OB Unit 2 (24, 25, 26, 27, 14, 15)

A 32-year-old pregnant client is diagnosed with active tuberculosis (TB). What fetal health issues is this client at risk for developing? Select all that apply.

1. Cleft palate 2. Preterm labor 3. Microcephaly 4. Spontaneous abortion 5. Suboptimal weight gain Answer: 2, 4, 5 2. Women with TB have a higher rate of preterm labor.. 4. Women with TB have a higher rate of spontaneous abortion. 5. Women with TB have a higher rate of suboptimal weight gain. Page 289

An infant born to a client with type 2 diabetes mellitus is lethargic, has a high-pitched cry, and has an initial plasma glucose level of 19 mg/dL. What should the nurse do immediately?

immediately? 1. Have the mother breastfeed the infant. 2. Start an IV with D5W dextrose solution. 3. Start an IV with D10W dextrose solution. 4. Wait 30 minutes and retest plasma glucose levels. Answer: 3 This is the proper nursing action. Infants with severe hypoglycemia should be aggressively treated with IV infusion of D10W dextrose. Page 624

An infant weighing 8 lb, 4 oz at birth weighs 7 lb, 15 oz 3 days later. What should the nurse explain to the parents about this change in the newborn's weight?

1. "This weight loss is unusual." 2. "This weight loss is less than expected." 3. "This weight loss is excessive." 4. "This weight loss is within normal limits." Answer: 4 This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5% to 10% in term newborns. Page Ref: 530

A 20-year-old woman at 28 weeks' gestation has a history of past drug abuse and her urine screening indicates recent heroin use. What should the nurse recognize this client is at risk for developing?

1. Diabetes mellitus 2. Abruptio placentae 3. Erythroblastosis fetalis 4. Pregnancy-induced hypertension Answer: 4 Women who use heroin are at risk for poor nutrition, anemia, and pregnancy-induced hypertension (or preeclampsia). Page Ref: 278

The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful?

1. "Giving the baby his first bath can really give me a chance to get to know him." 2. "Newborns cannot focus their eyes, so it does not matter how I hold my new baby." 3. "My baby will be very sleepy immediately after birth, so he can go to the nursery." 4. "I should avoid looking directly into the baby's eyes to prevent frightening the baby." Answer: 1 When parents give the first bath with the nurse, the nurse can point out behaviors and characteristics that help the parents understand their infant as unique and can model ways to respond to the baby's behavior. page 526

A newborn is diagnosed with fetal alcohol syndrome (FAS). Which statement indicates that the parents require additional teaching about this health problem?

1. "He might be a fussy baby because of this." 2. "His face looks like it does due to this problem." 3. "Cuddling and rocking will help him stay calm." 4. "Our baby's heart murmur is from this syndrome." Answer: 3 FAS babies are easily overstimulated and tend to cry more if swaddled, cuddled, or rocked. A dark and quiet environment helps keep the child calm. Page 596

The nurse is doing preconception counseling with a 28-year-old woman with no prior pregnancies. Which client statement indicates that teaching has been effective?

1. "A beer once a week will not damage the fetus." 2. "I can continue to drink alcohol until I am diagnosed as being pregnant." 3. "I can drink alcohol while breastfeeding since it does not pass into breast milk." 4. "I need to stop drinking alcohol completely when I start trying to get pregnant." Answer: 4 Because birth defects that are related to fetal alcohol exposure can occur in the first 3 to 8 weeks' gestation, often before the woman even knows she is pregnant, women should discontinue drinking alcohol when they start to attempt pregnancy. Page Ref: 277

A pregnant client has not decided on a feeding method for her infant and asks for more information about breastfeeding and formula-feeding. Which client statement indicates that the teaching was successful?

1. "Breastfeeding is more expensive than formula-feeding." 2. "My baby has a lower risk of food allergies if I breastfeed." 3. "Formula-feeding gives the baby protection from infections." 4. "Breast milk cannot be stored; it has to be thrown away after pumping." Answer: 2 Breast milk provides newborns with immunoglobulins and reduces the risk of food allergies in children. Page 537

Which statement by a breastfeeding class participant indicates that teaching was effective? Select all that apply.

1. "Breastfeeding is worthwhile, even if it costs more overall." 2. "Breastfed infants get more skin-to-skin contact and sleep better." 3. "Breastfed infants have fewer digestive and respiratory illnesses." 4. "Breastfeeding raises the level of a hormone that makes me feel good." 5. "Breastfeeding is complex and difficult, and I probably will not succeed." Answer: 2, 3, 4. 2. This is a true statement. Newborns are very responsive to touch, and it is vital for the infant's emotional well-being. The tactile stimulation associated with breastfeeding can communicate warmth, closeness, comfort, and the opportunity to learn each other's behavioral cues and needs. 3. This is a true statement. Reduced infections are due to immunologic properties in breast milk and to the fact that breastfed infants are not put to bed with a bottle, a practice known to increase ear infections. 4. Every time an infant suckles, the prolactin level doubles; prolactin creates feelings of euphoria and relaxation. Page 538

The nurse is teaching a class for new parents. Which statement indicates that additional information is needed?

1. "Car seats are installed the same way in different models of cars. Our friends can show us how to install it." 2. "Genitals of babies look swollen and enlarged at birth as a result of the hormones in the mother's circulation." 3. "We can call the nurse help line any time of day or night if we have questions about our baby after we get home." 4. "Baby girls sometimes have a little bloody mucus in their diapers as a reaction to the high estrogen level in the mother." Answer: 1 Each model of car seat is installed differently in different makes of car. Directions for car seats should be followed carefully. Car dealerships often offer a car seat installation instruction service. Page 559

A 26-year-old multigravida who is 28 weeks pregnant and follows a program of regular exercise develops gestational diabetes. What instructions should be included in a teaching plan for this client?

1. "Carry hard candy (or other simple sugar) when exercising." 2. "If your blood sugar is 120 mg/dL, eat 20 g of carbohydrate." 3. "Exercise either just before meals or wait until 2 hours after a meal." 4. "If your blood sugar is more than 120 mg/dL, drink a glass of whole milk." Answer: 1 A client should be encouraged to continue any exercise programs in which she already is involved. She should keep hard candy (simple sugar) with her at all times, just in case the exercise induces hypoglycemia. page 274

The postpartum client who delivered a newborn 2 days ago develops endometritis. Which entry in the medical record would the nurse expect to find when reviewing the client's history?

1. "Cesarean birth performed secondary to arrest of dilation." 2. "Rupture of membranes occurred 2 hours prior to delivery." 3. "External fetal monitoring used throughout labor." 4. "History of pregnancy-induced hypertension." Answer: 1 Cesarean birth is the greatest predictor of postpartum endometritis. The frequent cervical examinations necessary to assess for arrest of dilation are another risk factor for postpartum infection. Page 720

During the first antepartal visit, a client who is at 10 weeks' gestation learns of being HIV positive. Which client statement indicates an understanding of the plan of care both during the pregnancy and postpartally?

1. "I should not breastfeed my baby." 2. "When my baby is 2 months old, he or she will be tested for HIV." 3. "If I have a cesarean section, there is an increased risk that my HIV will be passed to my baby." 4. "I am supposed to take highly active antiretroviral therapy (HAART), but only during the first trimester." Answer: 1 HIV transmission can occur during pregnancy and through breast milk; however, it is believed that the majority of all infections occur during labor and birth. Page 286

A pregnant client who uses cocaine and ecstasy on a regular basis asks why ecstasy should not be used during pregnancy. What should the nurse explain about this drug?

1. "It produces intrauterine growth restriction and meconium aspiration." 2. "It leads to deficiencies of thiamine and folic acid, which help the baby develop." 3. "It produces babies with small heads and short bodies with brain function alterations." 4. "It can cause a high fever in you if high doses are taken and therefore cause the baby harm." Answer: 4 High body temperature is a side effect of MDMA (methylenedioxymethamphetamine: ecstasy). Increased body temperature increases fetal oxygen needs, which can lead to hypoxia and subsequent brain and major organ damage. Page Ref: 278

A postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks if there is something she can do to prevent mastitis this time. Which response by the nurse is most appropriate?

1. "Massage your breasts on a daily basis, and if you find a hardened area, massage it toward the nipple to unblock that duct." 2. "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." 3. "Apply cold packs to any areas that feel thickened or firm in order to relieve the swelling and stasis of the milk in that area." 4. "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe." Answer: 1 A hardened area could indicate a blocked duct. Massage of the blocked duct toward the nipple will help to unplug the duct and relieve stasis of the milk, thereby preventing mastitis. Page 726

A client who is at 18 weeks' gestation has been newly diagnosed with megaloblastic anemia. Which client statement indicates teaching has been effective?

1. "My body makes red blood cells that are smaller than they should be." 2. "Megaloblastic anemia is not known to cause any serious risks to my baby." 3. "Whenever possible, I should boil my vegetables in at least 2 quarts of water." 4. "I should include fresh leafy green vegetables, red meat, fish, poultry, and legumes in my diet." Answer: 4 Folic acid, which is used to treat megaloblastic anemia, is readily available in foods such as fresh leafy green vegetables, red meat, fish, poultry, and legumes. Page Ref: 276

The nurse is working with a family that just experienced the birth of their first child at 34 weeks. Which statements indicate that additional teaching is needed? Select all that apply.

1. "Our baby will be in an Isolette to keep him warm." 2. "The growth of our baby will be faster than if he were term." 3. "Breathing might be harder for our baby because he is early." 4. "Tube feedings will be required because his stomach is small." 5. "Because he came early, he will not produce urine for 2 days." Answer: 2, 4, 5 2. Preterm infants grow more slowly than do term infants. 4. Although tube feedings might be required, it would be because preterm babies lack sufficient suck and swallow reflexes to prevent aspiration. 5. Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they will make urine. Page Ref: 578

The nurse explains normal newborn behavior to new parents who are concerned about the baby's desire to be held. Which statement indicates that teaching has been effective?

1. "Some babies are easier to deal with than others." 2. "Our baby spends more time in the active alert phase." 3. "We are lucky to have a baby with a calm disposition." 4. "Cuddliness is a social behavior that some babies have." Answer: 4 Cuddliness or social behaviors refers to the newborn's need for, and response to, being held. Page Ref: 512

An infant with type O Rh-positive blood becomes visibly jaundiced at 12 hours of age. The mother with type O Rh-negative blood asks why this has occurred. How should the nurse respond?

1. "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." 2. "Your body has made antibodies against the baby's blood that are destroying her red blood cells." 3. ""The red blood cells of your baby are breaking down because you both have type O blood." 4. "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed." Answer: 2 Alloimmune hemolytic disease, also known as erythroblastosis fetalis, occurs when an Rh-negative mother is pregnant with an Rh-positive fetus and maternal antibodies cross the placenta. Maternal antibodies enter the fetal circulation, then attach to and destroy the fetal RBCs. The fetal system responds by increasing RBC production. Jaundice is the result. page 626

A client pregnant at 41 weeks asks if labor induction is necessary. Which response is best for the nurse to make?

1. "The healthcare provider wants to be proactive in preventing any problems with your baby if the baby gets any bigger." 2. "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." 3. "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." 4. "Babies can develop postmaturity syndrome, which increases their chances of having complications after birth." Answer: 4 This statement is correct. Babies older than 41 weeks' gestation are prone to developing postmaturity syndrome. Page Ref: 575

A client at 9 weeks' gestation learns about being HIV positive. Which client statement indicates teaching about the effects on the baby has been effective?

1. "The pregnancy will increase the progression of my disease and will reduce my CD4 counts." 2. "The HIV will not affect my baby, and I will have a low-risk pregnancy without additional testing." 3. "My baby will probably be born with anti-HIV antibodies, but that does not mean the baby is infected." 4. "I cannot take the medications that control HIV during my pregnancy because they will harm the baby." Answer: 3 Babies of HIV-positive women or women with AIDS are born with maternal anti-HIV antibodies. HIV infection in infants should be diagnosed using HIV virologic assays as soon as possible, with initiation of infant antiretroviral prophylaxis immediately if the test is positive. Page 281

The postpartum client presents to the maternity clinic with complaints of urinary urgency and dysuria 3 days after hospital discharge. Which statement is most important for the nurse to make?

1. "Void into this sterile cup without touching the inside of the cup." 2. "Be sure to wipe from back to front after you have a bowel movement." 3. "Call the clinic if you develop nausea and vomiting or constipation." 4. "Decrease your fluid intake for a few days, but eat a lot of vegetables." Answer: 1 A clean-catch urine sample will need to be obtained for urinalysis to determine if the client has developed a urinary tract infection. Page 725

The nurse is not familiar with the cultural background of new parents who have recently immigrated to the United States. What statement is best?

1. "You appear to be Muslim. Do you want your son to be circumcised?" 2. "Let me explain how newborn care takes place here in the United States." 3. "Your baby is a U.S. citizen. You must be very happy about that." 4. "Could you explain what your preferences are regarding child care?" Answer: 4 533

A new adolescent mother is concerned about being able to properly care for the newborn at home because her mother thinks she is too young. What should the nurse say to this client?

1. "You are very young, and parenting will be a challenge for you." 2. "Your mother was probably right. Be very careful with your baby." 3. "Mothers have instincts that kick in when they get their babies home." 4. "We can give the baby's bath together. I'll help you learn how to do it." Answer: 4 This response is best because it both teaches the new mother skills she does not have and increases her confidence. Page 556

A newly diagnosed type 1, insulin-dependent diabetic with good blood sugar control at 20 weeks' gestation asks how the diabetes will affect the baby. How should the nurse respond?

1. "Your baby may be smaller than average at birth." 2. "Your baby will probably be larger than average at birth." 3 "Your baby might have high blood sugar for several days." 4. "As long as you control your blood sugar, your baby will not be affected at all." Answer: 2 The infant of a diabetic mother produces excessive amounts of insulin in response to the high blood sugar. This hyperinsulinism stimulates growth (or macrosomia) in the infant because the infant utilizes the glucose in the bloodstream. page 268

A mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate?

1. "Your baby must be dehydrated." 2. "Bring your infant to the clinic immediately." 3. "This is due to overriding of the cranial bones during labor." 4. "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth." Answer: 4 This is a normal finding at 16 weeks. The posterior fontanelle closes within 8 to 12 weeks. Page Ref: 501

A new parent asks why the baby appears to be occasionally cross-eyed. When should the nurse instruct the parent that this finding will resolve?

1. 1 year 2. 2 weeks 3. 2 months 4. 4 months Answer: 4 The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. This will gradually regress in 3 to 4 months. Page Ref: 503

The nurse is reviewing clients scheduled for prenatal care. Which client should the nurse identify as being most likely to have a newborn at risk for mortality or morbidity?

1. 37-year-old G8 P2323, works in a chemical factory 2. 16-year-old primipara, began prenatal care at 30 weeks 3. 28-year-old G2 P1001, history of gestational diabetes 4. 23-year-old primipara, low socioeconomic status, unmarried Answer: 1 This client is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic. Page 566

An infant was born at 31 weeks' gestation and weighed 1430 g. What number of calories should this infant receive each day?

1. 72 2. 143 3. 200 4.258 Answer: 3 This is using the formula 140 kcal/g/day, which is appropriate for this infant's growth. Page 580

The nurse suspects that a newborn needs a complete neurologic examination by a healthcare provider. What finding did the nurse use to make this clinical decision? Select all that apply.

1. Absence of the plantar grasp 2. Absence of the truncal reflex 3. Presence of the stepping reflex 4. Presence of a nonnutritive sucking reflex 5. Presence of bringing the hand to the mouth Answer: 1, 2 1. Absence of the plantar grasp requires neurologic evaluation. 2. Absence of the Galant (truncal) incurvation reflex requires neurologic evaluation. Page 510

The nurse is concerned that a pregnant client is experiencing depression. Which potential health issues should the nurse include when planning care for this client? Select all that apply.

1. Alcohol use 2. Preterm birth 3. Poor appetite 4. Poor weight gain 5. Antenatal hemorrhage Answer: 2, 3, 4 2. A pregnant client with depression is at risk for preterm birth. 3. A pregnant client with depression is at risk for poor appetite. 4. A pregnant client with depression is at risk for poor weight gain. Page 279

A client who is 32 weeks pregnant is HIV positive, but asymptomatic. What would be important in managing her pregnancy and delivery?

1. An amniocentesis at 30 and 36 weeks 2. Weekly non-stress testing beginning at 32 weeks' gestation 3. Administration of intravenous antibiotics during labor and delivery 4. Application of a fetal scalp electrode as soon as her membranes rupture in labor Answer: 2 Clients who are HIV positive are considered high-risk pregnancies. Therefore, beginning at about 32 weeks, these clients have weekly non-stress tests to assess for placental function and an ultrasound every 2 to 3 weeks to assess for intrauterine growth retardation (IUGR). Page 282

At birth, an infant newborn has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best?

1. Assess blood pressure. 2. Deep suction the airways. 3. Begin chest compressions. 4. Begin bag-and-mask ventilation. Answer: 4 When an infant is not breathing and has poor muscle tone, bag-and-mask ventilation is the appropriate resuscitation measure. page 604

A 38-week newborn is small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn?

1. Assess for facial paralysis 2. Maintain a warm environment 3. Monitor for feeding difficulties 4. Monitor for signs of hyperglycemia Answer: 2 Hypothermia is a common complication of the SGA newborn; therefore, the newborn's environment must remain warm to decrease heat loss. Page 568

A student nurse is caring for a neonate undergoing intensive phototherapy. Which action indicates that the student understands how to provide care for an infant undergoing intensive phototherapy?

1. Assesses temperature every 6 hours 2. Assesses urine specific gravity with each voiding 3. Removes eye coverings to help keep the baby calm 4. Removes the infant from the Isolette for diaper changes Answer: 2 When excreted, the newborn's urine will be much darker in color/appearance because of the excreted higher conjugated bilirubin content. Darker urine can also indicate dehydration. Assessing the specific gravity will help differentiate the reason for the change in urine color. Page 628

The nurse is assisting a multiparous postpartum woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. Which is the priority nursing action?

1. Assist the client to empty her bladder. 2. Help the client back to bed to check her fundus. 3. Assess her blood pressure and pulse. 4. Begin an IV of lactated Ringer infusion. Answer: 2 Massaging the fundus is the priority because of the excessive blood loss. If the fundus is boggy, fundal massage may stimulate toning of the uterus and prevent further blood loss. Page 712

A client with type 2 diabetes mellitus delivered a fetus weighing 7 lb, 14 oz 2 hours ago. The infant's blood glucose is currently 45 mg/dL. What should the nurse do?

1. Begin an IV of 10% dextrose. 2. Document the findings in the chart. 3. Feed the baby 1 oz of formula. 4. Recheck the blood sugar in 4 hours. Answer: 2 A blood sugar of 45 mg/dL is a normal finding; documentation is an appropriate action. Page 574

The nurse is caring for an infant who delivered in a car on the way to the hospital and has developed cold stress. Which finding requires immediate intervention?

1. Blood glucose level of 45 2. Vasoconstriction and pallor 3. Room temperature IV running 4. Positioned under radiant warmer Answer: 3 IV fluids should be warmed prior to administration and wrapped in a blanket or other insulating material to keep them warm. Room temperature IV fluids will increase the cold stress. Page 623

The mother of a newborn with iron deficiency anemia asks if breastfeeding or using a formula high in iron is better for the baby. How should the nurse respond?

1. Breastfeeding, because breast milk has higher levels of iron compared to formula 2. Formula-feeding, because formula has higher levels of iron compared to breast milk 3. Breastfeeding, because although breast milk has lower levels of iron compared to formula, it is more easily absorbed by the infant 4. Formula-feeding, because although formula has lower levels of iron compared to breast milk, it is more easily absorbed by the infant Answer: 3 Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed if possible. Page 539

The nurse is assisting a new mother to breastfeed. In which order should the nurse review the steps with the mother?

1. Bring the newborn to the breast. 2. The newborn opens mouth wide. 3. Tickle the newborn's lips with the nipple. 4. Have the newborn face the mother tummy-to-tummy. 5. Position the newborn so the newborn's nose is at level of the nipple. Answer: 5, 4, 1, 3, 2 1. The newborn should then be brought to the breast. 2. The newborn then opens the mouth wide to latch on. 3. The newborn's lips should be tickled with the mother's nipple. 4. The newborn should be placed tummy-to-tummy. 5. The infant's nose should be at the level of the mother's nipple. Page Ref: 543

The nurse is making an initial assessment of a newborn. Which data would be considered normal?

1. Chest circumference 30 cm, head circumference 29 cm 2. Chest circumference 38 cm, head circumference 31.5 cm 3. Chest circumference 32.5 cm, head circumference 38 cm 4. Chest circumference 31.5 cm, head circumference 33.5 cm Answer: 4 The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Page Ref: 515

A 31-year-old woman who is at high risk for diabetes is at 18 weeks' gestation. During her first antenatal visit, which is the accurate approach to evaluate the client for diabetes?

1. Conduct screening for type 2 diabetes mellitus as soon as possible. 2. Begin serial testing of the client's serum glucose and HA1c at 24 weeks' gestation. 3. If diabetes is diagnosed, consider this condition to be gestational diabetes mellitus (GDM). 4. Recognize HA1c equal to or greater than 4.5% or a fasting plasma glucose level equal to or greater than 90 mg/dL as being diagnostic of diabetes. Answer: 1 1. Women at high risk for type 2 DM should be screened for diabetes as soon as possible. page 269

The nurse is planning to assess a newborn's neurologic status. Which behaviors should the nurse focus on during this assessment? Select all that apply.

1. Cry 2. Reflexes 3. Alertness 4. Motor activity 5. Resting posture Answer: 1, 3, 4, 5 1. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include cry. 3. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include the state of alertness. 4. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include motor activity. 5. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include resting posture. Page Ref: 508

The nurse is assessing a 36-week gestational age newborn. What assessment findings indicate that a cardiac defect is present? Select all that apply.

1. Cyanosis 2. Abdominal bruit 3. Peripheral pulses 4. Signs of heart failure 5. Presence of a heart murmur Answer: 1, 4, 5 1. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is cyanosis. 4. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is signs of heart failure. 5. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is the presence of a heart murmur. Page Ref: 604

A client at 24 weeks has a history of class II heart disease secondary to rheumatic fever. What should the nurse expect to see in the medical record?

1. Dyspnea and chest pain with mild exertion 2. Elective cesarean birth scheduled for 37 weeks 3. Discussed need for labor epidural and vacuum extraction 4. Respiratory rate 28, pulse 110, 3+ pre-tibial edema bilaterally Answer: 3 Lumbar epidural analgesia decreases the stress response during labor, while vacuum extraction or forceps decreases maternal pushing efforts. Both of these decrease stress on the heart during birth. page 286

A pregnant woman married to an intravenous drug user had a negative HIV screening test just after missing her first menstrual period. What would indicate that the client needs to be retested for HIV?

1. Elevated blood pressure and ankle edema 2. Shortness of breath and frequent urination 3. Hemoglobin of 11 g/dL and a rapid weight gain 4. Unusual fatigue and recurring Candida vaginitis Answer: 4 The client who is HIV-positive would have a suppressed immune system and would experience symptoms of fatigue and opportunistic infections such as Candida vaginitis page 282

A client in labor is demonstrating acute manifestations of schizophrenia. What should the nurse identify as a priority for this client? Select all that apply.

1. Ensuring fetal well-being 2. Ensuring maternal well-being 3. Maintaining a safe environment 4. Medicating for pain as necessary 5. Considering pharmacologic intervention Answer: 1, 2, 3, 5 1. Some women with severe psychologic disorders may have excessive symptoms during their labor and birth. Care of these women should focus on ensuring fetal well-being. 2. Some women with severe psychologic disorders may have excessive symptoms during their labor and birth. Care of these women should focus on ensuring maternal well-being. 3. Some women with severe psychologic disorders may have excessive symptoms during their labor and birth. Care of these women should focus on maintaining a safe environment. 5. Pharmacologic interventions may be necessary for excessive symptoms. Page Ref: 280

The parents of a newborn are concerned that their baby continues to lose weight despite being held and cuddled. What should the nurse instruct tell these parents? Select all that apply.

1. Excessive handling increases caloric use. 2. Permit the newborn to rest quietly when eyelids flutter. 3. Constant handling increases metabolic rate. 4. Gently flick the sole of the foot to stimulate. 5. Avoid stimulating when eye contact is absent. Answer: 1, 2, 3, 5 1. Excessive handling increases caloric use and causes fatigue, which will affect weight gain. 2. Fluttering eyelids are an indication of fatigue. When this occurs, stimulation should be stopped. 3. Excessive handling increases metabolic rate, which burns more calories. 5. A subtle cue of fatigue is the loss of eye contact. The infant should be permitted to sleep or rest. Page Ref: 530

The nurse suspects that a pregnant client is a substance user. Which approach should the nurse take during the health history?

1. Explaining how harmful drugs can be for her baby. 2. Asking the woman directly, "Do you use any street drugs?" 3. Asking the woman if she would like to talk to a counselor. 4. Asking some questions about over-the-counter medications and avoiding the mention of illicit drugs. Answer: 2 The best method of finding out if a client is using substances is to be direct and ask the question in a direct fashion without prejudice, bias, or negative body language. Lack of judgmental attitudes/body language typically results in honest answers. Page 279

During a home visit the nurse suspects that a newborn is experiencing chlamydial conjunctivitis. What did the nurse assess to make this clinical determination? Select all that apply.

1. Eyelid swelling 2. Yellow discharge 3. Eye inflammation 4. Purulent discharge 5. Corneal ulcerations Answer: 1, 2, 3 1. Manifestations of chlamydial conjunctivitis include eyelid swelling 5 to 14 days after birth. 2. Manifestations of chlamydial conjunctivitis include yellow discharge. 3. Manifestations of chlamydial conjunctivitis include eye inflammation. Page 635

What should be considered as potentially infectious when providing care to a newborn of a client who is HIV positive? Select all that apply.

1. Feces 2. Urine 3. Blood 4. Soiled linens 5. Feeding bottle Answer: 1, 2, 3, 4 1. Body fluids such as feces are considered potentially infectious. 2. Body fluids such as urine are considered potentially infectious. 3. Body fluids such as blood are considered potentially infectious. 4. Because body fluids are considered potentially infectious, soiled linens are also potentially infectious.

After completing a physical assessment the nurse determines that a laboring client is experiencing a panic attack. What findings did the nurse use to make this clinical determination? Select all that apply.

1. Flat affect 2. Monotone replies 3. Heart rate 120 bpm 4. Respiratory rate 28/minute 5. Disoriented to place and time Answer: 3, 4 3. A heart rate of 120 bpm indicates tachycardia, a manifestation of a panic attack. 4. A respiratory rate of 28/minute indicates hyperventilation, a manifestation of a panic attack. Page 280

A change in skin color requires further assessment of which physiologic functions? Select all that apply.

1. Hematocrit 2. Oxygenation 3. Glucose levels 4. Blood pressure 5. Bilirubin levels Answer: 1, 2, 3, 5 1. Changes in skin color may indicate the need for closer assessment of hematocrit. 2. Changes in skin color may indicate the need for closer assessment of cardiopulmonary status. 3. Changes in skin color may indicate the need for closer assessment of glucose. 5. Changes in skin color may indicate the need for closer assessment of bilirubin. Page 529

The nurse is caring for a newborn born to a client who abused drugs while pregnant. Which assessment findings would be common for this newborn? Select all that apply.

1. Hyperirritability 2. Transient tachypnea 3. Exaggerated reflexes 4. Decreased muscle tone 5. Depressed respiratory effort Answer 1, 2, 3 1. The newborn of a woman who abused drugs during her pregnancy is predisposed to hyperexcitability. 2. The newborn of a woman who abused drugs during her pregnancy is predisposed to transient tachypnea. 3. The newborn of a woman who abused drugs during her pregnancy is predisposed to exaggerated reflexes. 597

The nurse caring for a newborn on a ventilator for respiratory distress syndrome (RDS) informs the parents that the newborn is improving. Which of the following supports the nurse's assessment?

1. Increased PCO2 2. Increased urination 3. Decreased urine output 4. Increased pulmonary vascular resistance Answer: 2 In babies with respiratory distress syndrome (RDS) who are on ventilators, increased urination may be an early clue that the baby's condition is improving. As fluid moves out of the lungs into the bloodstream, alveoli open, and kidney perfusion increases; this results in increased voiding. Page 615

The day after a vaginal delivery, a client develops painful vesicular lesions on the perineum and vulva which are diagnosed as a primary herpes type 2 infection. What care should the newborn receive?

1. Intravenous acyclovir (Zovirax) and contact precautions 2. Cultures of blood and cerebrospinal fluid and serial chest x-rays every 12 hours 3. Parental rooming-in and four intramuscular injections of penicillin 4. Meticulous hand washing and antibiotic eye ointment administration Answer: 1 1. For a herpes type 2 infection, intravenous acyclovir (Zovirax) is indicated. Contact precautions should be implemented. Page 635

A newborn is diagnosed with sepsis. What finding should the nurse use to suspect this health problem?

1. Irritability and flushing of the skin at 8 hours of age 2. Respiratory distress syndrome developed 48 hours after birth 3. Bradycardia and tachypnea develop when the infant is 36 hours old 4. Temperature of 97.0°F 2 hours after warming the infant from 97.4°F Answer: 4 Temperature instability is often seen with sepsis. Fever is rare in a newborn. Page Ref: 638

The elderly grandmother of a newborn tells the client that rubbing alcohol should be applied to the cord stump to make it dry and fall off faster. What should the nurse instruct the client about cord care? Select all that apply.

1. Keep the umbilical cord stump clean. 2. Allow the umbilical cord stump to air dry. 43. Fold the diaper down under the cord stump. 54. Notify the healthcare provider if the cord stump appears dark in color. 35. Apply topical antibiotic ointment to the cord stump after each diaper change. Answer: 1, 2, 3 1. Keeping the umbilical stump clean reduces the chance of infection. 2. Allowing the umbilical stump to air dry reduces the chance of infection. 3. Folding the diaper down under the cord stump prevents contamination of the area. Page 530

A newborn has just been admitted to the special care nursery. What criteria should the nurse use to determine this newborn's classification and neonatal mortality risk? Select all that apply.

1. Length 2. Birth weight 3. Gestational age 4. Amount of lanugo 5. Occipital-frontal head circumference Answer: 1, 2,3, 5 1. A newborn is assigned to a category depending on length. 2. A newborn is assigned to a category depending on birth weight. 3. A newborn is assigned to a category depending on gestational age. 5. A newborn is assigned to a category depending on occipital-frontal head circumference. Page Ref: 566

The nurse is assessing newborns in the nursery. Which assessment finding places a newborn at risk for developing physiologic jaundice?

1. Molding 2. Mongolian spots 3. Cephalohematoma 4. Telangiectatic nevi Answer: 3 A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. The red blood cells present in the cephalohematoma begin to break down, which can lead to an increase in bilirubin levels in the blood. Page 501

The prenatal clinic nurse has received four phone calls. Which client should be called back first?

1. Multipara at 11 weeks with untreated hyperthyroidism describing the onset of vaginal bleeding 2. Multipara at 6 weeks with a seizure disorder inquiring what foods are good sources of folic acid 3. Primipara at 28 weeks with a history of asthma reporting difficulty breathing and shortness of breath 4. Primipara at 35 weeks with a positive hepatitis B surface antigen (HBsAG) wondering what treatment her baby will receive after birth Answer: 3 Asthma exacerbations are most common between 24 and 36 weeks. Asthma attacks can lead to maternal hypoxia, which can lead to fetal hypoxia. This client is the top priority. Page 287

During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. How should the nurse document this finding?

1. Nevus flammeus 2. Nevus vasculosus 3. A Mongolian spot 4. Telangiectatic nevi Answer: 4 Telangiectatic nevi (stork bites) are pale pink or red spots that appear on the eyelids, nose, lower occipital bone, or the nape of the neck. Page Ref: 500

The newborn of a mother with type 2 diabetes mellitus is experiencing tremors. What nursing action has the highest priority?

1. Obtain a bilirubin level. 2. Obtain a blood calcium level. 3. Measure the newborn's temperature. 4. Place a pulse oximeter on the newborn. Answer: 2 Tremors are the classic sign for hypocalcemia. Clients with diabetes who deliver newborns tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant. page 574

The nurse is assisting a mother to bottle-feed her newborn, who has been crying. What should the nurse instruct the client to do before feeding the infant?

1. Offer a pacifier. 2. Burp the newborn. 3. Unwrap the newborn. 4. Stoke Stroke the newborn's spine and feet. Answer: 2 If a newborn has been crying prior to feeding, air might have been swallowed; therefore, the newborn should be burped before feeding. Time should be taken to calm the newborn prior to feeding. Page 554

In the special care nursery, the nurse places an infant with hydrocephalus in the prone position and is careful to thoroughly cleanse the perineum after bowel movements. What was this infant most likely born with?

1. Omphalocele 2. Gastroschisis 3. Myelomeningocele 4. Diaphragmatic hernia Answer: 3 Myelomeningocele is a neural tube defect in which the meninges and spinal cord are exposed. Surgical repair is undertaken to prevent encephalitis. Meticulous cleaning of the perineum helps prevent infection. The infant is positioned prone to prevent pressure on the defect. Hydrocephalus often is present. Page 594

The nurse is caring for a newborn born to a client who experienced abruptio placentae. Which assessment findings suggest that the infant is experiencing anemia? Select all that apply.

1. Pallor 2. Tachypnea 3. Tachycardia 4. Elevated blood pressure 5. Capillary refill 6 seconds Answer: 1, 2, 3, 5 1. Pallor is a manifestation of anemia in a newborn. 2. Tachypnea is a manifestation of anemia that is compromised in a newborn. 3. Tachycardia is a manifestation of anemia in a newborn. 5. Capillary refill greater than 3 seconds is an indication of anemia in a newborn. Page Ref: 634

The mother of a 4-day-old infant is concerned that the infant's skin tone is yellow and asks if the baby should be hospitalized. What should the nurse consider as being the cause of this infant's skin color change?

1. Pathologic jaundice 2. Physiologic jaundice 3. Acute bilirubin encephalopathy 4. Hemolytic disease of the newborn Answer: 3 Acute bilirubin encephalopathy, or kernicterus, is a serious medical condition resulting from very high bilirubin levels as a result of pathologic jaundice. This is unlikely to occur with physiologic jaundice. Page 626

Place the following nursing interventions related to resuscitation in the correct order according to complexity of the method and seriousness of the infant's condition.

1. Perform chest compressions. 2. Administer epinephrine. 3. Rub the infant's back with a blanket. 4. Administer 21% oxygen in a positive-pressure ventilator. 5. Administer 100% oxygen in a positive-pressure ventilator. Answer: 3, 4, 5, 1, 2 1. Chest compressions should only be performed if the infant's heart rate is below 60 beats/min despite 30 seconds of effective positive-pressure ventilation. 2. Epinephrine should be administered when the heart rate remains below 60 beats/min despite 45 to 60 seconds of chest compressions and ventilation. 3. Rubbing the infant's back is the least invasive therapy and should be attempted before any other resuscitation method. 4. If rubbing the back does not establish adequate breathing, the infant should be placed on 21% oxygen with a positive-pressure ventilator. 5. Oxygen should be increased from 21% to 100% before chest compressions begin. Page Ref: 611

A client has delivered a small-for-gestational-age (SGA) infant. What long-term effect should the nurse recognize that this infant is at risk for experiencing?

1. Permanent disfiguration 2. Paralysis below the hips 3. Poor fine motor coordination 4. Thin and underweight as a child to overweight or obese as an adolescent Answer: 3 SGA infants are likely to develop cognitive disabilities such as poor fine motor coordination, hyperactivity, learning disabilities, and hearing loss. Page 568

The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. How should the nurse interpret this finding?

1. Prematurity 2. Facial paralysis 3. A normal position 4. A possible chromosomal abnormality Answer: 3 The top of the ear (pinna) should be parallel to the outer and inner canthus of the eye in the normal newborn. Page 504

A 2-hour-old newborn delivered by cesarean section at 38 weeks with clear amniotic fluid has a respiratory rate of 80 with grunting and nasal flaring. The mother experienced preeclampsia while pregnant. What is the most likely cause of this infant's condition?

1. Prematurity of the neonate 2. Respiratory distress syndrome 3. Meconium aspiration syndrome 4. Transient tachypnea of the newborn Answer: 4 The infant is term and born by cesarean section. The baby is most likely experiencing transient tachypnea of the newborn. Page Ref: 616

Which information is least likely recorded as a part of the initial newborn assessment?

1. Presence or absence of meconium-stained fluid 2. Blood draw for phenylketonuria (PKU) screening 3. Resuscitative measures required in the birthing area 4. Parents' desires regarding circumcision for a male infant Answer: 2 Blood is often drawn for laboratory testing, which should be recorded. However, blood draws for PKU screening must occur more than 24 hours after birth. Page 525

During a postpartum home visit the nurse reinforces the importance of holding the infant and having tummy time periodically through the day with the new mother. What did the nurse observe that indicated the mother needed additional teaching? Select all that apply.

1. Rapid respiratory rate 2. Weak gross motor skills 3. Crusted nasal secretions 4. Positional plagiocephaly 5. Sluggish upper body strength Answer: 2, 4, 5 2. Tummy time enhances gross motor skills. 4. Positional plagiocephaly, or flat head syndrome, occurs when the infant spends too much time in the supine position. The infant needs to be held or placed for tummy time more often. 5. Tummy time enhances upper body strength. Page Ref: 559

The nurse is concerned that a new mother is going to have difficulty caring for her newborn once the baby is discharged from the neonatal intensive care unit. What client behaviors are consistent with nonadaptive responses? Select all that apply.

1. Refusing to touch the infant 2. Grimacing when holding the infant 3. Expressing fear of taking the infant home 4. Asking staff questions about the infant's care 5. Blaming spouse for the infant's health problems Answer: 1, 2, 3, 5 1. Nonadaptive responses include a lack of interaction with the infant during hospitalization. 2. Nonadaptive responses include a negative view of the infant. 3. Nonadaptive responses include a fear of going home with the infant. 5. Nonadaptive responses include blaming others for the infant's condition. Page Ref: 640

The nurse assesses a sleeping 1-hour-old, 39-weeks' gestation newborn. Which data should cause the nurse the most concern?

1. Respirations 68/min 2. Blood pressure 72/44 mmHg 3. Skin temperature 97.6°F 4. Heart rate 156 beats/min Answer: 1 Normal respiratory rate is 30 to 60 breaths/min. Respirations of 68/min could represent a less-than-expected transition. Page 526

A pregnant client is diagnosed with a cardiac problem. What should the nurse prepare to instruct this client to do, to ensure a safe pregnancy? Select all that apply.

1. Restrict activities. 2. Follow a diet high in iron and protein. 3. Restrict the intake of sodium. 4. Obtain 8 to 10 hours of sleep. 5. Obtain pneumococcal vaccination. Answer: 1, 2, 3, 4 1. To help preserve her cardiac reserves, the woman may need to restrict her activities. 2. For the pregnant client with cardiac problems, the client should be instructed in the importance of a diet high in iron and protein. 3. For the pregnant client with cardiac problems, the client should be instructed in the importance of a diet low in sodium. 4. For the pregnant client with cardiac problems, 8 to 10 hours of sleep are essential. page 286

The nursing instructor is demonstrating a newborn assessment using the Ballard gestational assessment tool. Which assessment should be performed after the first hour of birth?

1. Scarf sign 2. Arm recoil 3. Popliteal angle 4. Square window sign Answer: 2 Recoil time is slower in fatigued newborns. Therefore, arm recoil is best elicited after the first hour of birth so the newborn can recover from the stress of birth. Page 494

The nurse notes that a newborn has tremor-like movements. For which health problems should this newborn be further assessed? Select all that apply.

1. Seizures 2. Bilirubinemia 3. Hypocalcemia 4. Hypoglycemia 5. Substance withdrawal Answer: 1, 3, 4, 5 1. Tremors or tremor-like movements must be evaluated to differentiate the tremors from seizures. 3. Tremors may be related to hypocalcemia. 4. Tremors may be related to hypoglycemia. 5. Tremors may be related to substance withdrawal. Page Ref: 510

A woman at 30 weeks' gestation and a history of sickle cell anemia is experiencing fever, chills, and diarrhea for 3 days. What are the most serious potential complications that this client faces?

1. Severe lethargy 2. Sickle cell crisis 3. Electrolyte imbalance 4. Fetal neural tube defects Answer: 2 Dehydration and fever can trigger sickling and crisis; for this reason, maternal infections are treated promptly. page 276

Before the nurse begins to dry the newborn off after birth, which assessment finding should be documented to ensure an accurate gestational rating on the Ballard gestational assessment tool?

1. Size of the areolae 2. Creases on the sole 3. Body surface temperature 4. Amount and area of vernix coverage Answer: 4 Drying the baby after birth will disturb the vernix and potentially alter the score when using the Ballard gestational assessment tool. The nurse first should document the amount and coverage of the vernix before drying the newborn. Page Ref: 490

A newborn delivered via cesarean birth at 32 weeks to a mother who experienced placenta previa has a low pulse rate, low blood pressure, and a capillary filling time of 3.6 seconds. Which interventions are indicated for the care of this newborn? Select all that apply.

1. Start the infant on phototherapy. 2. Start the infant on iron supplements. 3. Have isotonic saline ready for transfusion. 4. Draw several vials of blood for laboratory testing. 5. Monitor the infant's cardiac and respiratory status. 6. Have O-negative packed red cells ready for a transfusion. Answer: 2, 5, 6 2. Iron supplements should be given to help increase red blood cell production. 5. This is an appropriate nursing intervention. Monitoring the infant's cardiac and respiratory status will allow the nurse to detect symptoms of shock and assess the effectiveness of treatment. 6. Clients with severe anemia will need a blood transfusion. If the infant's blood type is not known, O-negative packed red cells can be used for transfusions. If the infant's blood type is known, the appropriate typed and cross-matched packed red cells should be used. Page Ref: 634

The nurse is assessing a newborn's musculoskeletal status. How should the nurse assess for clubfoot?

1. Stimulate the sole of the foot 2. Adduct the foot and listen for a click 3. Extend the foot and observe for pain 4. Move the foot to midline and determine resistance Answer: 4 Clubfoot is suspected when the foot will not turn to a midline position or align readily. Page Ref: 508

A newborn is demonstrating signs of needing comfort and security. What should the nurse instruct the parents about swaddling this infant? Select all that apply.

1. Swaddling should be loose. 2. Swaddling should be done with the arms at the sides. 3. Swaddling helps the newborn control body movements. 4. Swaddling should permit the newborn access to the mouth. 5. Swaddling should be tightly bound around the infant's torso. Answer: 1, 3, 4 1. Swaddling newborns is a way to provide comfort and security. Blanket swaddling should be loose.. 3. Swaddling newborns is a way to provide comfort and security. Swaddling helps the newborn control body movements. 4. Swaddling newborns is a way to provide comfort and security. Blanket swaddling allows the infant easy hand to mouth access to promote self-soothing abilities. Page 512

A newborn is diagnosed with tetralogy of Fallot. What findings indicate that this client is experiencing heart failure? Select all that apply.

1. Tachypnea 2. Diaphoresis 3. Tachycardia 4. Hepatomegaly 5. Splenomegaly Answer: 1, 2, 3, 4 1. Manifestations of heart failure in a newborn include tachypnea. 2. Manifestations of heart failure in a newborn include diaphoresis. 3. Manifestations of heart failure in a newborn include tachycardia. 4.Manifestations of heart failure in a newborn include hepatomegaly.

The nurse attempts to take the vital sign of the newborn, but the newborn is crying. What intervention would be appropriate?

1. Taking the vital signs 2. Waiting until the newborn stops crying 3. Placing a gloved finger in the newborn's mouth 4. Swaddling the newborn with several warm blankets in an attempt to calm the newborn Answer: 3 To soothe a newborn during assessment or other procedures, place a gloved finger into the newborn's mouth. Page 505

The nurse receives shift change reports on infants born within the last 4 hours. Which newborn should the nurse see first?

1. Term male, grunting respirations 2. 37-week male, respiratory rate 45 3. 8 lb, 1 oz female, pulse 150 4. 39-week female, temperature 97°F Answer: 1 Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly intervention immediately. Page 528

While eliciting the Moro reflex in a newborn, the nurse notes that only the right arm moves. What should the nurse immediately assess based upon this finding?

1. The clavicle 2. Babinski reflex 3. The rooting reflex 4. Ortolani maneuver Answer: 1 When the Moro reflex is elicited, the newborn will straighten both arms and hands outward while the knees are flexed, then slowly return the arms to the chest, as in an embrace. If this response is not elicited, the nurse will assess the clavicle. If the clavicle is fractured, the response will be demonstrated on the unaffected side only. Page 505

A new mother is concerned because the anterior fontanelle swells when the newborn cries. What normal findings should the nurse include when teaching the new mother about this concern? Select all that apply

1. The fontanelles might bulge. 2. The fontanelles might be depressed. 3. The fontanelles can swell with crying. 4. The fontanelles can pulsate with the heartbeat. 5. The fontanelles can swell when stool is passed. Answer: 3, 4, 5 3. Newborn fontanelles can swell when the newborn cries. 4. Newborn fontanelles can pulsate with the heartbeat. 5. Newborn fontanelles can swell when the newborn passes a stool. Page Ref: 501

The nurse notes the presence of a cephalohematoma on the head of a newborn. What did the nurse use to make this clinical determination? Select all that apply.

1. The head appears asymmetric. 2. The mass overrides the suture line. 3. The mass appears only on one side of the head. 4. The mass appeared on the second day after birth. 5. The mass appears larger when the newborn cries. Answer: 3, 4 3. Cephalohematomas can be unilateral or bilateral. 4. A cephalohematoma can appear between the first and second day after birth. Page 501

A client who delivered a day ago has chosen to breastfeed her infant. Which observation best indicates that the client understands breastfeeding?

1. The infant is crying when brought to the breast. 2. The client takes off her gown to achieve skin-to-skin contact. 3. The infant is held so that the nipple is accessed by turning the head. 4. The client puts the infant to breast when the baby is asleep to help wake the baby up. Answer: 2 Skin-to-skin contact creates tactile sensations that increase the sucking of newborns. Page 539

The nurse is assessing a 2-day-old male infant that has been circumcised. Which finding requires immediate intervention?

1. The umbilical cord clamp has been removed. 2. The mother is ready to breastfeed on demand. 3. The infant maintains temperature when wrapped in a blanket. 4. The infant has had a dry diaper since the circumcision procedure. Answer: 4 If the infant has not voided since the circumcision procedure, further assessment should be done to determine if a penile injury and/or edema is preventing urinary flow. Page Ref: 532

Which method of initial assessment would best indicate whether a postpartum client is experiencing a urinary complication?

1. Urine pH 2. Calculation of urine output 3. Urine specific gravity 4. Calculation of intake Answer: 2 Calculation of output would provide a better assessment of complete emptying of the bladder, because overdistention can cause trauma to the bladder, displace the uterus, and cause infection. Page 711

The nurse notes that a newborn has a dry scalp. What should the nurse include when teaching the parents about the care of this newborn? Select all that apply.

1. Use mild soap. 2. Use baby shampoo. 3. Wash the scalp daily. 4. Apply oil every other day. 5. Rinse the scalp with hot water. Answer: 1, 2, 3 1. For scalp care the nurse should instruct the parents to shampoo the scalp with mild soap. 2. For scalp care the nurse should instruct the parents to shampoo the scalp with baby shampoo. 3. For scalp care the nurse should instruct the parents to shampoo the scalp and anterior fontanel areas daily. Page 514

The client with insulin-dependent type 2 diabetes and an HbA1c of 5% is planning to become pregnant soon. What anticipatory guidance should the nurse provide this client?

1. Vascular disease that accompanies diabetes slows progression. 2. The risk of ketoacidosis decreases during the length of the pregnancy. 3. The baby is likely to have a congenital abnormality because of the diabetes. 4. Insulin needs decrease in the first trimester and increase during the third trimester. Answer: 4 In addition, insulin requirements drop suddenly after delivery of the placenta. Page Ref: 267

The mother of a severely premature infant is being prepared to see her baby for the first time. The infant has an IV and a feeding tube, is receiving phototherapy, and is being monitored for cardiac and respiratory functioning. What information would be the least supportive for the mother at this time?

1. Wash hands before holding the infant. 2. The infant has tubes and monitoring equipment in place. 3. The appearance of the different machines and tubes attached to the infant. 4. Avoid touching the infant because the baby's skin is fragile and could be easily hurt. Answer: 4 Physical contact between the mother and infant will facilitate bonding and should be encouraged. Page Ref: 641

The nurse is caring for an infant with abdominal contents protruding at the location of the umbilicus. What statement differentiates between omphalocele and gastroschisis?

1. With omphalocele, the abdominal contents are not covered with a sac; with gastroschisis, the abdominal contents are covered by a sac. 2. With omphalocele, the abdominal contents are covered with a sac; with gastroschisis, the abdominal contents are not covered by a sac. 3. With omphalocele, the abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord. 4. With omphalocele, the abdominal contents protrude to the right of an intact umbilical cord; with gastroschisis, the abdominal contents protrude into the base of the umbilical cord. Answer: 3 This is the correct way to differentiate between omphalocele and gastroschisis. Page Ref: 592-593

Which actions must a nurse perform before weighing the newborn during the admission procedure? Select all that apply.

1. Zero the scale. 2. Clean the scale. 3. Cover the scale. 4. Take the infant's temperature. 5. Wrap the infant tightly in a blanket to prevent heat loss. Answer: 1, 2, 3 1. This action should be performed to ensure an accurate measurement. 2. This action should be performed to prevent cross infection. 3. This action should be performed to prevent cross infection. Page 526

A pregnant client at 23 weeks' gestation has a hemoglobin of 9.5. Which diet choice indicates that teaching has been effective?

indicates that teaching has been effective? 1. Broiled fish, lettuce salad, grapefruit half, carrot sticks 2. Pork chop, mashed potatoes and gravy, cauliflower, tea 3. Roast beef, steamed spinach, tomato soup, orange juice 4. Tofu with mixed vegetables in curry, milk, whole-wheat bun Answer: 3 This client is anemic and needs iron. This meal contains iron in the beef, folic acid in the spinach, and vitamin C in the tomato soup and orange juice. Vitamin C helps absorption of the iron; folic acid is needed for production of red cells. page 276

A client is identified as having hepatitis B surface antigen (HBsAG) early in her pregnancy. Which client statement about the labor and birth process and having hepatitis B infection indicates the need for additional teaching?

indicates the need for additional teaching? 1. "Breastfeeding is a good feeding method for my baby." 2. "My baby will get a bath as soon as its temperature is stable." 3. "An internal fetal monitor will be applied as soon as possible during labor." 4. "Two shots will be given to my baby to prevent transmission of hepatitis B." Answer: 3 An internal fetal monitor will be avoided. Page 288

A client is experiencing excessive bleeding immediately after the birth of her newborn. After increasing the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse anticipates which prescriptions from the healthcare provider? Select all that apply.

that apply. 1. methylergonovine maleate (Methergine) 2. butorphanol tartrate (Stadol) 3. misoprostol (Cytotec) 4. betamethasone (Diprolene) 5. fentanyl (Duragesic) Answer: 1, 3 1. Methylergonovine maleate is a drug of choice for postpartum hemorrhage. 3.Misoprostol is commonly administered rectally for postpartum hemorrhage. page 714