OB PREPU//VSIM EXAM4
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 sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."
A nurse is caring for a child with complex esophageal atresia who will be undergoing surgery for repair. What comment by the parents indicates further teaching is required?
"After this surgery is done tomorrow, my baby will be able to eat and drink."
Four weeks before the birth of a client's already large child, the primary care provider has told the client that if the baby gets bigger and the baby's lungs are ready, the care provider would like to perform a cesarean birth. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse?
"As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress."
A newborn develops physiologic jaundice, and the mother asks the nurse why this happened. Which response by the nurse would be most accurate?
"Because his liver is a bit immature, the baby can't break down the bilirubin as fast as needed."
The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement?
"His stomach can hold approximately 10 ounces."
A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman?
"It is a normal skin finding in a newborn."
At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has has occurred when a participant makes which statement?
"Newborns who are appropriate for gestational age at birth have lower chance of complications than others."
A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching?
"Place the newborn on the back to sleep and stomach to play."
A nursing student, observing care of a 30-week-gestation infant in the neonatal intensive care unit, asks the nurse, "Are premature infants more susceptible to infection as I have to wash my hands so often in this department?" What is the nurse's best response?
"That is correct; a 30-week-gestation infant lacks the protective antibody called IgG."
The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?
"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."
The newborn weighing 6 lb 6 oz (2856 g), now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss?
"This is a normal response."
A nurse is teaching a newborn's parents how to change a diaper correctly. Which statement by the parents best demonstrates understanding of what they have been taught?
"We will fold down the front of her diaper under the cord until it falls off."
A young mother is concerned for her baby and asks the nurse if her baby is okay. What is the best response if the nurse notes: RR 66, nostrils flaring, and grunting sounds during respiration?
"Your baby is having a little trouble breathing. I'll let the RN know."
A neonatal nurse admits a preterm infant with the diagnosis of respiratory distress syndrome and reviews the maternal labor and birth record. Which factors in the record would the nurse correlate with this diagnosis? Select all that apply.
-32 weeks' gestation -cesarean birth -male gender -newborn asphyxia -maternal diabetes
The nurse is preparing for an emergency c-section for a patient who has prolapsed cord visible at the vulva. Which interventions would the nurse take for this surgical procedure? SATA
-Administer the ordered preoperative intravenous medication -Assess the intravenous site for patency and hang a full bag of IV fluid -Review results for diagnostic tests, including CBC, blood type, and crossmatch, and urinalysis -Obtain an informed consent from the patient or family member
The nurse is admitting a laboring woman at 39 weeks gestation. Which of the following are risk factors for prolapsed umbilical cord? SATA
-Amniotic fluid 2,200 mL -Estimated fetal weight of 2,400 g (5 lb, 1 oz) -Multiple gestation -Amniotomy performed; station -2
Which safety precautions should a nurse take to prevent infection in a newborn? Select all that apply.
-Avoid coming to work when ill. -Use sterile gloves for an invasive procedure. -Initiate universal precautions when caring for the infant.
The fetus's head emerges and a positive turtle sign is observed. Whom would the nurse call into the delivery room at this time? SATA
-Charge nurse -Neonatal intensive care unit (NICU) personnel
The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply.
-Dress the newborn in ways to preserve warmth. -Take the newborn's temperature often. -Supply oxygen for the newborn, if necessary.
Which of the following are common fetal or neonatal injuries seen after should dystocia? SATA
-Erb's palsy -Fractured clavicle -Asphyxia
What is the first action by the nurse to assist with the delivery of the fetal shoulders and body when there is should dystocia?
-Flex the mother's thighs toward her abdomen
When a shoulder dystocia emergency is anticipated, what additional actions should be implemented by the nurse? SATA
-Have extra staff available if needed -Explain to the patient and family what may happen -Put a step stool at the bedside
The provider directs the nurse to begin with McRobert's maneuver. The nurse knows to take which of the following actions?
-Hyperflex the patient's legs to her abdomen
The nurse monitors for adverse effects from terbutaline sulfate, which was given to Carla Hernandez after umbilical cord prolapse was identified. Which of the following are signs of adverse effects of this drug? SATA
-Maternal heart rate 154, regular -Auscultate crackles throughout lung fields -Maternal blood pressure 152/94 mm Hg
A patient is admitted to the labor and delivery unit at 40 weeks gestation. Which of the following pieces of information collected during the patient interview would be most significant in alerting the nurse to the potential for shoulder dystocia? SATA
-Maternal height 5 ft 3 in -Maternal weight gain greater than 50 lb -Estimated fetal weight 8 lb, 13 oz
After should dystocia is diagnosed, which maneuvers are implemented to facilitate the delivery of the fetal body? SATA
-McRobert's maneuver -Woods' screw maneuver -Suprapubic pressure
Which of the following nursing measures has the highest priority when an intrapartum woman has a prolapsed umbilical cord?
-Place sterile gloved hand into patient's vagina to push the fetus off the umbilical cord
After experiencing shoulder dystocia, the patient is at increased risk for which of the following complications?SATA
-Postpartum hemorrhage -Bladder trauma -Vaginal laceration
When the provider applied suprapubic pressure during Ms. Sung's delivery, what was the goal?
-Push the fetus's anterior shoulder downward and under the pubic bone
When assuming responsibility for Ms. Sung's care, the nurse reviews the patient's history and admissions assessment. Based on this information, which anticipatory tasks should the nurse implement before delivery? SATA
-Put a step stool next to the birthing bed -Educate the patient and family -Alert key personnel -Empty the patient's bladder
Which nursing actions limit overstimulation of the preterm infant? Select all that apply.
-Speak softly to the infant. -Keep lights low in the nursery. -Coordinate nursing care.
The nursery nurse is providing shift handoff on a newborn documented as small for gestational age. Which clinical manifestations would tbe communicated? Select all that apply.
-Sunken abdomen -Poor muscle tone over buttocks -Dry or thin umbilical cord
After the umbilical cord prolapse has been identified, which of the following personnel should the nurse inform of this emergency? SATA
-Surgery -Provider -NICU
During the initial assessment for Carla Hernandez, there was fetal bradycardia, late decelerations, and minimal variability. The nurse could determine that measures to relive umbilical cord compression were successful by which of the following evaluative findings? SATA
-The umbilical cord had a pulse -Longterm variability was 10 to 15 beats per minute -The umbilical cord had a pH of 7.3 and maternal oxygen saturation was at 98%
The nurse has assessed that the patient in labor is at risk of shoulder dystocia. After delivery of the fetal head, the nurse states in a clear loud voice "fetal heart rate 90 beats per minute w/minimal variability." Why is it important for the nurse to communicate this information?
-To inform the provider about the fetal status
The nurse takes measures to preserve the integrity of the visual umbilical cord prolapse to maintain blood flow to the fetus. Which of the following are appropriate measures ? SATA
-Use a gloved hand to lift the presenting part off the cord -Assess the exposed umbilical cord for color and pulsation
When was the diagnosis of shoulder dystocia made in Ms. Sung's case?
-When the newborn's head delivered without the delivery of the neck and body
A nurse is assessing a newborn's gestational age, When determining neuromuscular maturity, which parameters would the nurse assess? Select all that apply.
-arm recoil -scarf sign
Which situation is likely to result in the presence of developmental dysplasia of the hip (DDH) at birth? Select all that apply.
-breech birth -female gender -oligohydramnios
Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? Select all that apply.
-diabetes mellitus -postdates gestation -prepregnancy obesity
Shoulder dystocia is a complication of labor related to which of these factors?
-prolonged second stage of labor
The nurse documents the following events: crowning at 0749, fetal head emerged at 0800, McRoberts maneuver performed at 0802, suprapubic pressure applied at 0806, and fetal body delivered at 0808. What is the significant of documenting these events?
-provides an indicator of the potential for fetal compromise
A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply.
-temperature of 38.3° C (101° F) or higher -refuse feeding -abdominal distention
Which of the following pregnancy-related conditions increase the risk for shoulder dystocia?
-uncontrolled maternal gestational diabtes
The nurse is preparing to administer an intramuscular injection to a newborn. The nurse will ensure the maximum amount per injection is what?
0.5
A laboring woman called the nurse to report her bag of waters broke and she feels a pulsation in her vagina. The nurse notes variable decelerations w/fetal bradycardia on the fetal monitor and suspects prolapsed umbilical cord. Put into order the interventions the nurse should perform.
1) call the charge nurse to notify the provider and prepare for immediate delivery 2) insert a gloved hand into the vagina to relive pressure on the umbilical cord 3) assist the patient into a knee-chest position 4) administer oxygen by non-rebreather mask at 10L/min 5)explain emergency measures and rationales to the patient and her support person 6) ensure that there are no further abnormal fetal heart rate patterns 7) document the actions and procedures taken to resolve the situation
How long is the neonatal period for a newborn?
28
A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal?
37.0° C (98.6° F)
The nurse is caring for a client who is at her due date. The client asks. "How long is the health care provider going to let me go?" The nurse is correct to state that typical a mother should not pass how many weeks gestation?
42 weeks
A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of:
7
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:
7 to 10.
Why is it important for the nurse to thoroughly assess maternal bladder and bowel status during labor?
A full bladder or rectum can impede fetal descent.
The labor and delivery nurse notices that a laboring woman's external fetal monitor shows a variable deceleration. What is the common etiology of this nonreassuring fetal periodic pattern?
Cord compression
As Carla Hernandez is taken back to the operating room for an emergent c-section, her husband expresses anxiety about his wife and baby. What is the most therapeutic communication that the nurse can make?
Delivery is needed because the blood flow through the umbilical cord is not getting enough oxygen to the baby. I understand that you are concerned about the well being of your wife and baby. What are you feeling?
The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:
Epstein's pearls.
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?
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?
Expose the newborn's bottom to air several times a day.
Parents are taking home their second child. They also hve a 2-year-old at home. The nurse would anticipate which behavior by these parents?
General questions about different aspects of newborn care
The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex?
Gently stroke the newborn's cheek.
The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family?
Help the mother provide kangaroo care.
The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?
Hep B
What is the best rationale for trying to decrease the incidence of cold stress in the neonate?
If the neonate becomes cold stressed, it will eventually develop respiratory distress.
The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize?
Ineffective airway clearance related to mucus and secretions
The nurse caring for a newborn notes a distended abdomen approximately 24 hours after birth. Which action should the nurse prioritize after review of the medical record reveals an apparent healthy newborn at birth but no documentation of a bowel movement?
Inform the RN and/or primary care provider immediately
The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?
Injecting the medication into the vastus lateralis
The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?
Instill 0.5% ophthalmic erythromycin.
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. What does this rash indicate?
It is a normal skin finding in a newborn.
Which of the following statements is true concerning prolapsed umbilical cord?
It is an emergency that requires immediate measures to minimize fetal mortality or morbidity from hypoxia
When the nurse is assisting the parents in the grieving process after the death of their neonate, what is the nurse's most important action?
Keep the communication lines open.
A newborn is identifies as extremely low birth weight placing the newborn's weight at which level?
Less than 1,000 g.
An infant is suffering from neonatal abstinence syndrome. The nurse provides appropriate care and support for the infant during the infant's time on the unit. Besides nursing and medical care, what other step would the nurse take to support the infant?
Link the family with community sources for aid.
A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time?
Look for late decelerations on monitor, which is associated with fetal anoxia.
A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?
McRoberts maneuver
Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia?
McRoberts maneuver
When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications?
Morphine
A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?
Newborns have the ability to focus only on objects in close proximity.
The neonatal intensive care nurse is admitting a large-for-gestational-age infant with respiratory distress who has difficulty with hypothermia, appears lethargic, is jittery, and is not feeding well. What would be the nurse's first action?
Obtain a blood glucose level.
To prepare for an immediate c-section delivery for Carla Hernandez, what would the nurse do first?
Obtain an informed consent
A 26-year-old primigravida has brought her doula to the birthing center for support during her labor and birth. The doula has been helping her through the past 16 hours of labor. The laboring woman is now 6 cm dilated. She continues to report severe pain in her back with each contraction. The client finds it comforting when her doula uses the ball of her hand to put counterpressure on her lower back. What is the likely cause of the woman's back pain?
Occiput posterior position
A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy?
Oxygen saturation levels are at 98%.
A nurse is caring for a newborn client who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury?
Place the newborn in a prone or lateral position.
A laboring mother requests that she be allowed to participate in kangaroo care following delivery. The nurse understands that this involves what action?
Placing the diapered newborn skin-to-skin with the mother and cover them both with a blanket.
A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next?
Prepare the client for a cesarean birth.
A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child?
Provide a mobile the child can see no matter how the child is turned.
A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina?
Put her in bed immediately, call for help, and hold the presenting part of the cord.
An 18-year-old client has given birth in the 28th week of gestation, and her newborn is showing signs of respiratory distress syndrome (RDS). Which statement is true for a newborn with RDS?
RDS is caused by a lack of alveolar surfactant.
The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take?
Report the finding to the pediatrician.
Parents tell the nurse that they have been told to keep their newborn away from windows and be sure to cover the baby with a light blanket. They do not understand why this is necessary. What rationale would the nurse provide for this care?
Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.
The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski reflex. Which response would the nurse interpret as normal for the newborn?
Toes fan out when sole of foot is stroked.
Which congenital condition is an immediate emergency requiring notification of the health care provider?
Tracheoesophageal Fistula
Which respiratory disorder in a neonate is usually mild and runs a self-limited course?
Transient tachypnea
A meconium plug is an extremely hard portion of meconium that has completely blocked the intestinal lumen, causing bowel obstruction.
True
The nurse is caring for an infant born to a mother who abused cocaine during her pregnancy. The nurse would likely notice that this infant:
cries when touched.
A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?
diabetes
The nurse assesses an infant. Which finding may indicate heart failure?
diminished peripheral pulses
A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the:
ductus arteriosus remains open.
When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn?
during the first 24 hours of life
A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area?
face
A nurse is caring for an antenatal mother diagnosed with umbilical cord prolapse. For which should the nurse monitor the fetus?
fetal hypoxia
A nurse is conducting a class for expectant parents about newborns and the changes that they experience after birth. The nurse discusses the neonatal period, describing it as which time frame?
first 28 days of life
While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as:
harlequin sign.
The AGPAR score is based on which 5 parameters?
heart rate, muscle tone, reflex irritability, respiratory effort, and color
Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth?
hemoglobin: 17.5 g/dL
A pregnant woman has just found out that she is having twin girls. She asks the nurse the difference between fraternal and identical twins. The nurse explains that with one set of twins there is fertilization of two ova, and with the other set one fertilized ovum splits. What type of twins result from the split ovum?
identical
A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the baby is being born. Which intervention should the nurse implement as a result of this finding?
intubation and suctioning of the trachea
The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis?
jitteriness
A nurse is providing preoperative care to a female newborn client with the congenital abnormality myelomeningocele. Which intervention is the priority?
preventing infection
Circumcision is a very personal decision for parents, and the nurse's major responsibility is to inform the parents of the risks and benefits of the procedure. The nurse needs to recognize that this is mainly which type of decision?
social decision
A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation?
the 41-year-old client who conceived by in vitro fertilization
A mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that:
this is a normal finding.
A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is at 33 weeks' gestation. What treatment can the nurse expect this client to be prescribed?
tocolytic therapy
When assessing the newborn's umbilical cord, what should the nurse expect to find?
two smaller arteries and one larger vein
At what point should the nurse expect a healthy newborn to pass meconium?
within 24 hours after birth
A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction after making which statement?
"All congenital disorders can be diagnosed at birth."
What is a positive turtle sign?
-The fetal head emerges and then retracts tightly against the perineal floor
Hypoglycemia in a mature infant is defined as a blood glucose level below which amount?
40 mg/100 mL whole blood
A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?
A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.
After the fetal head emerges, the nurse notes that the fetal heart rate is 90 beats per minute with minimal variability. Which action should the nurse implement first?
Administer oxygen
The nurse received report for Carla Hernandez before taking over her care. What was the most important piece of information communicated to the nurse that expedited care for this patient?
Amniotomy performed by provider to facilitate labor
The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?
Anesthetic may not be effective during the procedure
What is the most important action the nurse would take when a prolapsed cord has been identified?
Apply gloved hand in the vagina to alleviate cord compression
Carla Hernandez's fetal membranes were ruptured by her provider. Immediately following the procedure, the nurse notes persistent fetal bradycardia on the fetal monitor. This could indicated which of the following?
Compression of the umbilical cord
A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize?
Depressed deep tendon reflexes
A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant?
Focus on decreasing blood viscosity by increasing fluid volume.
Which of the following nursing diagnoses has the highest priority in the care of Carla Hernandez during an umbilical cord prolapse?
Impaired gas exchange in the fetus related to decreased blood perfusion
In completing the newborn assessment checklist, the nurse documents a meconium stool. This documentation rules out which condition?
Imperforate anus
A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority?
Ineffective thermoregulation related to decreased amount of subcutaneous fat
Which types of play are most appropriate for the 3-month-old who is in an orthopedic cast?
Mobiles and rattles
A woman in active labor reports to the nurse that she things that her bag of waters has broken. What is the first assessment that the nruse performs at this time?
Monitor the FHR and pattern
The nurse is assessing the neonate shown. From the assessment, the nurse notes that there is paralysis of the lower extremities. For which condition does the nurse anticpate performing care?
Spina bifida with myelomeningocele
A 6-week gestation client asks the nurse what foods she should eat to help prevent neural tube disorders in her growing baby. The nurse would recommend which foods?
Spinach, oranges, and beans
Carla Hernandez was in active labor when umbilical cord prolapse was identified. The provider ordered a tocolytic agent to relax the uterine smooth muscle. What is the best route for administering terbutaline sulfate to the patient in this situation?
Subcutaneous, back of arm
A woman has just given birth vaginally to a newborn. Which action will the nurse do first?
Suction the mouth and nose.
At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate?
The infant was a preterm, low birth weight and small for gestational age
A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What most likely occurred?
The infant's mother probably had diabetes.
The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which occurrence?
The nurse begins intermittent oral feedings for a small-for-gestational-age newborn to prevent which occurrence?
Which of the following would be the best initial communication for the nurse to make when calling the NICU?
This is the nurse in birthing room 2. Ms. Sung is pushing and the head is delivered. Turtle sign is positive. Estimated weight is 4,000 grams. The fetal heart rate is currently 90 bpm with decreased variability. McRobert's maneuver is being doing. We need a NICU team for possible neonatal asphyxia or fetal injury
Which of the following pieces of information about the birth should be documented when shoulder dystocia has occurred?
Time the head emerges, time maneuvers are implemented, and time the shoulders/body emerge
What is the primary purpose for a provider order for terbutaline sulfate to be given to a laboring patient who presents w/a prolapsed umbilical cord?
To relax the uterine smooth muscle to allow for improved fetal blood flow
A 36-week neonate born weighing 1,800 g has microcephaly and microophthalmia. Based on these findings, which risk factor might be expected in the maternal history?
Use of alcohol
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?
Use the sealed and chilled milk within 24 hours.
A woman who has given birth to a postterm newborn asks the nurse why her baby looks so thin with so little muscle. The nurse integrates understanding about which concept when responding to the mother?
With postterm birth, the fetus uses stored nutrients to stay alive, and wasting occurs.
A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?
a sudden drop in hemocrit
A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the:
chest rises with each bag compression.
A newborn has not passed any stools in the first 24 hours after birth, and his abdomen is becoming distended. The nurse recognizes that which condition could explain such findings?
imperforate anus
An infant that is diagnosed with meconium aspiration displays which symptom?
intercostal and substernal retractions
When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode?
jitteriness
A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn?
newborn who is type A, mother who is type O
A nurse is working in the newborn observational unit and is assigned four newborns. In which newborn will the nurse suspect difficulties with thermal regulation?
newly born preterm infant
A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate?
peeling and wrinkling of the neonate's epidermis
At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate?
postterm
A nurse is caring for a baby girl born at 34 weeks' gestation. Which feature should the nurse identify as those of a preterm newborn?
shiny heels and palms
Which finding would lead the nurse to suspect that a large-for-gestational-age newborn is developing hyperbilirubinemia?
tea-colored urine
A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification?
term, small for gestational age, and low-birth-weight infant
Which newborn would the nurse suspect to be most at risk for intellectual disability due to the mother's actions during pregnancy?
the child of a client who admits to drinking a liter of alcohol daily during the pregnancy
A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of:
very low birth weight.
The nurse is teaching discharge instructions to the young parents of a healthy newborn boy, whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered?
Redness at the base of the umbilical cord
A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?
Stools should be yellow-gold, loose, and stringy to pasty.
A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate?
Stop the infusion immediately.
A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angerily says no and starts crying?
Tell her that the hospital will keep the photos for her in case she changes her mind.
The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?
blood sugar
A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal?
body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)
As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?
bright red, raised bumpy area noted above the right eye
Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?
continuing to monitor maternal and fetal status
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?
convection and evaporation
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 factor in the newborn?
lack of subcutaneous fat
The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence?
lack of thoracic compressions during birth
A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?
less than 3 hours
The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?
limited voluntary muscle activity
A nursing student working with a client in preterm labor correctly identifies which medication as being used to relax the smooth muscles of the uterus and for seizure prophylaxis and treatment in clients with preeclampsia?
magnesium sulfate
During a difficult labor of an infant in the face presentation, the nurse notes the infant has a large amount of facial edema with bruising and ecchymosis. Which assessment would be the priority for this infant?
patent airway
The Ballard scoring system evaluates newborns on which two factors?
physical maturity and neuromuscular maturity
When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:
potential lacerations and bleeding.
A client is told that she is already completely effaced and 9 cm dilated, and that the fetal head is showing. Contrary to the nurse's instructions, the client begins to push. Before the primary care provider can enter the room, the woman gives birth to the baby with only the nurse in attendance. This is an example of which occurrence?
precipitate labor
A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring?
preterm labor
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?
radiation, convection, and conduction
A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function?
reflex
After assessing a client's progress of labor, the nurse suspects the fetus is in a persistent occiput posterior position. Which finding would lead the nurse to suspect this condition?
reports of severe back pain
All the options are signs of respiratory distress in the newborn except:
respiratory rate >50 breaths/minute.
The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse apply the probe?
right upper abdominal quadrant
A client with a pendulous abdomen and uterine fibroid tumors had just begun labor and arrived at the hospital. After examining the client, the primary care provider informs the nurse that the fetus appears to be malpositioned in the uterus. Which fetal position or presentation should the nurse most expect in this woman?
transverse lie
A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?
administering oxytocin
Immediately after giving birth to a full-term infant, a client develops dyspnea and cyanosis. Her blood pressure decreases to 60/40 mm Hg, and she becomes unresponsive. What does the nurse suspect is happening with this client?
amniotic fluid embolism
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. The nurse's best action would be to:
assess the rate of flow of the oxytocin infusion.
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:
at least 24 hours after birth.
The nurse is assessng a newborn male in the presence of the parents and notes that he has a hypospadias. How should the nurse respond when questioned by the parents as to what this means?
"His urinary meatus in located on the under surface of the glans."
The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery?
Bathe the newborn thoroughly
When educating the post-term pregnant client, what should the nurse be sure to include to prevent fetal complications?
Be sure to monitor fetal movements daily.
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?
Breastfeed the infant every 2 to 4 hours on demand.
A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?
Caput succedaneum
The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?
Check the identification badge of any health care worker before releasing baby from room.
A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?
The infant is experiencing moderate difficulty in adjusting to extrauterine life.
The nurse has administered an opthlalmic agent for eye prophylaxis, as prescribed. What outcome indicates that this intervention has been effective?
The infant remains free of opthalmia neonatorum
Which statement is true regarding fetal and newborn senses?
The rooting reflex is an example that the newborn has a sense of touch.
The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?
The tint is due to jaundice.
A client has been admitted to the birthing suite in labor. She has been in labor for 12 hours and is dilated to 4 cm. The primary care provider notes that the client is in hypotonic labor. What does this mean?
The uterine contractions may or may not be regular, but the quantity or quality or strength is insufficient to dilate the cervix.
The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time?
Within one hour
Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?
a respiratory rate of 15 breaths per minute with nasal flaring
