2. Position the baby's crib in a quiet corner of the nursery. 3. Avoid the use of pacifiers. 4. Spend extra time holding and rocking the baby.

2. Neonatal abstinence syndrome, or drug withdrawal, causes hyper stimulation of the neonate's nervous system. Nursing interventions should focus on decreasing environmental and sensory stimulation during the withdrawal period. Pacifiers allow for nonnutritive sucking by the infant.

At two days of age, the nurse hears a murmur over the right and left auricles of the newborn's heart. The nurse concludes that this may represent patency of which infant structure? 1. Open umbilical vein 2. Foramen ovale 3. Patent ductus arteriosus 4. Patent ductus venosus

2. The foramen ovale is an opening between the right and left atria that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system. The open umbilical vein, patent ductus arteriosus, and patent ductus venous are incorrect as they do not connect the right and left atria.

A newborn admitted to the nursery 15 minutes after birth is moderately cyanotic, has a mottled trunk, active movement of the extremities, and is wrapped in a cotton blanket. With this information, what is the primary assessment by the nurse at this time? 1. Evaluate the umbilical stump for bleeding. 2. Assess the infant's temperature. 3. Perform a visual scan for visible abnormalities. 4. Assess the infant for a patent airway.

2. These symptoms reflect cold stress and require the temperature to be taken immediately. These symptoms are not associated with bleeding form the umbilical stump, congenital abnormalities, or respiratory distress.

A nurse is assessing a neonate born 12 hours ago and notes a yellow tint to the sclera. The nurse should read the medical record for what other assessment that is important to note at this time? 1. Blood glucose level 2. Blood type and Rh factor of both mother and newborn 3. Most recent infant blood pressure 4. Length of time membranes ruptured prior to delivery

2. This newborn has signs of jaundice, which include a yellow tint to the sclera and skin. Jaundice is considered pathologic if it occurs within the first 24 hours of life, when it is most often caused by Rh or ABO incompatibility. It would be important to assess both the mother's and newborn's blood type and Rh factor to determine if this could be causing the jaundice. A bilirubin level should also be obtained. A blood glucose level would be important if the infant showed signs of hypoglycemia. The most recent infant blood pressure is not relevant. The length of time membranes ruptured prior to delivery would affect the risk of maternal infection.

A newborn is admitted with a diagnosis of transient tachypnea of the newborn (TTN). When planning nursing care for this baby, what nursing goal should the nurse formulate? 1. Promote adequate quantity of surfactant. 2. Promote absorption of fetal lung fluid. 3. Assist in removal of meconium from airway. 4. Stimulate respirations.

2. Transient tachypnea of the newborn (TTN) is caused by delayed absorption of fetal lung fluid. Nursing care is focused on supporting oxygenation needs to allow the newborn's body to reabsorb the fluid. Inadequate surfactant is related to prematurity and respiratory distress syndrome. Meconium in the airway results in meconium aspiration syndrome and is usually associated with fetal asphyxia. TTN causes tachypnea so stimulating respirations is not appropriate.

Which would be considered a normal finding in a newborn less than 12 hours old? 1.Grunting respirations 2.Heart rate of 190 beats/min 3.Bluish discoloration of the hands and feet 4.A yellow discoloration of the sclera and body

3 Having bluish hands and feet is termed acrocyanosis and is a normal finding in the newborn. Grunting respirations is a sign of possible respiratory distress and the normal newborn heart rate is 100 to 160 beats/min. A yellow discoloration of the sclera and skin indicates jaundice.

The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? 1.Radiation 2.Convection 3.Conduction 4.Evaporation

3 Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Radiation occurs when heat from the body surface radiates to the surrounding environment. In convection, air moving across the infant's skin transfers heat to the air. Evaporation of moisture from a wet body surface dissipates heat along with the moisture.

The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes an Apgar score of 6. On the basis of this score, what should the nurse determine? 1.The newborn requires vigorous resuscitation. 2.The newborn is adjusting well to extrauterine life. 3.The newborn requires some resuscitative interventions. 4.The newborn is having some difficulty adjusting to extrauterine life.

3 One of the earliest indicators of successful adaptation of the newborn to extrauterine life is the Apgar score. Scoring ranges from 0 to 10. A score of 8 to 10 indicates that the newborn is adjusting well to extrauterine life. A score of 5 to 7 often indicates that the newborn requires some resuscitative interventions. Scores of less than 5 indicate that the newborn is having difficulty adjusting to extrauterine life and requires vigorous resuscitation.

Untreated hyperbilirunemia may lead to: 1) Hypoglycemia 2) Coombs disease 3) Kernicterus 4) Phototherapy

3) Kernicterus

The nurse understands that the results of which assessment of gestational age must be determined within 12 hours of birth for valid results? 1. Breast tissue enlargement in female infants 2. The usual posture the infant assumes 3. Assessment of the creases on the soles of feet 4. The angle of the Scarf sign

3. After 12 hours, edema of tissues present in most newborns begin to resolve and creases appear, these creases do not have the same predictive value as those assessed before resolution of newborn edema. Breast tissue enlargement, posture, and angle of the Scarf sign remain predictive beyond the first 12 hours after birth.

The nurse is assisting a new mother in breastfeeding. The mother asks how she will know if her infant is getting anything from her breasts. The nurse responds that which of the following is the best indicator that the infant is getting breast milk? 1. Very loud burping after five minutes at the first breast 2. Finishing both breasts within three to five minutes 3. Audible swallowing 4. Sleeping four hours between feedings

3. Audible swallowing during a feeding produces sounds heard as a soft "ka" or "ah." Burping is related to how much air the infant swallows during feedings. Newborns usually spend 15 to 20 minutes at the breast in the first few weeks. Some older infants may be able to finish a feeding in three to five minutes. Because breast milk is more digestible than formula, and a newborn's stomach is small, feeding is usually needed more frequently than every four hours. Frequent feedings are important in the early days to establish lactation.

A new mother questions the nurse about the "lump" on her baby's head. The nurse explains that it is a "collection of blood between the skull bone and its covering (periosteum)" and is called which of the following? 1. Caput succedaneum 2. Molding 3. Cephalohematoma 4. Subdural hematoma

3. Cephalohematoma is a collection of blood between the skull bone and periosteum. Caput succedaneum is swelling of tissue over the presenting part of the fetal head caused by pressure during labor. Molding is an overlapping of cranial bones or shaping of the fetal head to accommodate the bony and soft parts of the birth canal during labor. Subdural hematoma refers to bleeding between the dural and arachnoid membranes.

The nurse is assigned to a baby receiving phototherapy. Which assessment warrants further investigation by the nurse? 1. Loose, green stools 2. Yellow tint to skin 3. Temperature 97.2F 4. Fine, red rash on trunk

3. Infants should be unclothed while receiving phototherapy to increase the circulating blood volume exposed to the phototherapy light. However, this increases the risk of temperature instability and infant temperature should be monitored carefully. Any temperate below 97.6F is considered hypothermia and requires immediate attention. Loose, green stools and a yellow tint to the skin are expected findings with hyperbilirubinemia. A fine, raised red rash may appear on the infant's skin as a side effect of the phototherapy and does not require intervention.

When teaching umbilical cord care to a new mother, the nurse would include which information? 1. Apply peroxide to the cord with each diaper change 2. Cover the cord with petroleum jelly after bathing 3. Keep the cord dry and open to air 4. Wash the cord with soap and water each day during a tub bath

3. Keeping the cord dry and open to air helps reduce infection and hastens drying.

Which neonatal behavior is most commonly associated with fetal alcohol syndrome (FAS)? 1. Hypoactivity 2. High birth weight 3. Poor wake and sleep patterns 4. High threshold of stimulation

3. Poor wake and sleep patterns. Altered sleep patterns are caused by disturbances in the CNS from alcohol exposure in utero. Hyperactivity is a characteristic generally noted. Low birth weight is a physical defect seen in neonates with FAS. Neonates with FAS generally have a low threshold for stimulation.

When attempting to interact with a neonate experiencing drug withdrawal, which behavior would indicate that the neonate is willing to interact? 1. Gaze aversion 2. Hiccups 3. Quiet alert state 4. Yawning

3. Quiet alert state. When caring for a neonate experiencing drug withdrawal, the nurse needs to be alert for distress signals from the neonate. Stimuli should be introduced one at a time when the neonate is in a quiet and alert state. Gaze aversion, yawning, sneezing, hiccups, and body arching are distress signals that the neonate cannot handle stimuli at that time.

After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? 1. Hypoglycemia 2. Jitteriness 3. Respiratory depression 4. Tachycardia

3. Respiratory depression. Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and bradycardia.

A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: 1. Subcutaneous injection 2. Intravenous injection 3. Instillation of the preparation into the lungs through an endotracheal tube 4. Intramuscular injection

3. The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.

Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site? 1. Deltoid 2. Triceps. 3. Vastus lateralis 4. Biceps

3. Vastus lateralis (thigh) - Use a 5/8" needle at a 90 degree angle: Vitamin K is given in the middle third of the vastus lateralis muscle using a 25-gauge, 5/8-inch needle. It is injected into skin that has been cleansed with alcohol and allowed to dry for 1 minute. It is administered at a 90-degree angle. The site is massaged after removing needle to increase absorption of the medication.

A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: 1. "You infant needs vitamin K to develop immunity." 2. "The vitamin K will protect your infant from being jaundiced." 3. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." 4. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."

3. Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant's bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion.

The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? 1.A suture split greater than 1 cm 2.A hard, rigid, immobile suture line 3.Swelling of the soft tissues of the head and scalp 4.Edema resulting from bleeding below the periosteum of the cranium

4 A cephalohematoma indicates edema resulting from bleeding below the periosteum of the cranium. It does not cross the suture line. It is most likely to be caused by ruptured blood vessels from head trauma during birth. The lesion develops within 24 to 48 hours after birth and may take 2 to 3 weeks to resolve. Option 1 may indicate increased intracranial pressure. Option 2 may be associated with premature closure or craniosynostosis and should be investigated further. Option 3 identifies a caput succedaneum.

The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority? 1.Initiate an intravenous (IV) line on the newborn infant. 2.Place the newborn infant on a cardiorespiratory monitor. 3.Place the newborn infant in the radiant warmer incubator. 4.Administer oxygen via resuscitation bag to the newborn infant

4 Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more vigorous resuscitation. The immediate nursing action should be to administer oxygen via resuscitation bag. Although the newborn infant may require a cardiorespiratory monitor and an IV line and may need to be placed in a radiant warmer incubator, the initial action of the nurse should be to provide resuscitative measures.

The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. While performing an assessment, where should the nurse document the location of the viscera in this condition? 1.Inside the abdominal cavity and under the skin 2.Inside the abdominal cavity and under the dermis 3.Outside the abdominal cavity and not covered with a sac 4.Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane

4 Omphalocele is an abdominal wall defect. It involves a large herniation of the gut into the umbilical cord. The viscera are outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane. Options 1 and 2 describe an umbilical hernia.Option 3 describes a gastroschisis.

A nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside? 1.A rectal thermometer 2.A blood pressure cuff 3.A specific gravity urinometer 4.A bottle of sterile normal saline

4 Spina bifida is a central nervous system defect that results from failure of the neural tube to close during embryonic development. The newborn with spina bifida is at risk for infection before the closure of the sac, which is done soon after birth. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of the skin integrity at the site. A thermometer will be needed to assess temperature, but in this newborn the priority is to maintain sterile normal saline dressings over the sac. Blood pressure may be difficult to assess during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development.

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1.Avoid stimulation. 2.Decrease fluid intake. 3.Expose all of the newborn's skin. 4.Monitor skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with eye shields or patches.

4, 5, 6 Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.

The nurse tests the newborn's Babinski reflex by doing which of the following? 1. Touching the corner of the newborn's mouth or cheek 2. Changing the newborn's equilibrium 3. Placing a finger in the palm of the newborn's hand 4. Stroking the lateral sole from the heel upward and across the ball of the foot

4. A Babinski reflex is elicited by stroking the lateral aspect of the sole of the heel upward and across the ball of the foot. A positive test (in newborns) of fanning the toes and dorsiflexing the big toe is an indicator of fetal well-being. Touching the corner of the mouth or cheeks elicits the rooting reflex. Changing the newborn's equilibrium elicits the Moro reflex. Placing a finger in the palm of the newborn's hand elicits the palmar grasp reflex.

The nurse is preparing to initiate bottle-feeding in a preterm infant. In which situation would the nurse withhold the feeding and notify the health care provider? 1. Apical heart rate 120-130 2. Axillary temperature 97.2F-98.4F 3. Yellow tint to skin and sclera 4. Respiratory rate 62-68

4. Any sustained respiratory rate greater than 60 breaths/minute increases the risk of aspiration in the infant. Oral feedings should be withheld on infants experiencing tachypnea to decrease the risk of aspiration. An apical heart rate of 120-130 is a normal finding. Although an infant temperature of 97.2F is considered hypothermia, it would not be a contraindication to oral feedings. Jaundice may be considered abnormal but it alone would not be an indication to withhold an oral feeding.

A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? 1. Switch to bottle feeding the baby for 2 weeks 2. Stop the breast feedings and switch to bottle-feeding permanently 3. Feed the newborn infant less frequently 4. Continue to breast-feed every 2-4 hours

4. Continue to breast-feed every 2-4 hours - Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. The other options are not necessary.

A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: 1. Warming the crib pad 2. Turning on the overhead radiant warmer 3. Closing the doors to the room 4. Drying the infant in a warm blanket

4. Drying the infant in a warm blanket - Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.

A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn? 1. Sleepiness 2. Cuddles when being held 3. Lethargy 4. Incessant crying

4. Incessant crying - A newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and posture rather than cuddle when being held.

A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? 1. It usually resolves in 3-6 weeks 2. It doesn't cross the cranial suture line 3. It's a collection of blood between the skull and the periosteum 4. It involves swelling of tissue over the presenting part of the presenting head

4. It involves swelling of tissue over the presenting part of the presenting head. Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days. The edema in caput succedaneum crosses the suture lines. It may involve wide areas of the head or it may just be a size of a large egg. A collection of blood between the periosteum of a skull bone and the bone itself is a Cephalhematoma.

A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? 1. Negative Coombs test 2. Bleeding from the nose and ear 3. Jaundice after the first 24 hours of life 4. Jaundice within the first 24 hours of life

4. Jaundice within the first 24 hours of life. The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result.

A mother recently gave birth to her second child and began breastfeeding in the LDRP (labor, delivery, recovery, postpartum) suite. What would be an appropriate suggestion for the nurse to make? 1. Bottle-feed the baby between breastfeeding sessions 2. Routinely use plastic-lined nipple shields 3. Impose time limits for breastfeeding sessions 4. Offer both breasts at each feeding

4. Mothers are encouraged to offer both breasts to the infant in the beginning for simultaneous stimulation, but it is not imperative nor harmful if the infant does not feed off of one breast at a session. Giving supplemental feedings can upset the natural supply and demand and can shorten the breastfeeding experience. Prolonged exposure to plastic liners or wet nursing pads may result in skin breakdown. Time limits should not be imposed on breastfeeding infants as they each have different styles of suckling.

A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 99.5*F, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take? 1. Wrap the neonate warmly and place her in an open crib 2. Administer an oral glucose feeding of 10% dextrose in water 3. Increase the temperature setting on the radiant warmer 4. Obtain an order for IV fluid administration

4. Obtain an order for IV fluid administration. Assessment findings indicate that the neonate is in respiratory distress—most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldn't be fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer.

The nurse observes that a one-day postpartum client who is breastfeeding her first child appears frightened. The client says, "The baby has been breathing funny, fast and slow, off and on." What is an appropriate response by the nurse? 1. "That's normal when the baby breastfeeds." 2. "There's nothing to worry about. I'll go take the baby back to the nursery now." 3. "I'll watch the baby for a while to see if there is something wrong." 4. "Be reassured; it's a normal breathing pattern. I'll sit here while you finish feeding him."

4. Periodic breathing with no color or heart rate changes is normal in the newborn adapting to extrauterine life. The nurse provides verbal reassurance and also physical reassurance by his or her presence. Stating there's nothing to worry about and the nurse will watch the infant does not reassure the mother and confirms the mother's fears. Stating it's normal provides information but does not address the mother's subjective sense of fear.

A mother is crying while sitting by the isolette of her premature newborn who was born at 25 weeks' gestation. What is the most therapeutic communication by the nurse? 1. "It's important to try not to worry. Let's hope that everything will work out." 2. "Can you tell me some specific things that have gotten you upset?" 3. "Would you like me to call the hospital chaplain? This has helped many others." 4. "This must be hard for you. Can you share with me what has you most concerned at this time?"

4. Reflection allows the client to verbalize his or her feelings. The nurse should not give the client false hope. Clients often do not know why they feel the way they do and it is not helpful to ask them to determine this. Some clients may find comfort in a religious leader, but care should be taken not to stereotype the client's religious beliefs.

A newborn's head circumference is 34 cm (13.6 inches) and chest circumference is 32 cm (12.5 inches). Which nursing action would be appropriate? 1. Refer the newborn for evaluation for psychomotor retardation. 2. Prepare the mother for the probability that the physician will want to transilluminate the cranial vault. 3. Measure the occipitofrontal circumference daily. 4. Record the findings and take no further action.

4. This finding is normal. No further action is required. The newborn head measurement will be greater than or equal to the chest measurement.

A newborn's temperature is 97.4F. What is the priority nursing intervention by the nurse? 1. Notify the health care provider immediately. 2. Take the newborn to the nursery and observe for two hours. 3. Reassess the temperature in four hours. 4. Wrap the newborn in two warm blankets and place a cap on the head.

4. This newborn has a low temperature and the nurse must intervene quickly to prevent complications related to hypothermia. Wrapping the baby in warm blankets and covering the head will help prevent heat loss through conduction, convection, and radiation and is the most important initial intervention. It is unnecessary to notify the health care provider at this time. Observing the infant for two hours delays care and is unsafe. Reassessment of temperature does not do anything to raise the infant's temperature at this time.

The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism? 1. Candida albicans 2. Chlamydia trachomatis 3. Escherichia coli 4. Group B beta-hemolytic streptococci

4. transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.

A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol b. Cocaine c. Heroin d. Marijuana

A (The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction. The infant may have a shrill cry and sleep cycle disturbances and present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.)

A male client reports urethral pain and a creamy yellow, bloody discharge from the penis. The nurse associates these characteristics with which of the following sexually transmitted infections? a) Gonorrhea b) Candidiasis c) Chancroid d) Trichomoniasis

A) Gonorrhea In men, the initial symptoms of gonorrhea include urethral pain and a creamy, yellow, sometimes bloody discharge. Candidiasis, trichomoniasis, and bacterial vaginosis are vaginal infections that can be sexually transmitted, and the male partner usually is asymptomatic. Chancroid causes genital ulcers; the lesions begin as macules, progress to pustules, and then rupture.

A woman who has a seizure disorder and takes barbiturates and phenytoin sodium daily asks the nurse about the pill as a contraceptive choice. The nurse's most appropriate response is a. "This is a highly effective method, but it has some side effects." b. "Your current medications will reduce the effectiveness of the pill." c. "The pill will reduce the effectiveness of your seizure medication." d. "This is a good choice for a woman of your age and personal history."

ANS: B Because the liver metabolizes oral contraceptives, their effectiveness is reduced when they are taken simultaneously with anticonvulsants

An unmarried young woman describes her sex life as "active" and involving "many" partners. She wants a contraceptive method that is reliable and does not interfere with sex. She requests an intrauterine device (IUD). The nurse's most appropriate response is a. "The IUD does not interfere with sex." b. "The risk of pelvic inflammatory disease will be higher for you." c. "The IUD will protect you from sexually transmitted diseases." d. "Pregnancy rates are high with the IUDs."

ANS: B Disadvantages of IUDs include an increased risk of pelvic inflammatory disease (PID) in the first 20 days after insertion, as well as the risks of bacterial vaginosis and uterine perforation. The IUD offers no protection against sexually transmitted diseases (STDs) or the human immunodeficiency virus (HIV). Because this woman has multiple sex partners, she is at higher risk of developing an STD. The IUD does not protect against infection, as does a barrier method.

Which of the following should the nurse recognize as a possible maternal-infant blood group incompatibility? a. The mother is O positive and the infant is O negative. b. The mother is A positive and the infant is A negative. c. The mother is O positive and the infant is B negative. d. The mother is B positive and the infant is O negative.

ANS: C

4. An infant girl is preterm and on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time. It is important for the nurse to a. Suggest that the parents visit for only a short time to reduce their anxieties. b. Reassure the parents that the baby is progressing well. c. Encourage the parents to touch her. d. Discuss the care they will give her when she goes home.

ANS: C Feedback: Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant. It is important to keep the parents informed about the infant's progression, but the nurse needs to be honest with the explanations. Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the care giving responsive to the needs of both the parents and the infant. This is the most appropriate response by the nurse is encouragement to touch their infant and create a bonding experience. At home care is an important part of parent teaching, but it is not the most important priority during the first visit.

Which contraceptive method is contraindicated in a woman with a history of toxic shock syndrome? a. Condom b. Spermicide c. Cervical cap d. Norplant

ANS: C The cervical cap may increase the risk of toxic shock syndrome, because it may be left in the vagina for a prolonged period.

Which clinical findings would alert the nurse that the neonate is expressing pain? a.Low-pitched crying; tachycardia; eyelids open wide b.Cry face; flaccid limbs; closed mouth c.High-pitched, shrill cry; withdrawal; change in heart rate d.Cry face; eyes squeezed; increase in blood pressure

ANS: D Crying and an increased heart rate are manifestations indicative of pain in the neonate. Typically, infants tightly close their eyes when in pain, not open them wide. In addition, infants may display a rigid posture with the mouth open and may also withdraw limbs and become tachycardic with pain. A high-pitched, shrill cry is associated with genetic or neurologic anomalies.

Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs and symptoms of which of the following? A) Anemia. B) Hypertension. C) Dysmenorrhea. D) Acne vulgaris.

Answer: B Before advising a client about oral contraceptives, the nurse needs to assess the client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives. In addition, women who smoke, are older than 40 years of age, or have a history of pulmonary disease should be advised to use a different method. Iron-deficiency anemia, dysmenorrhea, and acne are not contraindications for the use of oral contraceptives. Iron-deficiency anemia is a common disorder in young women. Oral contraceptives decrease the amount of menstrual flow and thus decrease the amount of iron lost through menses, thereby providing a beneficial effect when used by clients with anemia. Low-dose oral contraceptives to prevent ovulation may be effective in decreasing the severity of dysmenorrhea (painful menstruation). Dysmenorrhea is thought to be caused by the release of prostaglandins in response to tissue destruction during the ischemic phase of the menstrual cycle. Use of oral contraceptives often improves facial acne

A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. The nurse should instruct the client to do which of the following? A) Check the cervical mucus to see if it is thick and sparse. B) Take her temperature at the same time every morning. C) Document ovulation when the temperature decreases at least 1°F. D) Avoid coitus for 10 days after a slight rise in temperature.

Answer: B The basal body temperature method requires that the client take her temperature each morning before arising, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the temperature falls by 0.5°F. At the time of ovulation, the temperature rises 0.4° to 0.8°F because of increased progesterone secretion in response to the luteinizing hormone. The temperature remains higher for the rest of the menstrual cycle. The client should keep a diary of about 6 months of menstrual cycles to calculate "safe" days. There is no mucus for the first 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses. Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3 to 4 days before and after ovulation to avoid a pregnancy.

Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives? a. Weight gain should be reported to the physician. b. An alternate method of birth control is needed when taking antibiotics. c. If the client misses one or more pills, two pills should be taken per day for 1 week. d. Changes in the menstrual flow should be reported to the physician.

Answer: B When the client is taking oral contraceptives and begins antibiotics, another method of birth control should be used. Antibiotics decrease the effectiveness of oral contraceptives. Approximately 5-10 pounds of weight gain is not unusual, so answer A is incorrect. If the client misses a birth control pill, she should be instructed to take the pill as soon as she remembers the pill. Answer C is incorrect. If she misses two, she should take two; if she misses more than two, she should take the missed pills but use another method of birth control for the remainder of the cycle. Answer D is incorrect because changes in menstrual flow are expected in clients using oral contraceptives. Often these clients have lighter menses.

. A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client's teaching plan? a) About midway through the menstrual cycle, cervical mucus is thick and sticky. b) During ovulation, the cervix remains dry without any mucus production. c) As ovulation approaches, cervical mucus is abundant and clear. d) Cervical mucus disappears immediately after ovulation, resuming with menses.

Answer: C As ovulation approaches, cervical mucus is abundant and clear, resembling raw egg white. Ovulation generally occurs 14 days (plus or minus 2 days) before the beginning of menses. During the luteal phase of the cycle, which occurs after ovulation, the cervical mucus is thick and sticky, making it difficult for sperm to pass. Changes in the cervical mucus are related to the influences of estrogen and progesterone. Cervical mucus is always present.

Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on contraceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Deficient Knowledge related to ovulation and fertility management. Which of the following would be important to include in the teaching plan for the client? A) The ovum survives for 96 hours after ovulation, making conception possible during this time. B) The basal body temperature falls at least 0.2°F after ovulation has occurred. C) Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. D) Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus.

Answer: C For a client with a menstrual cycle of 28 days, ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. Stated another way, the menstrual period begins about 2 weeks after ovulation has occurred. Ovulation does not usually occur during the menses component of the cycle when the uterine lining is being shed. In most women, the ovum survives for about 12 to 24 hours after ovulation, during which time conception is possible. The basal body temperature rises 0.5° to 1.0°F when ovulation occurs. Although some women experience some pelvic discomfort during ovulation (mittelschmerz), severe or unusual pain is rare. After ovulation, the cervical mucus is thin and copious.

A 20-year-old woman desiring to use a cervical cap for family planning is instructed on its use. Which of the following client statements would indicate to the nurse that the client needs further instruction? A) "Cervical caps can be left in place longer than a diaphragm." B) "Using a cervical cap may increase the risk of irritation." C) "Cervical caps usually fit better than a diaphragm." D) "Many women are unable to use cervical caps."

Answer: C The client needs further instruction when she says that cervical caps fit better than the diaphragm. Many women are unable to use cervical caps because their cervix is too short for the cap to fit the cervix properly. A cervical cap may remain in place for up to 48 hours after intercourse, whereas it is recommended that a diaphragm be left in place for only 24 hours. The cervical cap is associated with cervical irritation.

A multigravid client will be using medroxyprogesterone acetate as a family planning method. After the nurse instructs the client about this method, which of the following client statements indicates effective teaching? a) "This method of family planning requires monthly injections." b) "I should have my first injection during my menstrual cycle." c) "One possible side effect is absence of a menstrual period." d) "This drug will be given by subcutaneous injections."

Answer: C With medroxyprogesterone acetate, irregular menstrual cycles and amenorrhea are common side effects. Other side effects include weight gain, breakthrough bleeding, headaches, and depression. This method requires deep intramuscular injections every 3 months. The first injection should occur within 5 days after menses.

After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which of the following client statements indicates a need for further teaching? A) "I can continue to use the diaphragm for about 2 to 3 years if I keep it protected in the case." B) "If I get pregnant, I will have to be refitted for another diaphragm after the delivery." C) "Before inserting the diaphragm I should coat the rim with contraceptive jelly." D) "If I gain or lose 20 pounds, I can still use the same diaphragm."

Answer: D A client would need additional instructions when she says that she can still use the same diaphragm if she gains or loses 20 pounds. Gaining or losing more than 15 pounds can change the pelvic and vaginal contours to such a degree that the diaphragm will no longer protect the client against pregnancy. The diaphragm can be used for 2 to 3 years if it is cared for and well protected in its case. The client should be refitted for another diaphragm after pregnancy and delivery of a newborn because weight changes and physiologic changes of pregnancy can alter the pelvic and vaginal contours, thus affecting the effectiveness of the diaphragm. The client should use a spermicidal jelly or cream before inserting the diaphragm.

Which of the following would the nurse expect to include in the teaching plan for a 30-year-old multiparous client who will be using an intrauterine device (IUD) for family planning? a) Amenorrhea is a common side effect of IUDs. b) The client needs to use additional protection for conception. c) IUDs are more costly than other forms of contraception. d) Severe cramping may occur when the IUD is inserted.

Answer: D Severe cramping and pain may occur as the device is passed through the internal cervical os. The insertion of the device is generally done when the client is having her menses, because it is unlikely that she is pregnant at that time. Common side effects of IUDs are heavy menstrual bleeding and subsequent anemia, not amenorrhea. Uterine infection or ectopic pregnancy may occur. The IUD has an effectiveness rate of 98%. Therefore, additional protection is not necessary to prevent pregnancy. IUDs generally are less costly than other forms of contraception because they do not require additional expense. Only one insertion is necessary, in comparison to daily doses of oral contraceptives or the need for spermicides in conjunction with diaphragm use.

Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC: a. Early enteral feedings b. Breastfeeding c. Exchange transfusion d. Prophylactic probiotics

B (A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohn's disease, and celiac illness. The neonatal intensive care unit nurse can be very supportive of the mother in terms of providing her with equipment to pump breast milk, ensuring privacy, and encouraging skin-to-skin contact with the infant. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.)

The most common cause of pathologic hyperbilirubinemia is: a. Hepatic disease. b. Hemolytic disorders in the newborn. c. Postmaturity. d. Congenital heart defect.

B (Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause. Prematurity would be a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.)

In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Bronchopulmonary dysplasia (BPD) d. Intraventricular hemorrhage (IVH)

B (ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is caused by the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH results from rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.)

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: a. Hypertonia, tachycardia, and metabolic alkalosis. b. Abdominal distention, temperature instability, and grossly bloody stools. c. Hypertension, absence of apnea, and ruddy skin color. d. Scaphoid abdomen, no residual with feedings, and increased urinary output.

B (Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.)

A nurse is teaching a health class to a group of clients likely to be at highest risk for gonorrhea. What is the age range of the clients? a) 60 to 70 years b) 15 to 24 years c) 25 to 29 years d) 30 to 45 years

B) 15 to 24 yearsGonorrhea is the second most frequently reported communicable disease in the United States. Its highest incidence occurs in the 15- to 24-year-old age group.

A client is being treated for gonorrhea. Which agent would the nurse expect the physician to prescribe? a) Tetracycline b) Ceftriaxone c) Penicillin d) Levofloxacin

B) CeftriaxoneThe microorganism N. gonorrhoeae has become increasingly resistant to penicillin and tetracyclines, and fluoroquinolones (such as levofloxacin). Therefore, the current CDC (2006) recommendation for treating gonorrhea is a single intramuscular dose of a broad-spectrum cephalosporin such as ceftriaxone (Rocephin) or oral dosing with cefixime (Suprax).

A nurse is assessing a woman with vaginal discharge. The nurse suspects bacterial vaginosis when the client states which of the following? a) "The discharge is yellowish but thin." b) "I noticed a strange fishy odor during my period." c) "The discharge looks almost like cottage cheese." d) "I've been experiencing some really intense itching."

B) I noticed a strange fishy odor during my period Bacterial vaginosis is characterized by a fishlike odor that is particularly noticeable after sexual intercourse or during menstruation. Most clients do not experience local discomfort or pain; more than one half of clients do not notice any symptoms. Intense itching is often associated with candidiasis or trichomoniasis. A cottage-cheese like discharge is associated with candidiasis. A thin, yellow discharge is most commonly noted with trichomoniasis.

A plan of care for an infant experiencing symptoms of drug withdrawal should include: a. Administering chloral hydrate for sedation. b. Feeding every 4 to 6 hours to allow extra rest. c. Swaddling the infant snugly and holding the baby tightly. d. Playing soft music during feeding.

C (The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music) because this will increase activity and potentially increase CNS irritability.)

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds: a. "It is an eye ointment to help your baby see you better." b. "It is to protect your baby from contracting herpes from your vaginal tract." c. "Erythromycin is given prophylactically to prevent a gonorrheal infection." d. "This medicine will protect your baby's eyes from drying out over the next few days."

C (With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is not used for eye lubrication.)

A client with genital herpes asks the nurse about what to expect with the infection. Which of the following responses would be most appropriate? a) Once you take the medication, the infection will be gone for good. b) You might have to try several different medications before finding one that works. c) Even though you don't have symptoms, you could still spread the infection. d) You can expect other outbreaks, each of which will be longer than the first.

C) Even though you don't have symptoms, you could still spread the infection Genital herpes can be transmitted during asymptomatic periods of viral shedding. Herpes recurs because after the initial infection, the virus remains dormant in the ganglia of the nerves that supply the area. Symptoms usually are more severe with the initial outbreak. Subsequent episodes usually are shorter and less intense. When the virus is active, shedding viral particles are infectious. Herpes infection is a highly contagious STI that is controllable but not curable. Herpes virus responds well to the antiviral drugs acyclovir, valacyclovir, and famciclovir.

Screening for chlamydia is recommended for young women because A) Chlamydia is frequently comorbid with HIV. B) Chlamydial infections may progress to sepsis. C) Untreated chlamydial infections can lead to infertility. D) Chlamydial infections are treatable only in the early stages of infection.

C) Untreated chlamydial infections can lead to infertility.Because of the potential for infertility, screening for chlamydia is recommended for women under 25. Sepsis is not a primary risk of chlamydia and is not noted to be strongly correlated with HIV infection. The disease is treatable at all stages of infection.

A nurse is performing an assessment on a full-term newborn and eliciting the Moro reflex. Which of the following movements are expected responses to this reflex? (SATA) a. Thumb and forefinger forming a "C" b. Legs extending before pulling upwards c. Arms and legs adducting d. Arms flailing backwards after startling e. Head turning to the right

Correct answers A and B This response is present at birth and disappears within 6 months. Full-term newborns will ABduct their arms and legs when eliciting a Moro reflex. The arms will form a complete embrace after startling and return to flexion and movement. Pre-term newborns lack neurological maturity and their arms will fall backwards with the startle. Head turning to the right is a component of tonic neck, not Moro.

Human immunodeficiency virus (HIV) may be perinatally transmitted: a. Only in the third trimester from the maternal circulation. b. By a needlestick injury at birth from unsterile instruments. c. Only through the ingestion of amniotic fluid. d. Through the ingestion of breast milk from an infected mother.

D (Postnatal transmission of HIV through breastfeeding may occur. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases.)

Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are: a. Suffering from sleep or wakeful apnea. b. Experiencing severe swings in blood pressure. c. Trying to maintain a neutral thermal environment. d. Breathing in a respiratory pattern common to premature infants.

D (This pattern is called periodic breathing and is common to premature infants. It may still require nursing intervention of oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. It should not be confused with periodic breathing.)

A client is diagnosed as being in the primary stage of syphilis? Which of the following would the nurse expect as a finding? a) Palmar rash b) Development of gummas c) Development of central nervous system lesions d) Genital chancres

D) Genital chancres Primary syphilis is characterized by the appearance of a chancre at the site of exposure. A rash on the palms is associated with secondary syphilis, whereas gummas and central nervous system (CNS) lesions are indicative of tertiary syphilis.

A nurse is teaching a client with genital herpes. Education for this client should include an explanation of: a) why the disease is transmittable only when visible lesions are present. b) the need for the use of petroleum products. c) the option of disregarding safer-sex practices now that he's already infected. d) the importance of informing his partners of the disease.

D) Importance of informing his partners of the disease.Clients with genital herpes should inform their partners of the disease to help prevent transmission. Petroleum products should be avoided because they can cause the virus to spread. The notion that genital herpes is only transmittable when visible lesions are present is false. Anyone not in a long-term, monogamous relationship, regardless of current health status, should follow safer-sex practices.

The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score? a.3 b.5 c.7 d.10

D. 10 One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. Five criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 beats/min = 1; greater than 100 beats/min = 2. Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0; some extremity flexion = 1; active, moving, and well-flexed = 2. Irritability or reflexes (measured by response to bulb suctioning): no response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of extremities = 1; pink = 2.

Which laboratory test result would be a cause for concern if exhibited by an Rh-positive newborn 12 hours after birth? A. Direct Coombs': negative B. Hematocrit (Hct): 58% and hemoglobin (Hgb): 18 g/dL C. Blood glucose level: 55 mg/dL D. Rapid Plasma Reagin (RPR)/Venereal Disease Research Laboratories (VDRL): reactive

D. Rapid Plasma Reagin (RPR)/Venereal Disease Research Laboratories (VDRL): reactive. The negative Coombs' indicates absence of antibodies against Rh-positive blood. Hgb is between 15 and 20 g/dL, and Hct is between 43% and 61%. The blood glucose level should be 40 mg/dL or higher. A reactive RPR/VDRL indicates exposure to syphilis while in utero.

A nurse is providing teaching about a newborn to the parents, Which statement indicates understanding of the teaching? A. "I will wash my baby's umbilical cord stump with antibacterial soap" B. "I will cover my baby with a lightweight blanket during nap time" C. "I will use a cotton tipped swab to clean my baby's ears" D. "I will place a hat on my baby's head prior to going outside"

D. The parent should place a hat or bonnet on the newborns head to protect the scalp, minimize heat loss and protect against sunburn. The umbilical cord should remain dry until it falls off in 10 to 14 days. If it becomes soiled it should be cleaned with plain water only and dried. A blanket should not be placed over the newborn while sleeping, this puts the infant at risk for suffocation and SIDS. Newborn ears should be cleaned with the corner of a wet cloth. Cotton swabs can injure the ear canal.

The success rate of GIFT and ZIFT are approximately _____ per cycle. a. 25% b. 33% c. 50% d. 75%

a. 25%