OB Exam 2: Chapters 18, 20, 21, 22, 23, 24, & 25

A woman gave birth to an infant boy 10 hours ago. Where does the nurse expect to locate this woman's fundus? A) 1 centimeter above the umbilicus B) 2 centimeters below the umbilicus C) Midway between the umbilicus and the symphysis pubis D) Nonpalpable abdominally

A) 1 centimeter above the umbilicus - The fundus descends approximately 1 to 2 cm every 24 hours. Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. By the sixth postpartum week the fundus is normally halfway between the symphysis pubis and the umbilicus. The fundus should be easily palpated using the maternal umbilicus as a reference point.

The nurse is discussing infant care as part of the mother-infant's couplet discharge planning. The mother asks the nurse "When will my baby's cord fall off?" The nurse responds, "Your baby's cord should fall off by ____________________ (weeks/days) after birth."

2 weeks or 14 days

The nurse is performing a gestational age assessment on a preterm infant. An infant is categorized as low birth weight when the weight of the infant is ____________________ or less.

2500 g

A nurse is discussing the storage of breast milk with a mother whose infant is preterm and in the special care nursery. Which statement indicates that the mother requires additional teaching? A) "I can store my breast milk in the refrigerator for 3 months." B) "I can store my breast milk in the freezer for 3 months." C) "I can store my breast milk at room temperature for 4 hours." D) "I can store my breast milk in the refrigerator for 3 to 5 days."

A) "I can store my breast milk in the refrigerator for 3 months." - Breast milk for the hospitalized infant can be stored in the refrigerator for only 8 days, not for 3 months. Breast milk can be stored in the freezer for 3 months, in a deep freezer for 6 months, or at room temperature for 4 hours. Human milk for the healthy or preterm hospitalized infant can be kept in the refrigerator for up to 8 days or in the freezer for up to 3 months, but only for 4 hours or less at room temperature.

A mother is changing the diaper of her newborn son. She notices that his scrotum appears large and swollen. She asks the nurse, "What is that?" The best response from the nurse is: A) "That is a hydrocele, which is a common finding in newborn males. The swelling usually decreases without intervention." B) "I don't know, but I'm sure it is nothing." C) "Your baby might have testicular cancer." D) "Your baby's urine is backing up into his scrotum."

A) "That is a hydrocele, which is a common finding in newborn males. The swelling usually decreases without intervention."

A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, "What is this black, sticky stuff in her diaper?" What is the nurse's best response? A) "That's meconium, which is your baby's first stool. It's normal." B) "That's transitional stool." C) "That means your baby is bleeding internally." D) "Oh, don't worry about that. It's okay."

A) "That's meconium, which is your baby's first stool. It's normal." - Explaining what meconium is and that it is normal is an accurate statement and the most appropriate response. Transitional stool is greenish-brown to yellowish-brown and usually appears by the third day after the initiation of feeding. Telling the father that the baby is internally bleeding is not an accurate statement. Telling the father not to worry is not appropriate. Such responses are belittling to the father and do not teach him about the normal stool patterns of his daughter.

A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on high. The nurse instructs the mother that the fan should not be directed toward the newborn and that the newborn should be wrapped in a blanket. The mother asks why. How would the nurse respond? A) "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." B) "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." C) "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." D) "Your baby will easily get cold stressed and needs to be bundled up at all times."

A) "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped, and should prevent cool air from blowing on him." - Convection is the flow of heat from the body surface to cooler ambient air. Because of heat loss by convection, all newborns in open bassinets should be wrapped to protect them from the cold. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is a loss of heat that occurs when a liquid is converted into a vapor. In the newborn, heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss; however, this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infant's temperature.

How would the nurse optimally reassure the parents of an infant who develops a cephalhematoma? A) A cephalhematoma may occur with a spontaneous vaginal birth. B) A cephalhematoma only happens as a result of a forceps- or vacuum-assisted delivery. C) It is present immediately after birth. D) The blood will gradually absorb over the first few months of life.

A) A cephalhematoma may occur with a spontaneous vaginal birth. - The nurse should explain that bleeding between the skull and the periosteum of a newborn may occur during a spontaneous vaginal delivery as a result of the pressure against the maternal bony pelvis. Low forceps and other difficult extractions may result in bleeding. However, a cephalhematoma can also spontaneously occur. Swelling may appear unilaterally or bilaterally, is usually minimal or absent at birth, and increases over the first 2 to 3 days of life. Cephalhematomas gradually disappear over 2 to 3 weeks. A less common condition results in the calcification of the hematoma, which may persist for months

Part of the health assessment of a newborn is observing the infant's breathing pattern. What is the predominate pattern of newborn's breathing? A) Abdominal with synchronous chest movements B) Chest breathing with nasal flaring C) Diaphragmatic with chest retraction D) Deep with a regular rhythm

A) Abdominal with synchronous chest movements - In a normal infant respiration, the chest and abdomen synchronously rise and infant breaths are shallow and irregular. Breathing with nasal flaring is a sign of respiratory distress. Diaphragmatic breathing with chest retraction is also a sign of respiratory distress.

A new mother states that her infant must be cold because the baby's hands and feet are blue. This common and temporary condition is called what? A) Acrocyanosis B) Erythema toxicum neonatorum C) Harlequin sign D) Vernix caseosa

A) Acrocyanosis - Acrocyanosis, or the appearance of slightly cyanotic hands and feet, is caused by vasomotor instability, capillary stasis, and a high hemoglobin level. Acrocyanosis is normal and intermittently appears over the first 7 to 10 days after childbirth. Erythema toxicum neonatorum (also called erythema neonatorum) is a transient newborn rash that resembles flea bites. The harlequin sign is a benign, transient color change in newborns. One half of the body is pale, and the other one half is ruddy or bluish-red with a line of demarcation. Vernix caseosa is a cheeselike, whitish substance that serves as a protective covering for the newborn.

A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle feeding. Which statement regarding bottle feeding using commercially prepared infant formulas might influence their choice? A) Bottle feeding using a commercially prepared formula increases the risk that the infant will develop allergies. B) Bottle feeding helps the infant sleep through the night. C) Commercially prepared formula ensures that the infant is getting iron in a form that is easily absorbed. D) Bottle feeding requires that multivitamin supplements be given to the infant.

A) Bottle feeding using a commercially prepared formula increases the risk that the infant will develop allergies. - Exposure to cow's milk poses a risk of developing allergies, eczema, and asthma. Newborns should be fed during the night, regardless of the feeding method. Iron is better absorbed from breast milk than from formula. Commercial formulas are designed to meet the nutritional needs of the infant and to resemble breast milk. No supplements are necessary.

Which statements concerning the benefits or limitations of breastfeeding are accurate? (Select all that apply.) A) Breast milk changes over time to meet the changing needs as infants grow. B) Breastfeeding increases the risk of childhood obesity. C) Breast milk and breastfeeding may enhance cognitive development. D) Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. E) Benefits to the infant include a reduced incidence of SIDS.

A) Breast milk changes over time to meet the changing needs as infants grow. C) Breast milk and breastfeeding may enhance cognitive development. D) Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. E) Benefits to the infant include a reduced incidence of SIDS. - Breastfeeding actually decreases the risk of childhood obesity. Human milk is the perfect food for human infants. Breast milk changes over time to meet the demands of the growing infant. Scientific evidence is clear that human milk provides the best nutrients for infants with continued benefits long after weaning. Fatty acids in breast milk promote brain growth and development and may lead to enhanced cognition. Infants who are breastfed experience a reduced incidence of SIDS.

A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. Which findings should the nurse include in the discussion? (Select all that apply.) A) Breast tenderness B) Warmth in the breast C) Area of redness on the breast often resembling the shape of a pie wedge D) Small white blister on the tip of the nipple E) Fever and flu-like symptoms

A) Breast tenderness B) Warmth in the breast C) Area of redness on the breast often resembling the shape of a pie wedge E) Fever and flu-like symptoms - Breast tenderness, warmth in the breast, redness on the breast, and fever and flulike symptoms are commonly associated with mastitis and should be included in the nurse's discussion of mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis but is commonly seen in women who have a plugged milk duct.

A nurse providing couplet care should understand the issue of nipple confusion. In which situation might this condition occur? A) Breastfeeding babies receive supplementary bottle feedings. B) Baby is too abruptly weaned. C) Pacifiers are used before breastfeeding is established. D) Twins are breastfed together.

A) Breastfeeding babies receive supplementary bottle feedings. - Nipple confusion can result when babies go back and forth between bottles and breasts, especially before breastfeeding is established in 3 to 4 weeks; bottle feeding and breastfeeding require different skills. Abrupt weaning can be distressing to the mother and/or baby but should not lead to nipple confusion. Pacifiers used before breastfeeding is established can be disruptive but do not lead to nipple confusion. Breastfeeding twins require some logistical adaptations but should not lead to nipple confusion.

Which nursing intervention would result in an increase in maternal cardiac output? A) Change in position B) Oxytocin administration C) Regional anesthesia D) IV analgesic

A) Change in position - Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This position reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and to avoid the supine position. Oxytocin administration, regional anesthesia, and IV analgesic may reduce maternal cardiac output.

During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. What are these four essential factors? A) Chemical B) Mechanical C) Thermal D) Psychologic E) Sensory

A) Chemical B) Mechanical C) Thermal E) Sensory - Chemical factors are essential to initiate breathing. During labor, decreased levels of oxygen and increased levels of carbon dioxide seem to have a cumulative effect that is involved in the initiation of breathing. Clamping of the cord may also contribute to the start of respirations and results in a drop in the level of prostaglandins, which are known to inhibit breathing. Mechanical factors are also necessary to initiate respirations. As the infant passes through the birth canal, the chest is compressed. After the birth, the chest is relaxed, which allows for negative intrathoracic pressure that encourages air to flow into the lungs. The profound change in temperature between intrauterine and extrauterine life stimulates receptors in the skin to communicate with the receptors in the medulla. The stimulation of these receptors also contributes to the initiation of breathing. Sensory factors include handling by the health care provider, drying by the nurse, lights, smells, and sounds. Psychologic factors do not contribute to the initiation of respirations.

A new mother asks whether she should feed her newborn colostrum, because it is not "real milk." What is the nurse's most appropriate answer? A) Colostrum is high in antibodies, protein, vitamins, and minerals. B) Colostrum is lower in calories than milk and should be supplemented by formula. C) Giving colostrum is important in helping the mother learn how to breastfeed before she goes home. D) Colostrum is unnecessary for newborns.

A) Colostrum is high in antibodies, protein, vitamins, and minerals. - Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Supplementation is not necessary and will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge; however, the importance of the colostrum to the infant is the top priority. Colostrum provides immunities and enzymes necessary to cleanse the gastrointestinal system, among other things.

Which intervention can nurses use to prevent evaporative heat loss in the newborn? A) Drying the baby after birth, and wrapping the baby in a dry blanket B) Keeping the baby out of drafts and away from air conditioners C) Placing the baby away from the outside walls and windows D) Warming the stethoscope and the nurse's hands before touching the baby

A) Drying the baby after birth, and wrapping the baby in a dry blanket - Because the infant is wet with amniotic fluid and blood, heat loss by evaporation quickly occurs. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold surfaces.

The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks? A) Flexed posture B) Abundant lanugo C) Smooth, pink skin with visible veins D) Faint red marks on the soles of the feet

A) Flexed posture - Term infants typically have a flexed posture.

The nurse should be cognizant of which statement regarding the unique qualities of human breast milk? A) Frequent feedings during predictable growth spurts stimulate increased milk production. B) Milk of preterm mothers is the same as the milk of mothers who gave birth at term. C) Milk at the beginning of the feeding is the same as the milk at the end of the feeding. D) Colostrum is an early, less concentrated, less rich version of mature milk.

A) Frequent feedings during predictable growth spurts stimulate increased milk production. - Growth spurts (at 10 days, 3 weeks, 6 weeks, and 3 months) usually last 24 to 48 hours, after which the infants resume normal feeding. The milk of mothers of preterm infants is different from that of mothers of full-term infants to meet the needs of these newborns. Milk changes composition during feeding. The fat content of the milk increases as the infant feeds. Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals (but not fat).

Under which circumstance should the nurse immediately alert the pediatric provider? A) Infant is dusky and turns cyanotic when crying. B) Acrocyanosis is present 1 hour after childbirth. C) The infant's blood glucose level is 45 mg/dl. D) The infant goes into a deep sleep 1 hour after childbirth.

A) Infant is dusky and turns cyanotic when crying. - An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. Acrocyanosis is an expected finding during the early neonatal life and is within the normal range for a newborn.Infants enter the period of deep sleep when they are approximately 1 hour old.

A new mother asks the nurse what the "experts say" about the best way to feed her infant. Which recommendation of the American Academy of Pediatrics (AAP) regarding infant nutrition should be shared with this client? A) Infants should be given only human milk for the first 6 months of life. B) Infants fed on formula should be started on solid food sooner than breastfed infants. C) If infants are weaned from breast milk before 12 months, then they should receive cow's milk, not formula. D) After 6 months, mothers should shift from breast milk to cow's milk.

A) Infants should be given only human milk for the first 6 months of life. - Breastfeeding and human milk should also be the sole source of milk for the first 12 months, not for only the first 6 months. Infants should be started on solids when they are ready, usually at 6 months, whether they start on formula or breast milk. If infants are weaned from breast milk before 12 months, then they should receive iron-fortified formula, not cow's milk.

Which statement is the best rationale for recommending formula over breastfeeding? A) Mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. B) Mother lacks confidence in her ability to breastfeed. C) Other family members or care providers also need to feed the baby. D) Mother sees bottle feeding as more convenient.

A) Mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. - Breastfeeding is contraindicated when mothers have certain viruses, tuberculosis, are undergoing chemotherapy, or are using or abusing drugs. Some women lack confidence in their ability to produce breast milk of adequate quantity or quality. The key to encouraging these mothers to breastfeed is anticipatory guidance beginning as early as possible during the pregnancy. A major barrier for many women is the influence of family and friends. She may view formula feeding as a way to ensure that the father and other family members can participate. Each encounter with the family is an opportunity for the nurse to educate, dispel myths, and clarify information regarding the benefits of breastfeeding. Many women see bottle feeding as more convenient and less embarrassing than breastfeeding. They may also see breastfeeding as incompatible with an active social life. Although modesty issues related to feeding the infant in public may exist, these concerns are not legitimate reasons to formula-feed an infant. Often, the decision to formula feed rather than breastfeed is made without complete information regarding the benefits of breastfeeding

Which statements regarding physiologic jaundice are accurate? (Select all that apply.) A) Neonatal jaundice is common; however, kernicterus is rare. B) Appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. C) Because jaundice may not appear before discharge, parents need instruction on how to assess for jaundice and when to call for medical help. D) Jaundice is caused by reduced levels of serum bilirubin. E) Breastfed babies have a lower incidence of jaundice

A) Neonatal jaundice is common; however, kernicterus is rare. B) Appearance of jaundice during the first 24 hours or beyond day 7 indicates a pathologic process. C) Because jaundice may not appear before discharge, parents need instruction on how to assess for jaundice and when to call for medical help. - Neonatal jaundice occurs in 60% of term newborns and in 80% of preterm infants. The complication called kernicterus is rare. Jaundice in the first 24 hours or that persists past day 7 is cause for medical concern. Parents need to be taught how to evaluate their infant for signs of jaundice. Jaundice is caused by elevated levels of serum bilirubin. Breastfeeding is associated with an increased incidence of jaundice.

When preparing to administer a hepatitis B vaccine to a newborn, the nurse should: A) Obtain a syringe with a 25-gauge, -inch needle B) Confirm that the newborn's mother has been infected with the hepatitis B virus C) Assess the dorsogluteal muscle as the preferred site for injection D) Confirm that the newborn is at least 24 hours old

A) Obtain a syringe with a 25-gauge, -inch needle

Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them regarding pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? A) Premature infants more easily digest breast milk than formula. B) A glass of wine just before pumping will help reduce stress and anxiety. C) The mother should only pump as much milk as the infant can drink. D) The mother should pump every 2 to 3 hours, including during the night.

A) Premature infants more easily digest breast milk than formula. - Human milk is the ideal food for preterm infants, with benefits that are unique, in addition to those benefits received by full-term, healthy infants. Greater physiologic stability occurs with breastfeeding, compared with formula feeding. Consumption of alcohol during lactation is approached with caution. Excessive amounts can have serious effects on the infant and can adversely affect the mother's milk ejection reflex. To establish an optimal milk supply, the most appropriate instruction for the mother should be to pump 8 to 10 times a day for 10 to 15 minutes on each breast.

Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cures indicating pain, measures should be taken to manage the infant's pain. Examples of nonpharmacologic pain management techniques include (choose all that apply): A) Swaddling B) Nonnutritive sucking C) Skin-to-skin contact with the mother D) Sucrose E) Acetaminophen

A) Swaddling B) Nonnutritive sucking C) Skin-to-skin contact with the mother D) Sucrose - These interventions are all appropriate nonpharmacologic techniques used to manage pain in neonates. Acetaminophen is a pharmacologic method of treating pain

Which statements describe the first stage of the neonatal transition period? (Select all that apply.) A) The neonatal transition period lasts no longer than 30 minutes. B) It is marked by spontaneous tremors, crying, and head movements. C) Passage of the meconium occurs during the neonatal transition period. D) This period may involve the infant suddenly and briefly sleeping. E) Audible grunting and nasal flaring may be present during this time.

A) The neonatal transition period lasts no longer than 30 minutes. B) It is marked by spontaneous tremors, crying, and head movements. C) Passage of the meconium occurs during the neonatal transition period. E) Audible grunting and nasal flaring may be present during this time. - The first stage is an active phase during which the baby is alert; this stage is referred to as the first period of reactivity. Decreased activity and sleep mark the second stage, the period of decreased responsiveness. The first stage is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. Audible grunting, nasal flaring, and chest retractions may be present; however, these behaviors usually resolve within 1 hour of life.

The nurse caring for a newborn checks the record to note clinical findings that occurred before her shift. Which finding related to the renal system would be of increased significance and require further action? A) The pediatrician should be notified if the newborn has not voided in 24 hours. B) Breastfed infants will likely void more often during the first days after birth. C) Brick dust or blood on a diaper is always cause to notify the physician. D) Weight loss from fluid loss and other normal factors should be made up in 4 to 7 days.

A) The pediatrician should be notified if the newborn has not voided in 24 hours. - A newborn who has not voided in 24 hours may have any of a number of problems, some of which deserve the attention of the pediatrician. Formula-fed infants tend to void more frequently in the first 3 days; breastfed infants will void less during this time because the mother's breast milk has not yet come in. Brick dust may be uric acid crystals; blood spotting could be attributable to the withdrawal of maternal hormones (pseudomenstruation) or a circumcision. The physician must be notified only if the cause of bleeding is not apparent. Weight loss from fluid loss might take 14 days to regain.

Nurses can help parents deal with the issue and fact of circumcision if they explain: A) The pros and cons of the procedure during the prenatal period B) That the American Academy of Pediatrics (AAP) recommends that all newborn males be routinely circumcised C) That circumcision is rarely painful and that any discomfort can be managed without medication D) That the infant will likely be alert and hungry shortly after the procedure

A) The pros and cons of the procedure during the prenatal period - Many parents find themselves making the decision during the pressure of labor.

With regard to umbilical cord care, nurses should be aware that: A) The stump can easily become infected. B) A nurse noting bleeding from the vessels of the cord should immediately call for assistance. C) The cord clamp is removed at cord separation. D) The average cord separation time is 5 to 7 days.

A) The stump can easily become infected

Which actions are examples of appropriate techniques to wake a sleepy infant for breastfeeding? (Select all that apply.) A) Unwrapping the infant B) Changing the diaper C) Talking to the infant D) Slapping the infant's hands and feet E) Applying a cold towel to the infant's abdomen

A) Unwrapping the infant B) Changing the diaper C) Talking to the infant - Unwrapping the infant, changing the diaper, and talking to the infant are appropriate techniques to use when trying to wake a sleepy infant. The parent can rub, never slap, the infant's hands or feet to wake the infant. Applying a cold towel to the infant's abdomen may lead to cold stress in the infant. The parent may want to apply a cool cloth to the infant's face to wake the infant.

What is the correct term for the cheeselike, white substance that fuses with the epidermis and serves as a protective coating? A) Vernix caseosa B) Surfactant C) Caput succedaneum D) Acrocyanosis

A) Vernix caseosa - The protection provided by vernix caseosa is needed because the infant's skin is so thin. Surfactant is a protein that lines the alveoli of the infant's lungs. Caput succedaneum is the swelling of the tissue over the presenting part of the fetal head. Acrocyanosis is cyanosis of the hands and feet, resulting in a blue coloring.

Which component of the sensory system is the least mature at birth? A) Vision B) Hearing C) Smell D) Taste

A) Vision - The visual system continues to develop for the first 6 months after childbirth. As soon as the amniotic fluid drains from the ear (in minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell and can distinguish and react to various tastes.

A new father is ready to take his wife and newborn son home. He proudly tells the nurse who is discharging them that within the next week he plans to start feeding the infant cereal between breastfeeding sessions. Which information should the nurse provide regarding this feeding plan? A) "Feeding solid foods before your son is 4 to 6 months old may decrease your son's intake of sufficient calories." B) "Feeding solid foods between breastfeeding sessions before your son is 4 to 6 months old will lead to an early cessation of breastfeeding." C) "Your feeding plan will help your son sleep through the night." D) "Feeding solid foods before your son is 4 to 6 months old will limit his growth."

B) "Feeding solid foods between breastfeeding sessions before your son is 4 to 6 months old will lead to an early cessation of breastfeeding." - The introduction of solid foods before the infant is 4 to 6 months of age may result in overfeeding and decreased intake of breast milk. The belief that feeding solid foods helps infants sleep through the night is untrue. The proper balance of carbohydrate, protein, and fat for an infant to grow properly is in the breast milk or formula.

The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. What information provided by the nurse would be most useful to these new parents? A) "Infants can see very little until approximately 3 months of age." B) "Infants can track their parents' eyes and can distinguish patterns; they prefer complex patterns." C) "The infant's eyes must be protected. Infants enjoy looking at brightly colored stripes." D) "It's important to shield the newborn's eyes. Overhead lights help them see better."

B) "Infants can track their parents' eyes and can distinguish patterns; they prefer complex patterns." - Telling the parents that infants can track their parents' eyes and can distinguish patterns is an accurate statement. Development of the visual system continues for the first 6 months of life. Visual acuity is difficult to determine, but the clearest visual distance for the newborn appears to be 19 cm. Infants prefer to look at complex patterns, regardless of the color. They prefer low illumination and withdraw from bright lights.

A primiparous woman is watching her newborn sleep. She wants him to wake up and respond to her. The mother asks the nurse how much he will sleep every day. What is an appropriate response by the nurse? A) "He will only wake up to be fed, and you should not bother him between feedings." B) "The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing." C) "He will probably follow your same sleep and wake patterns, and you can expect him to be awake soon." D) "He is being stubborn by not waking up when you want him to. You should try to keep him awake during the daytime so that he will sleep through the night."

B) "The newborn sleeps approximately 17 hours a day, with periods of wakefulness gradually increasing." - Telling the woman that the newborn sleeps approximately 17 hours a day with periods of wakefulness that gradually increase is both accurate and the most appropriate response by the nurse. Periods of wakefulness are dictated by hunger, but the need for socializing also appears. Telling the woman that her infant is stubborn and should be kept awake during the daytime is an inappropriate nursing response.

At 1 minute after birth the nurse assesses the infant and notes: a heart rate at 80 beats/min, some flexion of extremities, a weak cry, grimacing, and a pink body but blue extremities. The nurse would calculate an Apgar score of _____. A) 4 B) 5 C) 6 D) 7

B) 5 - Each of the five signs the nurse noted would score a 1 on the Apgar scale, for a total of 5.

Which information about variations in the infant's blood counts is important for the nurse to explain to the new parents? A) A somewhat lower-than-expected red blood cell count could be the result of a delay in clamping the umbilical cord. B) An early high white blood cell (WBC) count is normal at birth and should rapidly decrease. C) Platelet counts are higher in the newborn than in adults for the first few months. D) Even a modest vitamin K deficiency means a problem with the blood's ability to properly clot.

B) An early high white blood cell (WBC) count is normal at birth and should rapidly decrease. - The WBC count is normally high on the first day of birth and then rapidly declines. Delayed cord clamping results in an increase in hemoglobin and the red blood cell count. The platelet count is essentially the same for newborns and adults. Clotting is sufficient to prevent hemorrhage unless the deficiency of vitamin K is significant.

What is the rationale for evaluating the plantar crease within a few hours of birth? A) Newborn has to be footprinted. B) As the skin dries, the creases will become more prominent. C) Heel sticks may be required. D) Creases will be less prominent after 24 hours.

B) As the skin dries, the creases will become more prominent. - As the infant's skin begins to dry, the creases will appear more prominent, and the infant's gestation could be misinterpreted. Footprinting nor heel sticks will not interfere with the creases. The creases will appear more prominent after 24 hours.

The breastfeeding mother should be taught a safe method to remove the breast from the baby's mouth. Which suggestion by the nurse is most appropriate? A) Slowly remove the breast from the baby's mouth when the infant has fallen asleep and the jaws are relaxed. B) Break the suction by inserting your finger into the corner of the infant's mouth. C) A popping sound occurs when the breast is correctly removed from the infant's mouth. D) Elicit the Moro reflex to wake the baby and remove the breast when the baby cries.

B) Break the suction by inserting your finger into the corner of the infant's mouth. - Inserting a finger into the corner of the baby's mouth between the gums to break the suction avoids trauma to the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple that makes it sore. A popping sound indicates improper removal of the breast from the baby's mouth and may cause cracks or fissures in the breast. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended.

The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would provide conflicting information to the client? A) Women who breastfeed have a decreased risk of breast cancer. B) Breastfeeding is an effective method of birth control. C) Breastfeeding increases bone density. D) Breastfeeding may enhance postpartum weight loss.

B) Breastfeeding is an effective method of birth control. - Although breastfeeding delays the return of fertility, it is not an effective birth control method. Women who breastfeed have a decreased risk of breast cancer, an increase in bone density, and a possibility of faster postpartum weight loss.

What are the various modes of heat loss in the newborn? (Select all that apply.) A) Perspiration B) Convection C) Radiation D) Conduction E) Urination

B) Convection C) Radiation D) Conduction

A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the client place the infant to her breast within 15 minutes after birth. The nurse is aware that the initiation of breastfeeding is most effective during the first 30 minutes after birth. What is the correct term for this phase of alertness? A) Transition period B) First period of reactivity C) Organizational stage D) Second period of reactivity

B) First period of reactivity - The first period of reactivity is the first phase of transition and lasts up to 30 minutes after birth. The infant is highly alert during this phase. The transition period is the phase between intrauterine and extrauterine existence. An organizational stage is not a valid stage. The second period of reactivity occurs approximately between 4 and 8 hours after birth, after a period of sleep

An assessment tool for pain in newborns uses the acronym CRIES to identify behavioral indicators of pain. In the acronym: A) R stands for requiring more medication. B) I stands for increased vital signs. C) E stands for elimination. D) S stands for sleepiness.

B) I stands for increased vital signs. - C stands for CRYING, R stands for REQUIRING INCREASED OXYGEN, I stands for INCREASED, E stands for EXPRESSION and S stands for sleeplessness.

Which cardiovascular changes cause the foramen ovale to close at birth? A) Increased pressure in the right atrium B) Increased pressure in the left atrium C) Decreased blood flow to the left ventricle D) Changes in the hepatic blood flow

B) Increased pressure in the left atrium - With the increase in the blood flow to the left atrium from the lungs, the pressure is increased, and the foramen ovale is functionally closed. The pressure in the right atrium decreases at birth and is higher during fetal life. Blood flow increases to the left ventricle after birth. The hepatic blood flow changes but is not the reason for the closure of the foramen ovale.

The condition during which infants are at an increased risk for subgaleal hemorrhage is called what? A) Infection B) Jaundice C) Caput succedaneum D) Erythema toxicum neonatorum

B) Jaundice - Subgaleal hemorrhage is bleeding into the subgaleal compartment and is the result of the transition from a forceps or vacuum application. Because of the breakdown of the red blood cells within a hematoma, infants are at greater risk for jaundice. Subgaleal hemorrhage does not increase the risk for infections. Caput succedaneum is an edematous area on the head caused by pressure against the cervix. Erythema toxicum neonatorum is a benign rash of unknown cause that consists of blotchy red areas.

Which statement best describes the transition period between intrauterine and extrauterine existence for the newborn? A) Consists of four phases, two reactive and two of decreased responses B) Lasts from birth to day 28 of life C) Applies to full-term births only D) Varies by socioeconomic status and the mother's age

B) Lasts from birth to day 28 of life - Changes begin immediately after birth; the cutoff time when the transition is considered over (although the baby keeps changing) is 28 days. This transition period has three phases: first reactivity, decreased response, and second reactivity. All newborns experience this transition period, regardless of age or type of birth. Although stress can cause variations in the phases, the mother's age and wealth do not disturb the pattern.

A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until the baby is frantically crying. Which feeding cue would indicate that the baby is ready to eat? A) Waves her arms in the air B) Makes sucking motions C) Has the hiccups D) Stretches out her legs straight

B) Makes sucking motions - Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding readiness cues. Waving her arms in the air, having the hiccups, and stretching out her extremities are not typical feeding readiness cues.

Which instruction should the nurse provide to reduce the risk of nipple trauma? A) Limit the feeding time to less than 5 minutes. B) Position the infant so the nipple is far back in the mouth. C) Assess the nipples before each feeding. D) Wash the nipples daily with mild soap and water.

B) Position the infant so the nipple is far back in the mouth. - If the infant's mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, thus causing trauma to the area. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need and will also limit access to the higher-fat hindmilk. Assessing the nipples for trauma is important; however, this action alone will not prevent sore nipples. Soap can be drying to the nipples and should be avoided during breastfeeding.

A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to: A) Destroy an infectious exudate caused by Staphylococcus that could make the infant blind B) Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal C) Prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes D) Prevent the infant's eyelids from sticking together and help the infant see

B) Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal

During the complete physical examination 24 hours after birth: A) The parents are excused to reduce their normal anxiety. B) The nurse can gauge the neonate's maturity level by assessing its general appearance. C) Once often neglected, blood pressure is now routinely checked. D) When the nurse listens to the heart, the S1 and S2 sounds can be heard; the first sound is somewhat higher in pitch and sharper than the second.

B) The nurse can gauge the neonate's maturity level by assessing its general appearance. - The nurse will be looking at skin color, alertness, cry, head size, and other features.

The nurse is circulating during a cesarean birth of a preterm infant. The obstetrician requests that cord clamping be delayed. What is the rationale for this directive? A) To reduce the risk for jaundice B) To reduce the risk of intraventricular hemorrhage C) To decrease total blood volume D) To improve the ability to fight infection

B) To reduce the risk of intraventricular hemorrhage - Delayed cord clamping provides the greatest benefits to the preterm infant. These benefits include a significant reduction in intraventricular hemorrhage, a reduced need for a blood transfusion, and improved blood cell volume. The risk of jaundice can increase, requiring phototherapy. Although no difference in the newborn's infection fighting ability occurs, iron status is improved, which can provide benefits for 6 months

A new mother wants to be sure that she is meeting her daughter's needs while feeding the baby commercially prepared infant formula. The nurse should evaluate the mother's knowledge about appropriate infant feeding techniques. Which statement by the client reassures the nurse that correct learning has taken place? A) "Since reaching 2 weeks of age, I add rice cereal to my daughter's formula to ensure adequate nutrition." B) "I warm the bottle in my microwave oven." C) "I burp my daughter during and after the feeding as needed." D) "I refrigerate any leftover formula for the next feeding."

C) "I burp my daughter during and after the feeding as needed." - Most infants swallow air when fed from a bottle and should be given a chance to burp several times during and after the feeding. Solid food should not be introduced to the infant for at least 4 to 6 months after birth. A microwave should never be used to warm any food to be given to an infant. The heat is not distributed evenly, which may pose a risk of burning the infant. Any formula left in the bottle after the feeding should be discarded because the infant's saliva has mixed with it

The nurse is assessing a full term, quiet, and alert newborn. What is the average expected apical pulse range (in beats per minute)? A) 80 to 100 B) 100 to 120 C) 120 to 160 D) 150 to 180

C) 120 to 160 - The average infant heart rate while awake is 120 to 160 beats per minute. The newborn's heart rate may be approximately 85 to 100 beats per minute while sleeping and typically a little higher than 100 to 120 beats per minute when alert but quiet. A heart rate of 150 to 180 beats per minute is typical when the infant cries.

How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day? A) 50 to 65 B) 75 to 90 C) 95 to 110 D) 150 to 200

C) 95 to 110 - For the first 3 months, the infant needs 110 kcal/kg/day. At ages 3 to 6 months, the requirement is 100 kcal/kg/day. This level decreases slightly to 95 kcal/kg/day from 6 to 9 months and increases again to 100 kcal/kg/day until the baby reaches 12 months.

The nurse is assessing a newborn girl who is 2 hours old. What finding would warrant a call to the physician? A) Blood glucose of 45 mg/dl using a Dextrostix B) Heart rate of 160 beats/min after crying vigorously C) A crepitant-like feeling when assessing the clavicles D) Passage of a dark black-green substance from the rectum

C) A crepitant-like feeling when assessing the clavicles - A crepitant-like feeling when assessing the clavicles may indicate a fracture. If a fracture is suspected, the physician should be notified.

An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed: A) Only if the newborn is in obvious distress B) Once by the obstetrician, just after the birth C) At least twice, 1 minute and 5 minutes after birth D) Every 15 minutes during the newborn's first hour after birth

C) At least twice, 1 minute and 5 minutes after birth - Apgar scoring is performed at 1 minute and at 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts.

The nurse administers vitamin K to the newborn for what reason? A) Most mothers have a diet deficient in vitamin K, which results in the infant being deficient. B) Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. C) Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. D) The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.

C) Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.

A breastfeeding woman develops engorged breasts at 3 days postpartum. What action will help this client achieve her goal of reducing the engorgement? A) Skip feedings to enable her sore breasts to rest. B) Avoid using a breast pump. C) Breastfeed her infant every 2 hours. D) Reduce her fluid intake for 24 hours.

C) Breastfeed her infant every 2 hours. - The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. Skipping feedings may cause further swelling and discomfort. If the infant does not adequately feed and empty the breast, then the mother may pump to extract the milk and relieve some of the discomfort. Dehydration further irritates swollen breast tissue.

While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the client accordingly. Which statement as part of this discussion would be incorrect? A) Breastfeeding requires fewer supplies and less cumbersome equipment. B) Breastfeeding saves families money. C) Breastfeeding costs employers in terms of time lost from work. D) Breastfeeding benefits the environment.

C) Breastfeeding costs employers in terms of time lost from work. - Actually, less time is lost to work by breastfeeding mothers, in part because infants are healthier. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment. It saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal.

Which statement regarding the nutrient needs of breastfed infants is correct? A) Breastfed infants need extra water in hot climates. B) During the first 3 months, breastfed infants consume more energy than formula-fed infants. C) Breastfeeding infants should receive oral vitamin D drops daily during at least the first 2 months. D) Vitamin K injections at birth are not necessary for breastfed infants.

C) Breastfeeding infants should receive oral vitamin D drops daily during at least the first 2 months. - Human milk contains only small amounts of vitamin D. All infants who are breastfed should receive 400 International Units of vitamin D each day. Neither breastfed nor formula-fed infants need to be fed water, not even in very hot climates. During the first 3 months, formula-fed infants consume more energy than breastfed infants and therefore tend to grow more rapidly. Vitamin K shots are required for all infants because the bacteria that produce it are absent from the baby's stomach at birth.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? A) Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B) Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. C) Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. D) Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.

C) Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. - This action is appropriate when caring for an infant who has had a circumcision.

While assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action is the highest priority for the nurse to take at this time? A) Immediately notify the physician. B) Move the newborn to an isolation nursery. C) Document the finding as erythema toxicum neonatorum. D) Take the newborn's temperature, and obtain a culture of one of the vesicles.

C) Document the finding as erythema toxicum neonatorum. - Erythema toxicum neonatorum (or erythema neonatorum) is a newborn rash that resembles flea bites. Notification of the physician, isolation of the newborn, or additional interventions are not necessary when erythema toxicum neonatorum is present.

In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would: A) Fall between the 25th and 75th percentiles for the infant's age B) Depend on the infant's length and the size of the head C) Fall between the 10th and 90th percentiles for the infant's age D) Be modified to consider intrauterine growth restriction (IUGR)

C) Fall between the 10th and 90th percentiles for the infant's age

At a 2-month well-baby examination, it was discovered that an exclusively breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse develop a feeding plan for the infant to increase his weight gain. Which change in dietary management will assist the client in meeting this goal? A) Begin solid foods. B) Have a bottle of formula after every feeding. C) Have one extra breastfeeding session every 24 hours. D) Start iron supplements.

C) Have one extra breastfeeding session every 24 hours. - Usually the solution to slow weight gain is to improve the feeding technique. Position and the latch-on technique are evaluated, and adjustments are made. Adding a feeding or two within a 24-hour period might help. Solid foods should not be introduced to an infant for at least 4 to 6 months. Bottle feeding may cause nipple confusion and may limit the supply of milk. Iron supplements have no bearing on weight gain.

While examining a newborn, the nurse notes uneven skinfolds on the buttocks and a clunk when performing the Ortolani maneuver. These findings are likely indicative of what? A) Polydactyly B) Clubfoot C) Hip dysplasia D) Webbing

C) Hip dysplasia - The Ortolani maneuver is used to detect the presence of hip dysplasia. Polydactyly is the presence of extra digits. Clubfoot (talipes equinovarus) is a deformity in which the foot turns inward and is fixed in a plantar-flexion position. Webbing, or syndactyly, is a fusing of the fingers or toes.

With regard to lab tests and diagnostic tests in the hospital after birth, nurses should be aware that: A) All states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. B) Federal law prohibits newborn genetic testing without parental consent. C) If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. D) Hearing screening is now mandated by federal law.

C) If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. - If done very early, genetic screening should be repeated.

As the nurse assists a new mother with breastfeeding, the client asks, "If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?" What is the nurse's best response? A) More calories B) Essential amino acids C) Important immunoglobulins D) More calcium

C) Important immunoglobulins - Breast milk contains immunoglobulins that protect the newborn against infection. The calorie count of formula and breast milk is approximately the same. All the essential amino acids are in both formula and breast milk; however, the concentrations may differ. Calcium levels are higher in formula than in breast milk, which can cause an excessively high renal solute load if the formula is not properly diluted.

The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that this finding: A) Is normal B) Indicates that the infant is hungry C) May indicate that the infant has a tracheoesophageal fistula or esophageal atresia D) May indicate that the infant has a diaphragmatic hernia

C) May indicate that the infant has a tracheoesophageal fistula or esophageal atresia - The presence of excessive saliva in a neonate should alert the nurse to the possibility of tracheoesophageal fistula or esophageal atresia.

A newborn is placed under a radiant heat warmer. The nurse understands that thermoregulation presents a problem for the newborn. What is the rationale for this difficulty? A) The renal function of a newborn is not fully developed, and heat is lost in the urine. B) The small body surface area of a newborn favors more rapid heat loss than does an adult's body surface area. C) Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation. D) Their normal flexed posture favors heat loss through perspiration.

C) Newborns have a relatively thin layer of subcutaneous fat that provides poor insulation. - The newborn has little thermal insulation. Furthermore, the blood vessels are closer to the surface of the skin. Changes in environmental temperature alter the temperature of the blood, thereby influencing temperature regulation centers in the hypothalamus. Heat loss does not occur through urination. Newborns have a higher body surface-to-weight ratio than adults. The flexed position of the newborn helps guard against heat loss, because it diminishes the amount of body surface exposed to the environment.

How would the nurse differentiate a meconium stool from a transitional stool in the healthy newborn? A) Observed at age 3 days B) Is residue of a milk curd C) Passes in the first 12 hours of life D) Is lighter in color and looser in consistency

C) Passes in the first 12 hours of life - Meconium stool is usually passed in the first 12 hours of life, and 99% of newborns have their first stool within 48 hours. If meconium is not passed by 48 hours, then obstruction is suspected. Meconium stool is the first stool of the newborn and is made up of matter remaining in the intestines during intrauterine life. Meconium is dark and sticky.

What marks on a baby's skin may indicate an underlying problem that requires notification of a physician? A) Mongolian spots on the back B) Telangiectatic nevi on the nose or nape of the neck C) Petechiae scattered over the infant's body D) Erythema toxicum neonatorum anywhere on the body

C) Petechiae scattered over the infant's body - Petechiae (bruises) scattered over the infant's body should be reported to the pediatrician because they may indicate underlying problems. Mongolian spots are bluish-black spots that resemble bruises but gradually fade over months and have no clinical significance. Telangiectatic nevi (stork bites, angel kisses) fade by the second year and have no clinical significance. Erythema toxicum neonatorum is an appalling-looking rash; however, it has no clinical significance and requires no treatment.

A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? A) Physiologic jaundice occurs during the first 24 hours of life. B) Physiologic jaundice is caused by blood incompatibilities between the mother and the infant blood types. C) Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life. D) Physiologic jaundice is also known as breast milk jaundice

C) Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life. - Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dl or higher when the baby is approximately 3 days old. This finding is within normal limits for the newborn. Pathologic jaundice, not physiologic jaundice, occurs during the first 24 hours of life and is caused by blood incompatibilities that result in excessive destruction of erythrocytes; this condition must be investigated. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids.

A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to: A) Apply an oil-based lotion to the newborn's skin to prevent dying and cracking B) Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea C) Place eye shields over the newborn's closed eyes D) Change the newborn's position every 4 hours

C) Place eye shields over the newborn's closed eyes - The infant's eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should cover the eyes completely but not occlude the nares.

Which action by the mother will initiate the milk ejection reflex (MER)? A) Wearing a firm-fitting bra B) Drinking plenty of fluids C) Placing the infant to the breast D) Applying cool packs to her breast

C) Placing the infant to the breast - Oxytocin, which causes the MER reflex, increases in response to nipple stimulation. A firm bra is important to support the breast; however, it will not initiate the MER reflex. Drinking plenty of fluids is necessary for adequate milk production, but adequate intake of water alone will not initiate the MER reflex. Cool packs to the breast will decrease the MER reflex.

Which type of formula is not diluted with water, before being administered to an infant? A) Powdered B) Concentrated C) Ready-to-use D) Modified cow's milk

C) Ready-to-use - Ready-to-use formula can be poured directly from the can into the baby's bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform in consistency. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cow's milk is more difficult for the infant to digest and is not recommended, even if it is diluted.

The nurse should be cognizant of which important information regarding the gastrointestinal (GI) system of the newborn? A) The newborn's cheeks are full because of normal fluid retention. B) The nipple of the bottle or breast must be placed well inside the baby's mouth because teeth have been developing in utero, and one or more may even be through. C) Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head. D) Bacteria are already present in the infant's GI tract at birth because they traveled through the placenta.

C) Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the baby's head. - Avoiding overfeeding can also reduce regurgitation. The newborn's cheeks are full because of well-developed sucking pads. Teeth do develop in utero, but the nipple is placed deep because the baby cannot move food from the lips to the pharynx. Bacteria are not present at birth, but they soon enter through various orifices

Which information should the nurse provide to a breastfeeding mother regarding optimal self-care? A) She will need an extra 1000 calories a day to maintain energy and produce milk. B) She can return to prepregnancy consumption patterns of any drinks as long as she gets enough calcium. C) She should avoid trying to lose large amounts of weight. D) She must avoid exercising because it is too fatiguing.

C) She should avoid trying to lose large amounts of weight. - Large weight loss releases fat-stored contaminants into her breast milk, and it also involves eating too little and/or exercising too much. A breastfeeding mother needs to add only 200 to 500 extra calories to her diet to provide the extra nutrients for her infant. However, this is true only if she does not drink alcohol, limits coffee to no more than two cups (including caffeine in chocolate, tea, and some sodas, too), and carefully reads the herbal tea ingredients. Although she needs her rest, moderate exercise is healthy.

The normal term infant has little difficulty clearing its airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can easily be cleared with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to: A) Avoid suctioning the nares B) Insert the compressed bulb into the center of the mouth C) Suction the mouth first D) Remove the bulb syringe from the crib when finished

C) Suction the mouth first - The mouth should be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned.

Which information related to the newborn's developing cardiovascular system should the nurse fully comprehend? A) The heart rate of a crying infant may rise to 120 beats per minute. B) Heart murmurs heard after the first few hours are a cause for concern. C) The point of maximal impulse (PMI) is often visible on the chest wall. D) Persistent bradycardia may indicate respiratory distress syndrome (RDS).

C) The point of maximal impulse (PMI) is often visible on the chest wall. - The newborn's thin chest wall often allows the PMI to be observed. The normal heart rate for infants who are not sleeping is 120 to 160 beats per minute. However, a crying infant could temporarily have a heart rate of 180 beats per minute. Heart murmurs during the first few days of life have no pathologic significance; however, an irregular heart rate beyond the first few hours should be further evaluated. Persistent tachycardia may indicate RDS; bradycardia may be a sign of congenital heart blockage.

As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is: A) To protect the baby from infection. B) It is part of the Apgar protocol. C) To protect the nurse from contamination by the newborn. D) Because the nurse has primary responsibility for the baby during the first 2 hours.

C) To protect the nurse from contamination by the newborn. - Gloves are worn to protect the nurse from infection until the blood and amniotic fluid are cleaned off the newborn.

The nurse is cognizant of which information related to the administration of vitamin K? A) Vitamin K is important in the production of red blood cells. B) Vitamin K is necessary in the production of platelets. C) Vitamin K is not initially synthesized because of a sterile bowel at birth. D) Vitamin K is responsible for the breakdown of bilirubin and the prevention of jaundice

C) Vitamin K is not initially synthesized because of a sterile bowel at birth. - The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is necessary to activate blood-clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other blood-clotting factors.

In assisting the breastfeeding mother to position the baby, which information regarding positioning is important for the nurse to keep in mind? A) The cradle position is usually preferred by mothers who had a cesarean birth. B) Women with perineal pain and swelling prefer the modified cradle position. C) Whatever the position used, the infant is "belly to belly" with the mother. D) While supporting the head, the mother should push gently on the occiput.

C) Whatever the position used, the infant is "belly to belly" with the mother. - The infant naturally faces the mother, belly to belly. The football position is usually preferred after a cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.

According to demographic research, which woman is least likely to breastfeed and therefore most likely to need education regarding the benefits and proper techniques of breastfeeding? A) Between 30 and 35 years of age, Caucasian, and employed part time outside the home B) Younger than 25 years of age, Hispanic, and unemployed C) Younger than 25 years of age, African-American, and employed full time outside the home D) 35 years of age or older, Caucasian, and employed full time at home

C) Younger than 25 years of age, African-American, and employed full time outside the home - Women least likely to breastfeed are typically younger than 25 years of age, have a lower income, are less educated, are employed full time outside the home, and are African-American.

While completing a newborn assessment, the nurse should be aware that the most common birth injury is: A) To the soft tissues B) Caused by forceps gripping the head on delivery C) Fracture of the humerus and femur D) Fracture of the clavicle

D) Fracture of the clavicle - The most common birth injury is fracture of the clavicle (collarbone). It usually heals without treatment, although the arm and shoulder may be immobilized for comfort.

Nurses should be able to teach breastfeeding mothers the signs that the infant has correctly latched on. Which client statement indicates a poor latch? A) "I feel a firm tugging sensation on my nipples but not pinching or pain." B) "My baby sucks with cheeks rounded, not dimpled." C) "My baby's jaw glides smoothly with sucking." D) "I hear a clicking or smacking sound."

D) "I hear a clicking or smacking sound." - The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. The tugging sensation without pinching is a good sign. Rounded cheeks are a positive indicator of a good latch. A smoothly gliding jaw also is a good sign.

An Apgar score of 10 at 1 minute after birth would indicate: A) An infant having no difficulty adjusting to extrauterine life and needing no further testing B) An infant in severe distress that needs resuscitation C) A prediction of a future free of neurologic problems D) An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth

D) An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth - An initial Apgar score of 10 is a good sign of healthy adaptation; it must be repeated, however, at the 5-minute mark.

The brain is vulnerable to nutritional deficiencies and trauma in early infancy. What is the rationale for this physiologic adaptation in the newborn? A) Incompletely developed neuromuscular system B) Primitive reflex system C) Presence of various sleep-wake states D) Cerebellum growth spurt

D) Cerebellum growth spurt - The vulnerability of the brain is likely due to the cerebellum growth spurt. By the end of the first year, the cerebellum ends its growth spurt that began at approximately 30 weeks of gestation. The neuromuscular system is almost completely developed at birth. The reflex system is not relevant to the cerebellum growth spurt. The various sleep-wake states are not relevant to the cerebellum growth spurt.

As part of their teaching function at discharge, nurses should tell parents that the baby's respiration should be protected by all of the following procedures except: A) Prevent exposure to people with upper respiratory tract infections B) Keep the infant away from secondhand smoke C) Avoid loose bedding, water beds, and beanbag chairs D) Don't let the infant sleep on his or her back

D) Don't let the infant sleep on his or her back - The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. Infants are vulnerable to respiratory infections; infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding and furniture that can trap them.

A postpartum woman telephones the provider regarding her 5-day-old infant. The client is not scheduled for another weight check until the infant is 14 days old. The new mother is worried about whether breastfeeding is going well. Which statement indicates that breastfeeding is effective for meeting the infant's nutritional needs? A) Sleeps for 6 hours at a time between feedings B) Has at least one breast milk stool every 24 hours C) Gains 1 to 2 ounces per week D) Has at least six to eight wet diapers per day

D) Has at least six to eight wet diapers per day - After day 4, when the mother's milk comes in, the infant should have six to eight wet diapers every 24 hours. Typically, infants sleep 2 to 4 hours between feedings, depending on whether they are being fed on a 2- to 3-hour schedule or cluster-fed. The infant's sleep pattern is not an indication whether the infant is breastfeeding well. The infant should have a minimum of three bowel movements in a 24-hour period. Breastfed infants typically gain 15 to 30 g/day.

What is the most critical physiologic change required of the newborn after birth? A) Closure of fetal shunts in the circulatory system B) Full function of the immune defense system C) Maintenance of a stable temperature D) Initiation and maintenance of respiration

D) Initiation and maintenance of respiration - The most critical adjustment of a newborn at birth is the establishment of respirations. The cardiovascular system changes significantly after birth as a result of fetal respirations, which reduce pulmonary vascular resistance to the pulmonary blood flow and initiate a chain of cardiac changes that support the cardiovascular system. After the establishment of respirations, heat regulation is critical to newborn survival. The infant relies on passive immunity received from the mother for the first 3 months of life.

An African-American woman noticed some bruises on her newborn daughter's buttocks. The client asks the nurse what causes these. How would the nurse best explain this integumentary finding to the client? A) Lanugo B) Vascular nevus C) Nevus flammeus D) Mongolian spot

D) Mongolian spot - A Mongolian spot is a bluish-black area of pigmentation that may appear over any part of the exterior surface of the infant's body and is more commonly noted on the back and buttocks and most frequently observed on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair observed on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma. A nevus flammeus, commonly called a port wine stain, is most frequently found on the face.

While evaluating the reflexes of a newborn, the nurse notes that with a loud noise the newborn symmetrically abducts and extends his arms, his fingers fan out and form a C with the thumb and forefinger, and he has a slight tremor. The nurse would document this finding as a positive _____ reflex. A) Tonic neck B) Glabellar (Myerson) C) Babinski D) Moro

D) Moro - The characteristics displayed by the infant are associated with a positive Moro reflex. The tonic neck reflex occurs when the infant extends the leg on the side to which the infant's head simultaneously turns. The glabellar (Myerson) reflex is elicited by tapping on the infant's head while the eyes are open. A characteristic response is blinking for the first few taps. The Babinski reflex occurs when the sole of the foot is stroked upward along the lateral aspect of the sole and then across the ball of the foot. A positive response occurs when all the toes hyperextend, with dorsiflexion of the big toe.

What are the most common causes for subinvolution of the uterus? A) Postpartum hemorrhage and infection B) Multiple gestation and postpartum hemorrhage C) Uterine tetany and overproduction of oxytocin D) Retained placental fragments and infection

D) Retained placental fragments and infection - Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection. Subinvolution may be caused by an infection and result in hemorrhage. Multiple gestations may cause uterine atony, resulting in postpartum hemorrhaging. Uterine tetany and overproduction of oxytocin do not cause subinvolution.

Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after: A) The bleeding stops completely. B) Yellow exudate forms over the glans. C) The PlastiBell rim falls off. D) The infant voids.

D) The infant voids. - The infant should be observed for urination after the circumcision.

A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. How should the client be instructed to position the infant to facilitate correct latch-on? A) The infant should be positioned with his or her arms folded together over the chest. B) The infant should be curled up in a fetal position. C) The woman should cup the infant's head in her hand. D) The infant's head and body should be in alignment with the mother.

D) The infant's head and body should be in alignment with the mother. - The infant's head and body should be in correct alignment with the mother and the breast during latch-on and feeding. The infant should be facing the mother with his arms hugging the breast. The baby's body should be held in correct alignment (i.e., ears, shoulder, and hips in a straight line) during feedings. The mother should support the baby's neck and shoulders with her hand and not push on the occiput.

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data? A) The nurse should immediately notify the pediatrician for this emergency situation. B) The neonate must have aspirated surfactant. C) If this baby was born vaginally, then a pneumothorax could be indicated. D) The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth.

D) The lungs of a baby delivered by cesarean section may sound moist during the first 24 hours after childbirth. - Moist lung sounds will resolve within a few hours. A surfactant acts to keep the expanded alveoli partially open between respirations for this common condition of newborns. In a vaginal birth, absorption of the remaining lung fluid is accelerated by the process of labor and delivery. The remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. Moist lung sounds are particularly common in infants delivered by cesarean section. The surfactant is produced by the lungs; therefore, aspiration is not a concern.

A newly delivered mother who intends to breastfeed tells her nurse, "I am so relieved that this pregnancy is over so that I can start smoking again." The nurse encourages the client to refrain from smoking. However, this new mother is insistent that she will resume smoking. How will the nurse adapt her health teaching with this new information? A) Smoking has little-to-no effect on milk production. B) No relationship exists between smoking and the time of feedings. C) The effects of secondhand smoke on infants are less significant than for adults. D) The mother should always smoke in another room.

D) The mother should always smoke in another room. - The new mother should be encouraged not to smoke. If she continues to smoke, she should be encouraged to always smoke in another room, removed from the baby. Smoking may impair milk production. When the products of tobacco are broken down, they cross over into the breast milk. Tobacco also results in a reduction of the antiinfective properties of breast milk. Research supports the conclusion that mothers should not smoke within 2 hours before a feeding (AAP Committee on Drugs, 2001). The effects of secondhand smoke on infants include excessive crying, colic, upper respiratory infections, and an increased risk of sudden infant death syndrome (SIDS).

Which infant response to cool environmental conditions is either not effective or not available to them? A) Constriction of peripheral blood vessels B) Metabolism of brown fat C) Increased respiratory rates D) Unflexing from the normal position

D) Unflexing from the normal position - The newborn's flexed position guards against heat loss, because it reduces the amount of body surface exposed to the environment. The newborn's body is able to constrict the peripheral blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may rise to stimulate muscular activity, which generates heat.