OB - Chapter 18: Nursing Management of the Newborn, OB - Chapter 17: Newborn Transitioning, OB - Chapter 15: Postpartum Adaptations

A woman who delivered her infant 1 week ago calls the clinic to complain of pain with urination and increased frequency. What response by the nurse is appropriate? a) "It is common for women to have yeast problems, try an over the counter cream and let us know if this continues." b) "Are you washing and providing good perineal hygiene? If not, this may be the reason for the irritation." c) "After delivery it is easier to develop an infection in the urinary system, we need to see you today." d) "This is normal, give it a few days and then call back."

"After delivery it is easier to develop an infection in the urinary system, we need to see you today."

A patient who gave birth 2 hours ago expresses concern about her baby developing jaundice. How should the nurse respond? Choose the best response. a) "I understand your concern because as many as 50% of babies can develop jaundice." b) "If you are concerned about your baby developing jaundice, don't breastfeed your baby until you get home." c) "We will monitor the baby now, and your baby will not develop jaundice after the first 24 hours of life." d) "You don't need to worry about your baby developing jaundice because you are both A+."

"I understand your concern because as many as 50% of babies can develop jaundice."

You are the home health nurse making an initial call on a new mother who delivered her third baby five days ago. The woman says to you "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? a) "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." b) "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the delivery. They will most likely go away in a day or two." c) "Tell me, are you seeing things that aren't there, or hearing voices?" d) "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to."

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the delivery. They will most likely go away in a day or two."

A new mother is concerned because it is 24 hours after childbirth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern? a) "It takes about 3 days after birth for milk to begin forming." b) "You are experiencing lactational amenorrhea. It may be several weeks before your milk comes in." c) "I'm sorry to hear that. There are some excellent formulas on the market now, so you will still be able to provide for your infant's nutritional needs." d) "You may have developed mastitis. I'll ask the physician to examine you."

"It takes about 3 days after birth for milk to begin forming."

A nursing student observes that the babies in the nursery are wrapped up warmly and are wearing knit caps. Which explanation by the nursery staff would be the most correct?? a) "Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes." b) "Studies show that newborns like the extra warmth." c) "That's how we have always done it and it seems to work out well." d) "The caps and blankets simulate the temperature of he mother's womb that they are used to."

"Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes."

A nursing instructor is teaching about changes the newborn must make to survive outside of the uterus. The instructor realizes that further teaching is needed when a student says which of the following? a) "When the baby is ready to leave the uterus, it takes its first breath." b) "When the umbilical cord is clamped the first breath is taken." c) "When the umbilical cord is clamped the lungs begin to function." d) "The first breath is taken when the baby is stimulated by a slight slap."

"When the baby is ready to leave the uterus, it takes its first breath."

A client who had a vaginal delivery 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate? a) "Within 1 to 3 weeks, your diaphragm should return to normal and your breathing will feel like it did before your pregnancy." b) "Everyone is different, so it is difficult to say when your respirations will be back to normal." c) "It usually takes about 3 months before all of your abdominal organs return to normal, allowing you to breathe normally." d) "You should notice a change in your respiratory status within the next 24 hours."

"Within 1 to 3 weeks, your diaphragm should return to normal and your breathing will feel like it did before your pregnancy."

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate? a) "It takes a while to get your body back to its normal function after having a baby." b) "This is entirely normal, and many women go through it. It just takes time." c) "Try doing Kegel exercises to get your pelvic muscles back in shape." d) "You might try using a water-soluble lubricant to ease the discomfort."

"You might try using a water-soluble lubricant to ease the discomfort."

The heart rate of the newborn in the first few minutes after birth will be in which of the following ranges? a) 80-120 bpm b) 120-180 bpm c) 180-220 bpm d) 120-130 bpm

120-180 bpm

Five days after giving birth, a new mother tells her nurse that she has lost some weight but still feels as if she has a long way to go to return to her prepregnancy weight. She asks what the average weight loss at 5 days into the postpartal period is. Which of the following should the nurse mention? a) 24 lb b) 14 lb c) 9 lb d) 19 lb

19 lb

The nurse is assigned to a patient on postpartum day 1. Prior to assessing her uterus, where should the nurse anticipate she will locate the fundus? a) At level of umbilicus b) 1cm above the umbilicus c) 1cm below the umbilicus d) At the symphysis pubis

1cm below the umbilicus

How long is the neonatal period for a newborn? _______ days

28

What is the expected range for respirations in a newborn? a) 10-30 breaths per minute b) 30-60 breaths per minute c) 20-40 breaths per minute d) 40-80 breaths per minute

30-60 breaths per minute

You record a newborn's Apgar score at birth. A normal 1-minute Apgar score is a) 5 to 9. b) 7 to 10. c) 1 to 2. d) 12 to 15.

7 to 10.

The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she's most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women? a) 85% b) 25% c) 100% d) 40%

85%

Upon assessing the newborn's respirations, when would the nurse need to notify the MD? a) A respiratory rate of 15 breaths per minute with nasal flaring b) A respiratory rate of 45 breaths per minute with acrocyanosis c) Coughing and sneezing in the newborn d) Short periods of apnea that last 10 seconds in a pink newborn

A respiratory rate of 15 breaths per minute with nasal flaring

Which newborn neuromuscular system adaptation would the nurse NOT expect to find? a) An extrusion reflux at 9 months of age b) A positive Babinski reflex at 2 months of age c) A Moro reflex at 3 months of age d) A plantar grasp reflex at 7 months of age

An extrusion reflux at 9 months of age

A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal? a) Recommend that the mother pump her breast milk and measure it before feeding b) Weigh the infant daily to ensure that she is gaining 1 1/2 to 2 ounces per day c) Add cereal to the newborn's feedings twice a day d) Breastfeed the infant every 2-3 hours on demand

Breastfeed the infant every 2-3 hours on demand

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which of the following observations would indicate the presence of tissue? a) Yellowish white lochia b) Easy to separate clots c) Foul-smelling lochia d) Difficult to separate clots

Difficult to separate clots

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? a) Milia b) Epstein's pearls c) Stork bites d) Mongolian spots

Epstein's pearls

A new mother asks the nurse why her baby's back and groin have a red and raised rash. Which of the following does the nurse correctly identify as the name of this condition? a) Mumps. b) Acrocyanosis. c) Erythema toxicum. d) Yeast infection.

Erythema toxicum

A woman who has just given birth seems to be bonding with her newborn, despite the fact that earlier in labor she had expressed an intent to give the baby up for adoption. In this case, the nurse should encourage the mother to keep her baby. a) False b) True

False

Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution? a) She experiences "pulling" pain while breastfeeding. b) Her uterus is at the level of the umbilicus. c) Her uterus is 2 cm above the symphysis pubis. d) Her uterus is three finger widths under the umbilicus.

Her uterus is at the level of the umbilicus.

A client in her sixth week postpartum complains of general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which of the following? a) Hypovolemia b) Hypertension c) Hypothyroidism d) Hyperglycemia

Hypovolemia

The nurse observes a newborn. He notes that the respiratory rate is 66, the newborn's nostrils flare out, and the newborn makes a grunting sound during respiration. What does the nurse conclude from these findings? The infant is: a) Burning brown fat b) Cold-stressed c) In respiratory distress d) Experiencing radiation heat loss

In respiratory distress

The process by which the reproductive organs return to the nonpregnant size and function is termed what? a) Evolution b) Involution c) Decrement d) Progression

Involution

A nurse is assessing a client's lochia every 15 minutes for the first hour during the fourth stage of labor. Which of the following would the nurse expect to assess? a) Lochia alba saturating at least 3 pads b) Moderate lochia rubra with no clots c) Lochia rubra with few clots d) Lochia rubra saturating two pads

Moderate lochia rubra with no clots

A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal findings a) Enlarged labia with pseudomenstruation b) Rounded, symmetrical abdomen c) Mottled hands and feet d) Heart rate of 90-100 e) Positive Ortolani sign

Mottled hands and feet

A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client? a) No action is need; this is normal b) Switch to feeding breast milk c) Change to a soy-based formula d) Increase the newborn's fluid intake

No action is need; this is normal

When caring for a newborn several hours after birth, the nurse assesses his respiratory rate and counts it at 42. What intervention should be implemented? a) Contact the pediatrician to report the newborn's tachypnea. b) Stimulate the newborn to cry. c) Nothing since this is a normal reading. d) Further assess the newborn for abnormal lung sounds.

Nothing since this is a normal reading.

A nurse is observing respiratory effort in a newborn as part of Apgar scoring. Which of the following methods should he use to do this? a) Observing chest movement b) Observing response to a suction catheter in the nostrils c) Observing and counting the pulsations of the umbilical cord d) Observing resistance to any effort to extend the newborn's extremities

Observing chest movement

A father is asking questions about the circumcision of his son. He is asking the nurse if there are any disadvantages to the procedure. How should the nurse respond? a) Reduced risk of penile cancer b) Pain administration may not be effective during the procedure c) Lower rate of urinary tract infections d) Fewer complications than if done later in life

Pain administration may not be effective during the procedure

A nurse teaches new parents that the best way to help prevent infections in the newborn is which of the following? a) keep them inside for the first month of life b) limit visitors c) breastfeed d) keep them warm at all times

breastfeed

A newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which of the following in response to cold exposure? a) brown fat b) muscles c) nerves d) white fat

brown fat

Forces of contractions, mild asphyxia, increased intracranial pressure, and cold stress all play a role in the newborn transition by releasing which of the following critical components? a) cortisol b) epinephrine c) norepinephrine d) catecholamines

catecholamines

A nursing student is aware that fetal gas exchange takes place in which of the following? a) lungs b) uterus c) bronchioles d) placenta

placenta

A nursing student correctly chooses which stage of behavioral adaptation in the infant to reinforce teaching about feeding, positioning for feeding, and diaper-changing techniques? a) none are good times b) first period of reactivity c) second period of reactivity d) period of decreased responsiveness

second period of reactivity

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply. a) Uterine infection b) Prolonged labor c) Empty bladder d) Early ambulation e) Breast-feeding f) Hydramnios

• Uterine infection • Prolonged labor • Hydramnios

A nursing instructor explains to students that, regardless of their gestational age, all newborns experience the same pattern that includes which of the following periods? (Select all that apply.) a) period of decreased responsiveness b) period of increased responsiveness c) third period of reactivity d) second period of reactivity e) first period of reactivity

• first period of reactivity • period of decreased responsiveness • second period of reactivity

A client who recently gave birth to her third child expresses a desire to have her older two come to the hospital for a visit. Which of the following should the nurse say in response to this request? a) "Your baby is so vulnerable to infections right now that it would be better to wait until you are at home to introduce her to her siblings." b) "I recommend that you introduce the new baby to her siblings once you are back at home. Right now you need to rest and recover." c) "That's a great idea! They can also take the baby out into the hall and walk with it for a while to give you a break." d) "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"

A client who gave birth 5 days ago complains to the nurse of profuse sweating during the night. What should the nurse recommend to the client in this regard? a) "Be sure to change your pajamas to prevent you from chilling." b) "I'm not sure why this is occurring since this usually doesn't occur until much later in the postpartum perio" c) "Drink plenty of cold fluids before you go to bed." d) "I would suggest that you speak with your physician about this."

"Be sure to change your pajamas to prevent you from chilling."

After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, which statement indicates the need for additional teaching? a) "I can't wait for these stretch marks to disappear after delivery." b) "My nipples won't be so dark after I give birth." c) "This line on my belly will go away over time." d) "I might lose some hair, but it will grow back."

"I can't wait for these stretch marks to disappear after delivery."

When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage? a) "I didn't realize all that went into being a dad. I wasn't prepared for this." b) "It'll be fun to have a baby in the house, but things shouldn't change too much." c) "I may not be a pro at helping out with the baby, but I enjoy being involved." d) "I've learned how to diaper and bathe the baby so I can be a really involved dad."

"I didn't realize all that went into being a dad. I wasn't prepared for this."

A nurse is examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give to the client? a) "It is normal for the discharge to be deep red since it consists of leukocytes, decidual tissue, RBCs, and serous fluid." b) "This discharge is called lochia, and it consists of leukocytes and decidual tissue." c) "The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color." d) "The discharge at this point in the postpartum period consists of RBCs and leukocytes."

"The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color."

Which of the following would the nurse do first after the birth of a newborn? a) Administer vitamin K. b) Apply identification bracelet. c) Obtain footprints. d) Suction the mouth and nose.

Suction the mouth and nose.

A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestions should the nurse give to the client's husband to resolve the issue? a) Recommend that she speak to the physician on her husband's behalf. b) Advise that her husband read up on parental care. c) Encourage the husband to speak to his friends who have children. d) Suggest that her husband begin by holding the baby frequently.

Suggest that her husband begin by holding the baby frequently.

A nurse is caring for a client in the postpartum period. The nurse observes that distention of the abdominal muscles during pregnancy has resulted in separation of the rectus muscles. What intervention should the nurse perform to assist in healing the distended abdominal muscles? a) Suggesting proper exercise b) Applying warm compresses c) Massaging the muscles d) Applying moist heat

Suggesting proper exercise

Which factor might result in a decreased supply of breast milk in a postpartum client? a) Maternal diet high in vitamin C b) Supplemental feedings with formula c) An alcoholic drink d) Frequent feedings

Supplemental feedings with formula

A newborn infant born by a cesarean birth is experiencing a common problem seen in these type of deliveries.What finding would the nurse anticipate in an infant following a cesarean birth? a) Cardiac murmur b) Hypoglycemia c) Tachypnea d) Hyperthermia

Tachypnea

A client is exhibiting signs of early engorgement, but her milk is still flowing easily. Which of the following suggestions would the nurse give to treat engorgement? a) Apply ice packs before a feeding. b) Restrict fluid intake. c) Have the baby nurse on both breasts with every feeding. d) Take a warm shower before a feeding.

Take a warm shower before a feeding

When caring for a newborn who is jittery and irritable 30 minutes after birth, what should the nurse do? a) Assess the baby's temperature with a thermal skin probe. b) Take blood, using a heel stick, to check for hypoglycemia. c) Rule out hypoglycemia by checking the mother's chart for diabetes or other risk factors. d) Place the child beneath a radiant warmer.

Take blood, using a heel stick, to check for hypoglycemia.

While caring for a client following a lengthy labor and delivery, the nurse notes that the client repeatedly reviews her labor and delivery and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? a) Taking-in b) Letting-go c) Taking-hold d) Acquaintance/attachment

Taking-in

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the puerperium is this client in? a) Letting-go phase b) Taking-hold phase c) Taking-in phase d) Rooming-in phase

Taking-in phase

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is a) Taking-in, taking-hold, letting-go b) Taking-in, taking-on, letting-go c) Taking-in, holding-on, letting-go d) Taking, holding-on, letting-go

Taking-in, taking-hold, letting-go

To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate for 6 seconds. What should the count minimally be? a) 9 b) 10 c) 11 d) 12

11

Why should a nurse monitor a newborn after cesarean birth more closely than after a vaginal birth? a) Fetal lungs are uninflated and full of amniotic fluid that must be absorbed. b) Much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. c) The baby will have more fluid in its lungs, making respiratory adaptation more challenging. d) The baby's lifeline to oxygen is cut off when the umbilical cord is clamped, resulting in oxygen levels falling and carbon dioxide rising.

The baby will have more fluid in its lungs, making respiratory adaptation more challenging.

While educating a class of postpartum patients before discharge home after delivery, one woman asks when "will I stop bleeding?" How should the nurse respond? a) The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks b) You should stop bleeding and have no discharge in the next 1 to 2 weeks c) The bleeding may continue for 6 weeks d) Bleeding may occur on and off for the next 2 to 3 weeks

The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks

The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long? a) The first 28 days b) The first 3 months c) The first 4 months d) The first 6 months

The first 6 months

With a hepatitis B (HbsAG) positive mother, what should the newborn receive? a) Two doses of the hepatitis B immunoglobulin within 24 hours of birth b) The hepatitis B vaccination and 2 doses of hepatitis B immunoglobulin within 24 hours of birth c) The hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth d) The hepatitis Bvaccination and 1 dose of hepatitis B immunoglobulin within 24 hours of birth

The hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth

A client delivers a baby at a local health care facility. The nurse observes that the infant is fussy and begins to move her hands to her mouth and suck on her hand and fingers. How should the nurse interpret these findings? a) The infant is entering the habituation state. b) The infant is in a state of hyperactivity. c) The infant is attempting self-consoling maneuvers. d) The infant is displaying a state of alertness.

The infant is entering the habituation state.

Which of the following is true regarding fetal and newborn senses? a) A newborn cannot experience pain. b) A newborn does not have the ability to discriminate between tastes. c) The rooting reflex is an example that the newborn has a sense of touch. d) A fetus is unable to hear in utero. e) A newborn cannot see until several hours after birth.

The rooting reflex is an example that the newborn has a sense of touch.

The nurse is assessing an infant's reflexes. While eliciting a rooting reflex, the infants strongly sucks on the nurse's finger. How does the nurse interpret this finding? a) The infant does not have a normal rooting reflex. b) The rooting reflex shows a strong sucking response. c) The rooting reflex was tested incorrectly. d) The infant displays a normal rooting reflex.

The rooting reflex was tested incorrectly.

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which of the following does the nurse recognize as the phase the woman is experiencing? a) The taking hold phase. b) The taking in phase. c) The binding in phase. d) The letting go phase.

The taking hold phase.

Which reason explains why women should be encouraged to perform Kegel exercises after delivery? a) They assist with lochia removal. b) They promote the return of normal bowel function. c) They assist the woman in burning calories for rapid postpartum weight loss. d) They promote blood flow, enabling healing and muscle strengthening.

They promote blood flow, enabling healing and muscle strengthening.

Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which of the following? a) Hyperglycemia b) Varicose veins c) Thromboembolism d) Calcium depletion

Thromboembolism

For the first hour after birth, the height of the fundus is at the umbilicus or even slightly above it. a) False b) True

True

After teaching a class about the changes in the gastrointestinal system of a newborn, which of the following if stated by the class indicates the need for additional teaching? a) A newborn's stomach capacity is approximately 300 mL. b) The cardiac sphincter is immature. c) The newborn's gut is sterile at birth. d) Oral intake is necessary for vitamin K production.

A newborn's stomach capacity is approximately 300 mL.

Bonding between a mother and her infant can be defined how? a) A process of developing an attachment and becoming acquainted with each other b) An ongoing process in the year after delivery c) Family growing closer together after the birth of a new baby d) The skin to skin contact that occurs in the delivery room

A process of developing an attachment and becoming acquainted with each other

On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document as: a) Potential for respiratory distress. b) Cold stress. c) Poor oxygenation. d) Acrocyanosis.

Acrocyanosis

A preterm infant is experiencing cold stress after delivery. For which symptom should the nurse assess to best validate the problem? a) Hyperglycemia b) Metabolic alkalosis c) Shivering d) Apnea

Apnea

A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused due to perineal edema? a) Use ointments locally b) Use a warm sitz bath or tub bath c) Apply moist heat d) Apply ice

Apply ice

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a) Applying ice b) Administering bromocriptine (Parlodel) c) Applying warm compresses d) Restricting fluids

Applying ice

Louisa has just delivered her second child and will breast-feed. Although she wants "lots of kids," she doesn't want to become pregnant again until her second child is at least 2 years old. You counsel her to start using birth control at what point? a) Within 6 weeks b) As soon as she stops breast-feeding c) As soon as she resumes sexual activity d) Within 18 months

As soon as she resumes sexual activity

A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." Which of the following is the nurse's most appropriate response? a) Inform the physician that the client does not want to go home. b) Ask the client if she has any support in the home. c) Tell the client that she must go home as per hospital policy. d) Ask the client why she does not want to go home.

Ask the client why she does not want to go home.

A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate? a) Ask if she wants a breast pump to empty her breasts b) Explain to the woman that she should breastfeed because she is producing so much milk c) Assist the woman in placing ice packs on her breasts d) Assist the woman into the shower and have her run cold water over her breasts

Assist the woman in placing ice packs on her breasts

Which of the following would alert the nurse to suspect that a newborn is experiencing respiratory distress? a) Asymmetrical chest movement b) Acrocyanosis c) Short periods of apnea (less than 15 seconds) d) Respiratory rate of 50 breaths/minute

Asymmetrical chest movement

A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which of the following? a) Attachment b) Involution c) Engorgement d) Engrossment

Attachment

What is the best way for the nurse to assess the newborn's heartbeat? a) Auscultating the apical pulse for 30 seconds and multiplying by 2 b) Palpating the femoral pulse for 30 seconds and multiplying by 2 c) Auscultating the apical pulse for 60 seconds d) Palpating the brachial pulse for 60 seconds

Auscultating the apical pulse for 60 seconds

A nurse is caring for a client who has been treated for a deep vein thrombosis (DVT). Which teaching point should the nurse stress when discharging the client? a) Avoid use of oral contraceptives. b) Avoid using compression stockings. c) Avoid using products containing aspirin. d) Plan long rest periods throughout the day.

Avoid use of oral contraceptives.

A nurse tests a newborn's nervous functioning by stroking the sole of the baby's foot in an inverted "J" curve from the heel upward. The baby responds by fanning his toes. Which reflex has just been demonstrated? a) Rooting reflex b) Moro c) Extrusion d) Babinski reflex

Babinski reflex

You are the oncoming nursery nurse in a normal newborn nursery. You receive report on four infants. Baby A is reported as being 16 hours old, vital signs within normal limits (WNL), bilirubin 3.5 mg/dL rooming in with mother; Baby B is 8 hours old, vital signs WNL, bilirubin 3 mg/dL, returning to nursery for night; Baby C is 19 hours old, vital signs WNL, bilirubin 4 mg/dL, rooming in with mother; Baby D is 4 hours old, vital signs WNL, bilirubin 2 mg/dL, returning to nursery for night. Which baby would you assess first? a) Baby C b) Baby B c) Baby A d) Baby D

Baby C

Which is NOT a cause of jaundice in the newborn? a) Bilirubin overproduction b) Impaired bilirubin excretion c) Decreased bilirubin conjugation d) Bilirubin hyperexcretion

Bilirubin hyperexcretion

Question: Place in the order in which they occur the following items regarding changes in fetal circulation at birth. 1. An increase in systemic blood pressure with continued increase in blood flow to the lungs 2. Pulmonary blood flow increases and pulmonary venous return to the left side of the heart increases 3. Birth 4. The foramen ovale closes 5. Pulmonary vascular resistance decreases 6. The ductus arteriosus closes

Birth Pulmonary vascular resistance decreases Pulmonary blood flow increases and pulmonary venous return to the left side of the heart increases The foramen ovale closes An increase in systemic blood pressure with continued increase in blood flow to the lungs The ductus arteriosus closes

On assessment of a 2-day postpartum patient the nurses finds the fundus is boggy, at the umbilicus and slightly to the right. What is the most likely cause of this assessment finding? a) Bladder distention b) Full bowel c) Uteruine atony d) Poor bladder tone

Bladder distention

Which vital sign is not routinely assessed in a term, healthy newborn with 9/9 AGPARs? a) Pain b) Pulse c) Temperature d) Respirations e) Blood pressure

Blood pressure

A woman has just delivered a baby. Her prelabor vital signs were temperature: 98.8°F (37.1°C); blood pressure: 120/70 mmHg; pulse; 80 beats/min. and respirations: 20breaths/min. Which combination of findings during the early postpartum period are the most concerning? a) Shaking chills with a fever of 100.4°F (38°C) b) Blood pressure 90/50 mmHg, pulse 120 beats/min, respirations 24 breaths/min. c) Bradycardia and excessive, soaking diaphoresis d) Blood loss of 250 mL and WBC 25,000 cells/mL

Blood pressure 90/50 mmHg, pulse 120 beats/min, respirations 24 breaths/min.

You are admitting a 10-pound newborn to the nursery. You know that it will be important to monitor what during the transition period? a) Temperature b) Heart rate c) Blood sugar d) Apgar score

Blood sugar

A patient who delivered her infant 3 days ago and was discharged home calls her provider's office with a complaint of sweating all night. What is the cause of the increased perspiration? a) Change in pregnancy hormone b) Body secreting the excess fluids from pregnancy c) The body is trying to get rid of the extra blood made during pregnancy d) The patient may be drinking too much fluid

Body secreting the excess fluids from pregnancy

Ophthalmia neonatorum is contracted when a mother has which sexually transmitted infection(s)? a) Chlamydia b) Gonorrhea c) Trichomonas d) Both B and C e) Both A and B

Both A and B

What is the primary mechanism for temperature regulation in a newborn infant? a) External with blankets by the nursing staff b) Shivering and increased metabolic rate c) Skin to skin contact with mother d) Brown fat store usage

Brown fat store usage

A nurse is caring for a client who has just undergone delivery. What is the best method for the nurse to assess this client for postpartum hemorrhage? a) By assessing blood pressure b) By assessing skin turgor c) By monitoring hCG titers d) By frequently assessing uterine involution

By frequently assessing uterine involution

What is the term for a small collection of blood that forms underneath the skull as a result of birth trauma? a) Caput succedaneum b) Erythema toxicum c) Cephalhematoma d) Vernix caseosa

Cephalhematoma

A primiparous mother delivered a 8 pound 12 ounce infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice? a) Rh positive blood type b) Hepatitis A vaccine c) Female gender d) Cephalohematoma e) Formula feeding

Cephalohematoma

A nurse is caring for a client postpartum who complains of sore nipples. The nurse observes that the client's newborn is unable to suck properly although latched well. What intervention should the nurse perform to assist the baby to suck properly? a) Prolong the gap between feedings b) Check the baby's frenulum c) Position baby to face the nipple d) Suggest bottle feeding

Check the baby's frenulum

On inspecting a newborn's abdomen, which finding would you note as abnormal? a) Liver palpable 2 cm under the right costal margin b) Bowel sounds present at two to three per minute c) Abdomen slightly protuberant (rounded) d) Clear drainage at the base of the umbilical cord

Clear drainage at the base of the umbilical cord

A newborn is challenged to maintain an adequate body temperature. If a baby is placed too close to a cold air vent, the nurse can assume that the infant will lose heat by which mechanism? a) Conduction b) Convection c) Radiation d) None. This will not cause the infant to lose body heat.

Convection

A newborn's axillary temperature is 97.6°F (36.4°C). He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn? a) Conduction and evaporation b) Convection and radiation c) Conduction and radiation d) Convection and evaporation

Convection and evaporation

All of the following are signs of respiratory distress in the newborn EXCEPT a) Chest retractions b) Central cyanosis c) Nasal flaring d) Grunting e) Coughing and a respiratory rate above 50

Coughing and a respiratory rate above 50

The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate? a) Vernix caseosa b) Cyanosis c) Dehydration d) Increased intracranial pressure

Dehydration

A client in the postpartum period complains of constipation. The nurse should inform the client of which of the following that contributes to postpartum constipation? a) Separation of rectus muscles b) Relaxation of abdominal muscles c) Distention of abdominal muscles d) Discomfort due to hemorrhoids

Discomfort due to hemorrhoids

While making a follow up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which of the following would be the most likely reason for the weight loss? a) Blood loss b) Diuresis c) Lactation d) Nausea

Diuresis

You are the oncoming nursery nurse caring for a 3-hour-old newborn boy. You make your initial assessment and find the following: Respiratory rate 30 bpm, B/P 60/40 mm/Hg, heart rate 155, axillary temperature 98.2°F (36.8°C). You assess that the newborn is in a state of quiet alert. What would you do? a) Stimulate the newborn b) Document the data c) Call the physician d) Inform the charge nurse

Document the data

For several hours after delivery, Norah, a multigravida who experienced a much more difficult labor this time than any time previously, wants to talk about why the birthing process was so hard for her this time. In fact, she's focusing on this aspect to the point that she seems relatively indifferent to her newborn. How should you handle this situation? a) Redirect her attention to the baby by reminding her of the details of newborn care b) Encourage her to discuss her experience of the birth and answer any questions or concerns she may have c) Ask her to describe how she plans to integrate the newcomer into her existing family, including any actions she has taken to prepare the siblings d) Point out positive features of her baby and encourage her to hold and cuddle the baby

Encourage her to discuss her experience of the birth and answer any questions or concerns she may have

The patient under your care is complaining she has not had a bowel moment since her infant was born 2 days ago. She asks the nurse what she can do to help her have a bowel movement. What intervention is appropriate to encourage having a bowel movement? a) Encourage the patient to eat more fiber rich foods b) Offer the patient a stimulant laxative c) Have her hold her feces until she really feels the need to defecate d) Add dairy products to the patient's diet

Encourage the patient to eat more fiber rich foods

The nurse is assessing a breastfeeding mom 72 hours after delivery. When assessing her breast, the patient complains of bilateral breast pain around the entire breast. What is the most likely cause of the pain? a) Engorgement b) Blocked milk duct c) Mastitis d) Interductal yeast infection

Engorgement

Which of the following would the nurse expect to administer for eye prophylaxis in the newborn? a) Gentamicin ophthalmic ointment b) Erythromycin ophthalmic ointment c) Silver nitrate solution d) Vitamin K

Erythromycin ophthalmic ointment

When describing the hormonal changes that occur after birth of a newborn, the nurse would identify a decrease in which hormone as being associated with breast engorgement? a) Progesterone b) Human chorionic gonadotropin (hCG) c) Prolactin d) Estrogen

Estrogen

It is common for a newborn to have one or two erupted teeth (natal teeth) at birth. a) False b) True

False

Neonatal red blood cells have a life span of 120 days, while those of adults last 80 to 100 days. a) False b) True

False

A nurse is caring for a breastfeeding client who complains of engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which of the following should the nurse suggest to help her prevent engorgement? a) Apply cold compresses to the breasts b) Feed the baby at least every two or three hours c) Provide the infant oral nystatin d) Dry the nipples following feedings

Feed the baby at least every two or three hours

On an Apgar evaluation, reflex irritability is tested by which of the following? a) Flicking the soles of the feet and observing the response b) Dorsiflexing a foot against pressure resistance c) Tightly flexing the infant's trunk and then releasing it d) Raising the infant's head and letting it fall back

Flicking the soles of the feet and observing the response

A 12-hour-old infant is receiving IV fluids for polycythemia. Which complications should a nurse monitor for in this client? a) Tachycardia b) Fluid overload c) Hypotension d) Decreased level of consciousness

Fluid overload

On examining a newborn's eyes, which of the following would you expect to assess? a) Has a white rather than a red reflex b) Produces tears when he cries c) Follows your finger a full 180 degrees d) Follows a light to the midline

Follows a light to the midline

A nursing student will pick which of the following as a correct laboratory value for a newborn? a) Hematocrit (HCT) 45% - 50% b) White blood cells (WBC)s 5-10,000mm³ c) Platelets 50,000-75,000/µL d) Hemoglobin (HBG) 17-20 g/dL

Hemoglobin (HBG) 17-20 g/dL The normal laboratory values for a newborn include HGB 17-20g/dL, HCT 52%-63%, platelets 100,000-300,000µL , RBCs 5.1-5.8, WBCs 10-30,000/mm³3

As the nurse caring for postpartum patients, what laboratory study would you expect to have ordered by the birth attendant the morning after delivery of the baby? a) Blood type b) Complete blood count (CBC) c) Hemoglobin and hematocrit (H&H) d) Iron level

Hemoglobin and hematocrit (H&H)

A nurse is assessing a breastfeeding client in the third week postpartum. During assessment, the nurse observes that the rugae in the vagina have not reappeared. Which of the following should the nurse identify as the possible cause of delayed return of rugae? a) Low circulating progesterone level b) Low circulating oxytocin level c) High circulating estrogen level d) High circulating prolactin level

High circulating estrogen level

At birth changes from fetal to newborn circulation must occur. What change causes the ductus arteriosus to close? a) Higher oxygen content of the circulating blood b) Increase in pressure in the left atrium of the heart c) Higher oxygen levels at the respiratory centers of the brain d) Drop in pressure in the neonate's chest

Higher oxygen content of the circulating blood

A nurse is educating the mother of a newborn about feeding and burping. Which strategy should the nurse offer to the mother regarding burping? a) Gently rub the newborn's abdomen while the newborn is in a sitting position b) Hold the newborn upright with the newborn's head on the mother's shoulder c) Lay the newborn on its abdomen in the mother's lap and gently pat the buttocks d) Lay the newborn on its back on its mother's lap

Hold the newborn upright with the newborn's head on the mother's shoulder

While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breast-feeding because it is a major source of which immunoglobulin? a) IgG b) IgM c) IgE d) IgA

IgA

A nurse is explaining the benefits of breastfeeding to a client who has just delivered. Which statement correctly explains the benefits of breastfeeding to this mother? a) Breastfed infants gain weight faster than formula fed infants after 6 month of age b) Breastfeeding provides more iron and calcium for the infant c) Immunoglobulin IgA in breast milk boosts a newborn's immune system d) Mothers who breastfeed have increased breast size following nursing

Immunoglobulin IgA in breast milk boosts a newborn's immune system

Which of the following is FALSE regarding newborn behavioral patterns? a) An initial period of reactivity is followed by a longer period of decreased responsiveness. b) Newborns are usually predictable in the first several hours after birth. c) In the first few hours after birth, newborns do not typically demonstrate a response to visual stimuli. d) Newborns are usually awake in the first 30 following birth and will demonstrate a spontaneous Moro and rooting reflexes.

In the first few hours after birth, newborns do not typically demonstrate a response to visual stimuli.

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which of the following would the nurse identify as the most likely factor for this development? a) Cracking of the nipple b) Improper positioning of infant c) Inability of infant to empty breasts d) Inadequate secretion of prolactin

Inability of infant to empty breasts

The nurse is caring for a client who had been administered an anesthetic block during labor. Which of the following are risks that the nurse should watch for in the client? Select all that apply. a) Perineal laceration b) Incomplete emptying of bladder c) Bladder distention d) Urinary retention e) Ambulation difficulty

Incomplete emptying of bladder Bladder distention Urinary retention

When assessing a postpartum woman, which finding would be most significant in identifying possible postpartum hemorrhage? a) Increased hematocrit level b) Increased blood pressure c) Increased cardiac output d) Increase heart rate

Increase heart rate

When describing the events that occur in a newborn when he or she experiences a cold environment, which of the following would the nurse identify as occurring first? a) Increased release of norepinephrine b) Breakdown of triglycerides c) Increased cardiac output d) Increased blood flow through brown fat

Increased release of norepinephrine

Which of the following nursing diagnosis would be highest in priority for a newborn? a) Ineffective thermoregulation related to heat loss to the environment. b) Altered nutrition less than body requirement related to limited formula intake. c) Altered urinary elimination related to post-circumcision status. d) Ineffective airway clearance related to mucous obstruction.

Ineffective airway clearance related to mucous obstruction.

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. This is likely an indication of what? a) It is a self-limiting virus that does not require treatment. b) It is an indication that the woman has mistreated her newborn. c) It is a sign of a group beta streptocoous skin infection. d) It is a normal skin finding in a newborn.

It is a normal skin finding in a newborn.

A client delivers a newborn in a local health care facility. What guidance should the nurse give to the client before discharge regarding thermoregulation of the newborn at home? a) Keep the newborn wrapped in a blanket, with a cap on its head b) Encourage the mother to keep the infant in her bed to ensure that the infant stays warm c) Ensure cool air is circulating over the newborn to prevent overheating d) Keep the infant's room temperature at least 80 degrees

Keep the newborn wrapped in a blanket, with a cap on its head

Infants have a substance in their lungs, surfactant. What is role of surfactant in the respiratory system? a) Allows oxygen to move in the lungs b) Keeps alveoli from collapsing with breaths c) Removes fluid from the lungs d) Expands the lungs with breaths

Keeps alveoli from collapsing with breaths

A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which of the following should the nurse recommend to the client to improve pelvic floor tone? a) Sitz baths b) Kegel exercises c) Urinating immediately when the urge is felt d) Abdominal crunches

Kegel exercises

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which of the following in the newborn? a) Continual kicking b) Lack of subcutaneous fat c) Continual crying d) Constriction of blood vessels

Lack of subcutaneous fat

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8°F (36°C). Which observed manifestation would confirm the occurrence of cold stress in this client? a) Increase in the body temperature b) Lethargy and hypotonia c) Hyperglycemia d) Increased appetite

Lethargy and hypotonia

What should the nurse consider when checking results of blood work done on a newborn? a) Site of the blood sample does not make a difference. b) The newborn's platelet count is higher than an adult's. c) The newborn's aggregation ability is lower than an adult's. d) Leukocytosis is usually present.

Leukocytosis is usually present.

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which of the following would the nurse include? a) Expanded stores of glucose and glycogen b) Enhanced shivering ability c) Thick skin with deep lying blood vessels d) Limited voluntary muscle activity

Limited voluntary muscle activity

What should the nurse expect for a full-term newborn's weight during the first few days of life? a) Loss of 5% to 10% of the birth weight in the first few days in breastfed infants only b) Loss of 5% to 10% of birth weight in formula-fed and breastfed newborns c) A formula-fed newborn should gain 3% to 5% of the initial birth weight in the first 48 hours, but a breastfed newborn may lose up to 3%. d) An increase in 3% to 5% of birth weight by day 3 in formula-fed babies

Loss of 5% to 10% of birth weight in formula-fed and breastfed newborns

A client complains to the nurse of pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints? a) Apply ice to the sore joints. b) Soak in a warm bath several times a day. c) Maintain correct posture and positioning. d) Try to avoid carrying the baby for a few days.

Maintain correct posture and positioning.

The nurse observes tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as: a) Vernix caseosa b) Harlequin sign c) Lanugo d) Milia

Milia

Which lochia pattern should be reported immediately? a) Moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 b) Moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 c) Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5 d) Lochia progresses from rubra to serosa to alba within 10 days

Moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5

A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which of the following about newborn vision whould the student accurately include in the presentation? a) Newborns have the ability to focus only on objects in close proximity. b) Newborns have the ability to focus on objects in midline. c) Newborns cannot focus on any objects. d) Newborns have the ability to focus only on objects far away.

Newborns have the ability to focus only on objects in close proximity.

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? a) 24 hours after admission to the nursery b) On admission to the nursery c) 4 hours after admission to the nursery d) After the newborn has received the initial feeding

On admission to the nursery

When applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate? a) Over the opposite hip b) Between the scapulae c) In the mediastinal area d) Over the liver

Over the liver

A client delivered vaginally 2 days prior and wishes to prevent getting pregnant again. She asks the nurse when she will need to begin birth control measures. How should the nurse respond? a) You will not ovulate until your menstrual cycle returns b) Ovulation does not return for 6 months after delivery c) You may have intercourse until next month with no fear of pregnancy d) Ovulation may return as soon as 3 weeks after delivery

Ovulation may return as soon as 3 weeks after delivery

A nurse is caring for a client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. The nurse would be accurate in identifying which hormone as the cause of these afterpains? a) Relaxin b) Prolactin c) Oxytocin d) Progesterone

Oxytocin

A nurse is caring for a client who is nursing her baby boy. The client complains of afterpains. Secretion of which of the following should the nurse identify as the cause of afterpains? a) Estrogen b) Prolactin c) Progesterone d) Oxytocin

Oxytocin

You are used to working on the postpartum floor taking care of women who have had normal vaginal deliveries. Today, however, you have been assigned to help care for woman who are less than 24 hours post cesarean delivery. You know that in making your assessments you will have to change some things that you would not normally assess. What would you leave out of your patient assessments? a) Breasts b) Lower extremities c) Perineum d) Respiratory status

Perineum

The New Ballard scoring system evaluates newborns on which 2 factors? a) Body maturity and cranial nerve maturity b) Physical maturity and neuromuscular maturity c) Skin maturity and reflex maturity d) Tone maturity and extremities maturity

Physical maturity and neuromuscular maturity

During a postpartum exam on the day of delivery, the woman complains that she is still so sore that she can't sit comfortably. You examine her perineum and find the edges of the episiotomy approximated without signs of a hematoma. Which intervention will be most beneficial at this point? a) Apply a warm washcloth b) Place an ice pack c) Put on a witch hazel pad. d) Notify a physician

Place an ice pack

A nurse is required to obtain the temperature of a healthy newborn who was placed in an open crib. Which is the most appropriate method for measuring a newborn's temperature? a) Obtain the temperature rectally b) Place electronic temperature probe in the midaxillary area c) Obtain the temperature orally d) Tape electronic thermistor probe to the abdominal skin

Place electronic temperature probe in the midaxillary area

A nurse is assessing the temperature of a newborn using a skin temperature probe. Which point should the nurse keep in mind while taking the newborn's temperature? a) Ensure that the newborn is lying on its abdomen b) Place the temperature probe over the liver c) Use the skin temperature probe only in open bassinets d) Tape the temperature probe on the forehead

Place the temperature probe over the liver

During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse does which of the following to prevent prolapse or inversion of the uterus? a) Palpates the abdomen while feeling the uterine fundus b) Places index and middle fingers across the muscle c) Massaging the fundus carefully to expel any blood clots d) Placing a gloved hand just above the symphysis pubis

Placing a gloved hand just above the symphysis pubis

A woman who delivered a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which of the following factors/conditions does the nurse believe is causing this experience? a) Postpartum depression. b) Postpartum anxiety. c) Postpartum baby blues. d) Postpartum reaction.

Postpartum baby blues.

A nurse is caring for a client in the postpartum period. The client is emotionally sensitive, feels a sense of failure, and attempts to hurt herself and the baby. The nurse understands that the client is exhibiting symptoms of which of the following conditions? a) Postpartum psychosis b) Postpartum blues c) Anxiety disorders d) Postpartum depression

Postpartum depression Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which of the following should the nurse identify as a potential cause for urinary frequency? a) Urinary overflow b) Trauma to pelvic muscles c) Postpartum diuresis d) Urinary tract infection

Postpartum diuresis

At birth there are multiple changes in the cardiac and respiratory systems. Which of the following is one of the changes to occur at birth in the cardiovascular system? a) Oxygen is exchanged in the lungs b) Fluid is removed from the alveoli and replaced with air c) Pressure changes occur and result in closure of the ductus arteriosus d) The oxygen in the blood decreases

Pressure changes occur and result in closure of the ductus arteriosus

The nurse cares for a newborn with a congenital cardiac anomaly. What component of nursing care is the priority for the newborn? a) Maintain oxygen saturation at 95% or above b) Teach the parents to take pulse and blood pressure measurements c) Prevent pain as much as possible d) Accompany the newborn to all radiologic examinations

Prevent pain as much as possible

The nurse wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met? a) Promote early breastfeeding for the infants b) Avoid bathing the newborn until they are 24 hours old c) Avoid skin-to-skin contact with the mother until the infants are 8 hours old d) Keep the infant transporter temperature between 80 and 85 degrees F

Promote early breastfeeding for the infants

As you are examining the newborn female, you notice a small pinkish discharge from the vaginal area. What should you suspect? a) Impending hemorrhage from a congenital defect b) Pseudomenstruation, a normal finding c) Infection d) Evidence of birth trauma

Pseudomenstruation, a normal finding

The nurse uses a radiant warmer to transport a newborn to reduce heat loss via which mechanism? a) Evaporation b) Convection c) Conduction d) Radiation

Radiation

A nurse is teaching newborn care to students. The nurse correctly identifies which of the following as the predominant form of heat loss in the newborn? a) Nonshivering thermogenesis. b) Lack of brown adipose tissue. c) Sweating and peripheral vasoconstriction. d) Radiation, convection, and conduction.

Radiation, convection, and conduction.

A newborn in the nursery has a temperature of 97.4°F (36.3°C). What may happen first, if the infant continues to be cold stressed? a) Seizure b) Hypoglycemia c) Respiratory distress d) Cardiovascular distress

Respiratory distress

The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse most likely apply the probe? a) Lower back b) Upper left arm c) Right great toe d) Right upper abdominal quadrant

Right upper abdominal quadrant

Charting on the nursing care plan patient care, which nursing diagnosis has the highest priority for a postpartum patient? a) Acute pain related to afterpains or episiotomy discomfort b) Risk for infection related to multiple portals of entry for pathogens, including the former site of the placenta, episiotomy, bladder and breasts c) Risk for injury: postpartum hemorrhage related to uterine atony d) Risk for injury: falls related to postural hypotension and fainting

Risk for injury: postpartum hemorrhage related to uterine atony

The nurse is documenting assessment of infant reflexes. She strokes the side of the infants face and the baby turns toward the stroke. What reflex has the nurse elicited? a) Tonic neck b) Sucking c) Moro d) Rooting

Rooting

What is the primary function of uterine contractions after delivery of the infant and placenta? a) Return the uterus to normal size b) Seal off the blood vessels at the site of the placenta c) Stop the flow of blood d) Close the cervix

Seal off the blood vessels at the site of the placenta

Which of the following actions would lead you to assess that a postpartal woman is entering the taking-hold phase of the postpartal period? a) She did her perineal care independently. b) She is eager to talk about her delivery experience. c) She has not asked for anything for pain all day. d) She sits and rocks her infant for long intervals.

She did her perineal care independently.

Which maternal reaction is the most concerning? a) She neglects to engage with or provide care for the baby and shows little interest in it b) She expresses doubt about her ability to care for the baby as well as the nurse can c) She hesitates to take her newborn when offered and expresses disappointment with the way the baby looks d) She is tearful for several days and has difficulty eating and sleeping

She neglects to engage with or provide care for the baby and shows little interest in it

Which of the following actions would most make you believe that a postpartum woman is accepting a child well? a) She asks you to use her camera to take a photo of the child. b) She turns her face to meet the infant's eyes when she holds her. c) She states she has named the child after a well-loved friend. d) She comments that her baby has the most hair of any in the nursery.

She turns her face to meet the infant's eyes when she holds her.

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breast-feeding, the nurse should tell her which of the following? a) Stools should be brown and loose. b) Stools should be yellow-gold, loose, and stringy to pasty. c) Stools should be yellow-green and loose. d) Stools should be greenish and formed in consistency.

Stools should be yellow-gold, loose, and stringy to pasty.

A nurse who has worked in a nursery for 15 years informs the nursing student that feeding an infant early has advantages and describes the biggest advantage as which of the following? a) allows the mother to see if the baby can tolerate formula b) helps to ease the baby's hunger c) allows the baby to sleep longer d) allows the baby to pass stools, which helps to reduce bilirubin

allows the baby to pass stools, which helps to reduce bilirubin

While trying to decide whether to bottle feed or breastfeed her newborn infant, a new mother questions the lactation specialist concerning the greatest benefit of breastfeeding her infant. What would be the best response? a) decreased expense for feedings b) immunity against many different bacteria c) Ease of digestion of breast milk d) convenience of breastfeeding

immunity against many different bacteria

A newborn is passing greenish-black stool of tarry consistency. The nursing student correctly identifies this type of stool as which of the following? a) stool of a formula-fed newborn b) transitional stool c) stool of a breast-fed newborn d) meconium stool

meconium stool

A nursing student observing newborns in the nursery is amazed that a crying infant put her fingers in her mouth, instantly stops crying, and then falls asleep. This behavior can best be explained as: a) motor maturity. b) the sleep state. c) social behavior. d) self-quieting ability.

self-quieting ability.

A nurse working in the neonatal nursery anticipates the physician to order which of the following for a premature newborn having difficulty breathing? a) epinephrine b) norepinephrine c) surfactant d) albuteral

surfactant

A mother points out to you that following three meconium stools, her newborn has had a bright green stool. THe nurse would explain to her that a) her child will need to be isolated until the stool can be cultured. b) her child may be developing an allergy to breast milk. c) this is most likely a symptom of impending diarrhea. d) this is a normal finding.

this is a normal finding.

A mother points out to you that following three meconium stools, her newborn has had a bright green stool. THe nurse would explain to her that a) her child will need to be isolated until the stool can be cultured. b) this is a normal finding. c) this is most likely a symptom of impending diarrhea. d) her child may be developing an allergy to breast milk.

this is a normal finding.

The nurse explains to a client who recently gave birth that she will undergo both retrogressive and progressive changes in the postpartal period. Which of the following are retrogressive changes? (Select all that apply.) a) Beginning of a parental role b) Involution of the uterus c) Formation of breast milk d) Return of blood volume to prepregnancy level e) Decrease of pregnancy hormones f) Contraction of the cervix

• Involution of the uterus • Return of blood volume to prepregnancy level • Decrease of pregnancy hormones • Contraction of the cervix

A client who has given birth a week ago complains to the nurse of discomfort when defecating and ambulating. The birth involved an episiotomy. Which of the following should the nurse suggest to the client to provide local comfort? Select all that apply. a) Maintain correct posture b) Use of anesthetic sprays c) Use of warm sitz baths d) Use good body mechanics e) Use of witch hazel pads

• Use of warm sitz baths • Use of witch hazel pads • Use of anesthetic sprays

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breast-fed newborns? Select all that apply. a) Stringy to pasty consistency b) Completely odorless c) Yellowish gold color d) Formed in consistency e) Firm in shape

• Yellowish gold color • Stringy to pasty consistency

A nursing instructor informs the student that the following are stimuli for initiating respirations in the newborn? (Select all that apply.) a) elevated CO2 b) hypoxia c) hypercapnia d) alkalosis e) acidosis

• hypercapnia • hypoxia • acidosis

A nursing instructor informs students that recent research has shown advantages of delayed cord clamping include which of the following? (Select all that apply.) a) improving the newborn's cardiopulmonary adaptation b) improving oxygen transport c) increasing blood pressure d) preventing childhood anemia e) preventing childhood obesity f) increasing red blood cell flow

• improving the newborn's cardiopulmonary adaptation • preventing childhood anemia • increasing blood pressure • improving oxygen transport • increasing red blood cell flow

When assessing the newborn's umbilical cord, what should the nurse expect to find? a) One smaller artery and two larger veins b) Two smaller arteries and one larger vein c) One smaller vein and two larger arteries d) Two smaller veins and one larger artery

Two smaller arteries and one larger vein

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention will help the client most? a) Practicing good body mechanics b) Urinary catheterization c) A warm shower d) A warm compress

Urinary catheterization

During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After delivery, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this? a) Urinary elimination b) Being too tired to eat c) Elimination of solid wastes d) Breathing off fluid vapor

Urinary elimination

A postpartum client complains of urinary frequency and burning. Which of the following would the nurse suspect? a) Urinary tract infection b) Stress incontinence c) Subinvolution d) Uterine atony

Urinary tract infection

The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse then would monitor the client for which of the following? a) Stress incontinence b) Loss of pelvic muscle tone c) Increased urine output d) Urinary tract infection

Urinary tract infection

A nurse is caring for a client with postpartum hemorrhage. Which of the following should the nurse identify as the significant cause of postpartum hemorrhage? a) Iron deficiency b) Hemorrhoid c) Uterine atony d) Diuresis

Uterine atony

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? a) Edematous vagina b) Diaphoresis c) Uterus 1 cm below umbilicus d) Lochia serosa

Uterus 1 cm below umbilicus

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? a) Uterus 1 cm below umbilicus b) Diaphoresis c) Edematous vagina d) Lochia serosa

Uterus 1 cm below umbilicus

The nurse assesses a postpartum woman for thromboembolism based on the understanding that her risk is increased because of which of the following? a) Increased white blood cell count b) Vessel damage during birth c) Episiotomy d) Decrease in coagulation factors

Vessel damage during birth

A mother asks the nurse why her newborn is getting an Vitamin K injection in the delivery room. The nurse explains that the injection is necessary because: a) the mother was febrile at the time of delivery and prophylactic Vitamin K is necessary. b) Vitamin K aids in protein metabolism. Newborns have defective protein metabolism until 24 hours of life. c) Vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth. d) Newborns are prone to hypoglycemia and Vitamin K helps maintain a steady blod glucose level.

Vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth.

The nurse is providing education to a mother who is going to bottle feed her infant. What information will the nurse provide to this mom regarding breast care? a) Wear a tight, supportive bra b) Run warm water over the breast in the shower c) Express small amounts of milk when they are too full d) Massage the breast when they are painful

Wear a tight, supportive bra

A nurse is caring for a non-breastfeeding client in the postpartum period. The client complains of engorgement. What suggestion should the nurse provide to alleviate breast discomfort? a) Wear a well-fitting bra b) Apply hydrogel dressing c) Apply warm compress d) Express milk frequently

Wear a well-fitting bra

Which measurements were most likely obtained from a normal newborn delivered at 38 weeks to a healthy mother with no maternal complications? a) Weight = 2000 g, length = 17 inches, head circumference = 32 cm, and chest circumference = 30 b) Weight = 2500 g, length = 18 inches, head circumference = 32 cm, and chest circumference = 30 cm c) Weight = 3500 g, length = 20 inches, head circumference = 34 cm, and chest circumference = 32 cm d) Weight = 4500 g, length = 22 inches, head circumference = 36 cm, and chest circumference = 34 cm

Weight = 3500 g, length = 20 inches, head circumference = 34 cm, and chest circumference = 32 cm

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn? a) 24 hours after the newborn's birth b) Prior to the newborn being discharged c) Within 30 minutes after birth, in the birthing area d) Within the first 2 to 4 hours, when the newborn reaches the nursery

Within the first 2 to 4 hours, when the newborn reaches the nursery

A newborn is born and the nurse realizes that the infant is at risk for evaporative heat loss. Which intervention would best prevent this from occurring? a) Wrap the infant in a warm, dry blanket b) Place the infant in the mother's abdomen after delivery c) Turn the delivery room temperature up. d) Bathe the infant immediately after birth

Wrap the infant in a warm, dry blanket

A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment? a) Yellow sclera b) Abdominal distension c) Heart rate of 130 bpm d) Respiratory rate of 24

Yellow sclera

A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment? a) Yellow sclera b) Heart rate of 130 bpm c) Respiratory rate of 24 d) Abdominal distension

Yellow sclera

The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which of the following best indicates what the mother would observe after several days? a) Yellow-green, pasty, unpleasant-smelling stool b) Greenish, tarry, thick black stool c) Sour-smelling, yellowish-gold stool d) Thin, yellowish, seedy brown stool

Yellow-green, pasty, unpleasant-smelling stool

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which of the following would the nurse interpret as an expected finding? a) Yellowish pink b) Yellowish white c) Red d) Pink

Yellowish white

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct? a) "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." b) "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding." c) "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight." d) "Your newborn should finish a bottle in less than 15 minutes."

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."

When counseling a patient about the advantages of circumcision, which should NOT be included in the nurse's teaching? a) "Circumcision decreases rates of urinary tract infection." b) "Circumcision decreases risks of skin dehiscence, adhesions, and urethral fistulas." c) "Circumcision decreases rates of penile cancer." d) "Males who are circumcised have lower rates of sexually transmitted infection."

"Circumcision decreases risks of skin dehiscence, adhesions, and urethral fistulas."

The nurse is educating a client who is breastfeeding her 2-week-old newborn regarding the nutritional requirements of newborns, according to the recommendations of the American Academy of Pediatrics (AAP). Which response by the mother would validate her understanding of the information she received? a) "I will feed him at least 30 cc of water daily." b) "Since we live in a rural area, I must ensure he receives adequate fluoride supplementation." c) "I need to give him iron supplements daily." d) "I will give him vitamin D supplements daily for the first 2 months of life."

"I will give him vitamin D supplements daily for the first 2 months of life."

A woman comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." The woman is dressed in hospital scrub attire but has no name badge showing. What is the best response by the nurse caring for the baby? a) "You must be Mrs. Smith's sister. She said her sister is a nurse." b) "Leave immediately! I'm calling security." c) "May I see your identification, please?" d) "I don't know you. Are you trying to take a baby?"

"May I see your identification, please?"

The nurse has presented a teaching session to graduate nurses on physiologic jaundice. Which student statement indicates that additional teaching is needed? a) "Physiologic jaundice begins before the neonate goes home." b) "Physiologic jaundice happens as a result of a breakdown of RBCs." c) "Physiologic jaundice happens because the RBC count built in utero is being decreased." d) "Physiologic jaundice begins in the first 24 hours of after birth."

"Physiologic jaundice begins in the first 24 hours of after birth."

The parents of a newborn baby boy ask you about circumcising their son. They are undecided as to what to do. Which response by the nurse is best? a) "It is best not to circumcise your baby because the procedure is very painful." b) "Circumcision is best in order to protect the baby from diseases like cancer." c) "If you do not circumcise your baby, he will always have difficulty maintaining adequate hygiene." d) "There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure."

"There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure."

When instructing a new mom on providing skin care to her newborn, which of the following should NOT be included in the teaching? a) "Give the newborn sponge baths until the umbilical cord falls off." b) "Change diapers frequently." c) "Use talc powders to prevent diaper rash." d) "Daily tub baths are not necessary."

"Use talc powders to prevent diaper rash."

A patient expresses concern to the nurse that her baby is dehydrated and is not getting enough milk from breastfeeding. What is the best response from the nurse? a) "We will give him some water through a bottle in the nursery tonight while you rest." b) "Does he pass urine that is a light amber color right after eating?" c) "You can tell that your baby is adequately hydrated because he is making 8 wet diapers a day." d) "You should supplement with formula because your baby is 24 hours old and has not passed meconium yet."

"You can tell that your baby is adequately hydrated because he is making 8 wet diapers a day."

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? a) When the infant is 48 hours old. b) 24 hours after the newborn's first protein feeding. c) 36 hours before the infant is discharged home with its parents. d) Just before discharge home..

24 hours after the newborn's first protein feeding.

The nurse has completed the initial assessment and vital signs for an infant born at 12 noon. The assessment and vital signs were completed at 1:30pm. What time will the nurse plan to complete the next set of vital signs? a) 1:45pm b) 2:00pm c) 2:30pm d) 3:30pm

2:00pm

Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a) 6 b) 3 c) 4 d) 5

5

One minute after delivery, the neonate's heart rate is 98 beats per minute (bpm), respirations are slow and irregular, arms are flexed, hips are extended, the neonate has no grimace, and the hands/feet are acrocyanotic. What Apgar score should the nurse assign to the neonate? a) 5 b) 6 c) 4 d) 7

5

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which of the following within the first week of life? a) 10% to 15% of their birth weight b) 5% to 10% of their birth weight c) 15% to 18% of their birth weight d) 20% of their birth weight

5% to 10% of their birth weight

The infant has APGAR scores of 7 at one minute and 9 at five minutes. What is the indication of this assessment finding? a) Adjusting to extrauterine life. b) Predicts fair neurologic future outcomes. c) Moderate difficulty and may need intervention. d) Severe distress and absolute need of resuscitation.

Adjusting to extrauterine life.

What is the best thing the nurse can do to manage pain in a neonate? a) Teach the infant's caregivers ways to soothe and comfort the child during any episode of pain. b) Adhere carefully to the plan for administration of any analgesics to the child. c) Advocate to the physician to use effective treatment methods that cause no pain or less pain. d) Provide a soothing environment, swaddling, and holding to the newborn experiencing pain.

Advocate to the physician to use effective treatment methods that cause no pain or less pain.

A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is: a) At least 24 hours after birth. b) Within 24 hours of birth. c) At least 36 hours after birth. d) Before the baby has received 8 feeds of breast milk or formula.

At least 24 hours after birth.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? a) Limit the bathing time to 5 minutes. b) Bathe the baby under a radiant warmer. c) Bathe the baby in water between 90-93 degree water. d) Postpone breastfeeding until after the initial bath.

Bathe the baby under a radiant warmer.

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation? a) Small pink or red patches on the baby's eyelids, and back of the neck b) Bright red, raised bumpy area noted above the right eye c) Blue or purplish splotches on buttocks d) Fine red rash noted over the chest and back

Bright red, raised bumpy area noted above the right eye

A nurse, while examining a newborn, observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities? a) Bruising from the birth process b) An immature autoregulation of blood flow c) An allergic reaction to the soap used for the first bath d) Concentration of immature blood vessels

Concentration of immature blood vessels

When educating patients in a maternal-newborn unit about prevention of infant abduction, what is essential in the effectiveness of prevention of abduction? a) Use of monitor attached to babies b) Cooperation by the parents with the hospital policies c) Staff awareness of infant abduction profiles d) Policy posted about security

Cooperation by the parents with the hospital policies

A newborn male is circumcised. Which of the following instructions would you include in the discharge teaching plan for his parents? a) Cleanse the glans daily with alcohol. b) Notify her physician if it appears red and sore. c) Cover the glans generously with Vaseline. d) Soak the penis daily in warm water.

Cover the glans generously with Vaseline.

The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate? a) Dehydration b) Increased intracranial pressure c) Vernix caseosa d) Cyanosis

Dehydration

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? a) Convective b) Conductive c) Radiating d) Evaporative

Evaporative

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? a) Use products such as talcum powder with each diaper change b) Expose the newborn's bottom to air several times a day c) Place the newborn's buttocks in warm water after each void or stool d) Use only baby wipes to cleanse the perianal area

Expose the newborn's bottom to air several times a day

The AGPAR score is based on which 5 parameters? a) Heart rate, muscle tone, reflex irritability, respiratory effort, and color b) Heart rate, breaths per minute, irritability, reflexes, and color c) Hear rate, breaths per minute, irritability, tone, and color d) Heart rate, respiratory effort, temperature, tone, and color

Heart rate, muscle tone, reflex irritability, respiratory effort, and color

Infants receive vitamin K within the first hour after delivery. What is the rationale for administering the vitamin? a) Is a routine vitamin needed by the infant. b) Helps in formation of clotting factors, to prevent bleeding. c) Used to help infant fight infections. d) Administered to give the infant better eye sight.

Helps in formation of clotting factors, to prevent bleeding.

The standard of care and recommendation by the Centers for Disease Control is to administer an immunization to all newborns. Which immunization is recommended to be administered prior to discharge? a) HiB b) DTaP c) Prevnar d) Hep B

Hep B

You are doing discharge teaching with the parents of a newborn baby girl. You know that it is important to teach them about diarrhea and dehydration. When should the parents notify the physician about diarrhea in the newborn.? a) If the infant has more than one episode of diarrhea in one day b) If the infant has more than four episodes of diarrhea in one day c) If the infant has more than two episodes of diarrhea in one day d) If the infant has more than three episodes of diarrhea in one day

If the infant has more than two episodes of diarrhea in one day

What is the best rationale for trying to decrease the incidence of cold stress in the neonate? a) Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. b) It takes energy to keep warm, so the neonate has to remain in an extended position. c) The neonate will stabilize its temperature by 8 hours after birth if kept warm and dry. d) If the neonate becomes cold stressed, it will eventually develop respiratory distress.

If the neonate becomes cold stressed, it will eventually develop respiratory distress.

A very healthy mother delivered a newborn with an immediate Apgar score of 10. The newborn was cradled in a kangaroo hold by both her mother and her father for 45 minutes. The parents feel ready to get cleaned up and let the newborn be taken care of by the health care personnel for a little while. What eye care action will the nurse now take? a) Instill 1 percent erythromycin eye drops b) Instill antibiotic 0.5 percent erythromycin c) Wait to see if the eyes show signs of irritation before any eye care treatment is completed d) Instill 0.5 percent silver nitrate eye drops

Instill antibiotic 0.5 percent erythromycin

When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse? a) At the midsternum, just below the suprasternal notch b) Lateral to the midclavicular line at the fourth intercostal space c) At the fifth intercostal space at the right midclavicular line d) At the third intercostal space adjacent to the midclavicular line

Lateral to the midclavicular line at the fourth intercostal space

Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be? a) Cavernous hemangioma b) Mongolian spot c) Strawberry hemangioma d) Nevus flammeus

Mongolian spot

An African American baby has discoloring which appears similar to bruising on his buttock after a normal vaginal delivery. This assessment should be documented as: a) Mongolian spots. b) Vascular nevi. c) Lanugo. d) Bruising.

Mongolian spots

When assessing infant reflexes the nurse documents a startled response and extension of the arms and legs as which reflex? a) Fencing b) Moro c) Rooting d) Tonic neck

Moro

To prevent misidentification of a newborn identification bands are placed on the newborn and on the parents before the newborn is separated from the parents. What information is on all the bands? a) Mother's name and date and time of her birth b) Father's name and date and time of birth c) Hospital number, attending physician, and father's name d) Newborn's sex and date and time of birth

Newborn's sex and date and time of birth

You are assisting with the circumcision of a 16-hour-old male infant. Immediately after the procedure, what kind of dressing would you apply to the surgical area? a) Petrolatum gauze dressing b) Small pressure dressing c) Sterile 2×2s and paper tape d) Steri strips

Petrolatum gauze dressing

The infant's temperature is 97.2°F (36.2°C) axillary an hour after birth. Which intervention is the appropriate for the nurse? a) Take the infant to the mother for bonding. b) Place a second stockinette on the baby's head c) Place the infant under a radiant warmer or in a heated isolette. d) Administer a warm bath with temperature slightly higher than usual

Place the infant under a radiant warmer or in a heated isolette.

Newborn Ming has secretions in his mouth and nose. What are the first steps the nurse should take to clear his airways? a) Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his nose. b) Position Ming on his side and guide his caregivers in suctioning his mouth with a bulb syringe. c) Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his mouth. d) Position Ming on his side with his head slightly below his body; use a small suction catheter to clear his nose.

Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his mouth.

A father asks the nurse what medication is in the baby's eyes and why it is needed. Which of the following is the appropriate explanation? a) Destroy an infectious exudate of the vaginal canal. b) Prevent infection of the baby's eyes by bacteria which may have been in the vaginal canal. c) Prevent potentially harmful virus from invading the tear ducts. d) Prevent the baby's eyelids from sticking together to help see.

Prevent infection of the baby's eyes by bacteria which may have been in the vaginal canal.

Baby Tarik has been circumcised, his temperature is stable, his breathing and heart rate are healthy, and he is ready to be discharged from the hospital. What can the nurse tell his parents to be on the lookout for that might indicate that Tarik needs medical attention? a) Redness at the base of the umbilical cord b) Crying for 2 hours or more each day c) Straining when he is passing stools d) A yellowish crusty substance on the circumcision site

Redness at the base of the umbilical cord

When evaluating neurologic maturity to determine gestational age, which of the following is not part of the assessment? a) Popliteal angle b) Square window c) Rooting d) Posture

Rooting

A nurse is discussing breastfeeding with a new mother and demonstrates that when she strokes the baby's cheek, the baby turns his head in that direction. This reflex is known as which of the following? a) Extrusion reflex b) Rooting reflex c) Moro reflex d) Babinski reflex

Rooting reflex

The nurse is providing discharge education on newborn care at home. The nurse provides instructions that infants need to be placed on their back to sleep. What is the nurse reducing the risk for with this education? a) Apnea episodes b) Sudden infant death syndrome c) Waking at night d) Gastroesophageal reflux

Sudden infant death syndrome

Which is the best place to perform a heel stick on a newborn? a) The front of the heel (the outer arch) b) The fat pads on the lateral aspects of the foot c) The calcaneus d) The vascularized flat surface of the foot

The fat pads on the lateral aspects of the foot

The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick Hct of 66. What is the best response to this finding? a) The infant is suffering from polycythemia and needs a partial exchange transfusion to prevent complications. b) The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is. c) This is a normal lab value and no intervention is needed. d) A capillary hematocrit needs to be rechecked in 8 hours to see if is increases or decreases.

The hematocrit needs to be repeated as a venous stick to see what the central hematocrit level is.

A male baby is born at 5:15 AM on a Wednesday. At 1:15 PM on the same day, the nurse notes yellow staining of the skin on the head and face of this infant. What does this finding likely indicate? a) The infant has pathologic jaundice. b) The infant has physiologic jaundice. c) The unconjugated bilirubin levels in the infant are less than 4 mg/dL. d) The nurse should not expect the yellow staining to occur on the trunk or extremities.

The infant has pathologic jaundice.

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding? a) The infant requires immediate and aggressive interventions for survival. b) The infant is experiencing moderate difficulty in adjusting to extrauterine life. c) The infant probably has either a congenital heart defect or an immature respiratory system. d) The infant is adjusting well to extrauterine life.

The infant is experiencing moderate difficulty in adjusting to extrauterine life.

When performing Ortolani maneuver, which of the following should occur? Select all that apply. a) Attempt to abduct the hips 90 degrees while applying upward pressure. b) The newborn should be in a supine position. c) A click should be heard when the legs are abducted. d) Attempt to abduct the hips 180 degrees while applying upward pressure. e) The newborn should be in a prone position.

The newborn should be in a supine position. Attempt to abduct the hips 180 degrees while applying upward pressure.

Which of the following is FALSE regarding bathing the newborn? a) Bathing should not be done until the newborn is thermally stable. b) While bathing the newborn, the nurse should wear gloves. c) To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth. d) Mild soap should be used on the body and hair, but not on the face.

To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth.

Which of the following is FALSE regarding bathing the newborn? a) While bathing the newborn, the nurse should wear gloves. b) To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth. c) Mild soap should be used on the body and hair, but not on the face. d) Bathing should not be done until the newborn is thermally stable.

To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth.

Babies of mothers with human immunodeficiency virus (HIV) infection should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. a) True b) False

True

When assessing the umbilical cord of a newborn, which of the following would the nurse expect to find? a) Three arteries and no veins b) Two arteries and two veins c) Two arteries and one vein d) One artery and two veins

Two arteries and one vein

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? a) Use microwave ovens to warm the chilled milk b) Refreeze any unused milk for later use if it has not been out more that 2 hours c) Use the sealed and chilled milk within 24 hours d) Use any frozen milk within 6 months of obtaining it

Use the sealed and chilled milk within 24 hours

Which of the following interventions would a nurse implement to best prevent heat loss in a 1 day of age newborn? a) Bathe and wash the newborn when temperature is 97.5°F (36.4°C) b) Warm all surfaces and objects that come in contact with the newborn. c) Keep the newborn under the radiant heater when not with mom. d) Cover the newborn with several blankets while under the warmer.

Warm all surfaces and objects that come in contact with the newborn.

Newborn Isaac has been taken to the nursery after delivery. He has been cleaned in the labor and delivery suite and swaddled in a blanket. The nurse is going to check his pulse. What must the nurse do? a) Wear gloves. b) Use infection transmission precautions. c) Clean his or her hands with a betadine scrub. d) Perform a 3-minute surgical type scrub before touching him.

Wear gloves

Discharge teaching is an important part of the labor and delivery room nurse's position. New parents need to know the basics of baby care, like how to monitor fluid volume and when to call the physician. What are the parameters for calling the physician in regards to an infants' temperature? a) less than 96°F (35.6°C) or greater than 101°F (38.3°C) b) less than 96.7°F (35.9°C) or greater than 99.5°F (37.4°C). c) less than 97°F (36.1°C) or greater than 100.5°F (38.1°C). d) Less than 97.7°F (36.5°C) or greater than 100°F (37.8°C).

less than 97°F (36.1°C) or greater than 100.5°F (38.1°C).

A 25-year-old P3023 spontaneously ruptured clear fluid at home and has had a normal labor progression. The nurse and the midwife do not anticipate any complications. What should the nurse do to prepare for the birth? Select all that apply. a) Move the newborn warmer to the delivery area and turn it on. b) Document events as they are happening. c) Open the newborn crash cart or box to ensure easy access to all supplies. d) Check the functionality of the oxygen source and equipment. e) Connect the meconium aspirator to the wall suction and turn it on.

• Document events as they are happening. • Check the functionality of the oxygen source and equipment. • Move the newborn warmer to the delivery area and turn it on.

A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply. a) Ensure the newborn's warmth b) Massage the newborn's back c) Provide oxygen supplementation d) Provide warm water to drink e) Observe respiratory status frequently

• Ensure the newborn's warmth • Provide oxygen supplementation • Observe respiratory status frequently

While teaching a student, the nurse should include which of the following signs and symptoms to recognize hypoglycemia in the neonate? (Select all that apply.) a) Tachypnea b) Jitteriness c) Poor feeding d) Bradypnea

• Jitteriness • Poor feeding • Tachypnea

When assessing a newborn's gestational age, the nurse evaluates which of the following parameters to indicate physical maturity? Select all that apply. a) Genitals b) Scarf sign c) Arm recoil d) Posture e) Lanugo

• Lanugo • Genitals

When assessing a newborn's gestational age, the nurse evaluates which of the following parameters to indicate physical maturity? Select all that apply. a) Lanugo b) Posture c) Scarf sign d) Genitals e) Arm recoil

• Lanugo • Genitals

Which of the following findings would the nurse identify as normal when assessing a newborn? Select all that apply. a) Chest circumference of 35 cm b) Weight of 3,300 grams c) Apical pulse rate of 100 beats/minute d) Head circumference of 30 cm e) Temperature of 98.6°F (37°C) f) Length of 54 cm

• Length of 54 cm • Weight of 3,300 grams • Temperature of 98.6°F (37°C)

A nurse is performing a detailed newborn assessment of a female newborn. Which observations indicate a normal finding? Select all that apply. a) Low-set ears b) Swollen genitals c) Enlarged fontanelles d) Mongolian spots e) Short, creased neck

• Mongolian spots • Swollen genitals • Short, creased neck

A mother who is 4 days postpartum, and is breastfeeding, expresses to the nurse that her breast seems to be tender and engorged. What education should the nurse give to the mother to relieve breast engorgement? Select all that apply. a) Massage the breasts from the nipple toward the axillary area b) Express some milk manually before breastfeeding c) Take warm-to-hot showers to encourage milk release d) Feed the newborn in the sitting position only e) Apply warm compresses to the breasts prior to nursing

• Take warm-to-hot showers to encourage milk release • Express some milk manually before breastfeeding • Apply warm compresses to the breasts prior to nursing

When performing Ortolani maneuver, which of the following should occur? Select all that apply. a) Attempt to abduct the hips 180 degrees while applying upward pressure. b) Attempt to abduct the hips 90 degrees while applying upward pressure. c) A click should be heard when the legs are abducted. d) The newborn should be in a prone position. e) The newborn should be in a supine position.

• The newborn should be in a supine position. • Attempt to abduct the hips 180 degrees while applying upward pressure.

A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Beside placing the infant on a firm sleep surface, the nurse tells the mother to: (Select all that apply) a) keep the infant dressed warmly at night. b) provide a pacifier when putting the infant to sleep. c) not allow anyone to smoke around the infant. d) let the newborn sleep in the same bed as the parents. e) place the infant on his or her back.

• place the infant on his or her back. • not allow anyone to smoke around the infant.