ped

A nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of:

7.5

A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)?

Gravida I who has had an intrauterine fetal death -Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and high birthweight are not risk factors for DIC.

Shortly after birth a newborn is found to have Erb's palsy. What condition does the nurse suspect caused this problem? Disorder acquired in utero X-linked inheritance pattern Tumor arising from muscle tissue Injury to brachial plexus during birth

Injury to brachial plexus during birth Rationale Erb's palsy is caused by forces that alter the alignment of the arm, shoulder, and neck; stretching or pulling away of the shoulder from the head during birth damages the brachial plexus. Erb's palsy is not acquired in utero. Erb's palsy is not caused by an X-linked inherited disease. Erb's palsy is not caused by a tumor.

PKU

PKU testing is done to detect the level of phenylalanine in the infant's blood. Most states require a PKU screening test for all newborns.

Placenta previa

When the placenta covers the opening in the mother's cervix. placenta comes before the baby

hematoma

a solid swelling of clotted blood within the tissues.

A client at 35 weeks' gestation asks a nurse why her breathing has become more difficult. How should the nurse respond?

"Your diaphragm has been displaced upward."

After treatment for a bladder Infection; a client asks whether there is anything she can do to prevent cystitis in the future. What is the best response by the nurse?

-Increase daily fluid consumption. Increasing fluid intake flushes the urinary tract of microorganisms. Tampons do not increase the risk of cystitis. Fluids should be increased, not decreased; prune juice promotes acidic urine, which is desirable because it discourages the growth of microorganisms. The preferred method of cleansing is from front to back (urethra to vagina); however, studies have shown that this method of cleansing is not a significant factor in the prevention of cystitis.

The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies of: Early rooming-in Taking-in behaviors Taking-hold behaviors Parent-child attachment

4. Parent-child attachment Rationale There is a sensitive period in the first minutes or hours after birth during which it is important for later interpersonal development that the parents have close contact with their newborn. Rooming-in may not be instituted immediately after birth. Taking-in is a maternal psychological behavior described by Reva Rubin that occurs during the first 2 postpartum days. Taking-hold is a maternal psychological behavior described by Rubin that occurs after the third postpartum day.

A client at 32 weeks' gestation is admitted in active labor. Her cervix is effaced and dilated 4 cm. Intramuscular betamethasone (Celestone) 12 mg is prescribed. What should the nurse tell the client about why the medication is being given? <p>A client at 32 weeks' gestation is admitted in active labor. Her cervix is effaced and dilated 4 cm. Intramuscular betamethasone (Celestone) 12 mg is prescribed. What should the nurse tell the client about why the medication is being given?</p> Cervical dilation is increased. Fetal lung maturity is accelerated. The risk of a precipitous birth is reduced. The potential for maternal hypertension is minimized.

Fetal lung maturity is accelerated. -A steroid such as betamethasone (Celestone) or dexamethasone (Decadron) administered to the mother crosses the placenta and promotes lung maturity in the fetus.

Which statement is true regarding caput succedaneum in newborns? It is swelling consisting of serum, blood, or both. It increases in size on the second and third day after birth. It is a collection of blood between the bone and its periosteum. It is mostly associated with vacuum extraction and forceps delivery.

It is swelling consisting of serum, blood, or both.

A nurse notes that a healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. Which reflex does the nurse identify

TONIC NECK

A nurse suspects that a newborn's mother had rubella during the first trimester of pregnancy. Which newborn problems support this assumption? Select all that apply.

deafness, cardiac anomalies

While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond? "Flat feet are more common in children than adults." "That's hard to assess because the feet are so small." "There may be a bone defect that needs further assessment." "Infants' feet appear flat because the arch is covered with a fat pad."

"Infants' feet appear flat because the arch is covered with a fat pad." Rationale A fat pad covers the arch in newborns and infants; the arch develops when the child begins to walk. Flat feet are no more common in children than in adults. The size of the feet is not relevant; arch development is related to walking. Flat feet are not associated with deformities of the bones

What should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder? 1. Maintaining sterility of the exposed bladder 2. Measuring output from the exposed bladder 3. Protecting the skin surrounding the exposed bladder 4. Applying a pressure dressing to the exposed bladder

3. Protecting the skin surrounding the exposed bladder Rationale Constant drainage of urine on the skin promotes excoriation and Infection; so the skin must be protected. Sterility is impossible to maintain because of the leakage of urine. Output will be difficult to measure because of the constant leakage of urine. A pressure dressing is contraindicated because it will traumatize the exposed bladder.

A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse tell the parents this response represents? 1. A reflex that is expected in the healthy newborn 2. A reflex that remains for the newborn's first year 3. An autonomic reflex indicating that the newborn is hungry 4. An autonomic reflex indicating the newborn's basic insecurity (Nugent 326) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.

A reflex that is expected in the healthy newborn...This is the Moro reflex , which indicates an intact nervous system. The Moro reflex continues as long as the third to sixth month of life; if it persists there may be a neurological disturbance. This reflex has no relationship to hunger; it is an involuntary response to environmental stimuli.

A nurse is assessing a newborn. Which sign should the nurse report? Temperature of 97.7° F (36.5° C) Pale-pink to rust-colored stain in the diaper Heart rate that decreases to 115 beats/min Breathing pattern with recurrent sternal retractions

Breathing pattern with recurrent sternal retractions Rationale This infant's breathing pattern is indicative of respiratory distress ; the expected pattern is abdominal with synchronous chest movement. A temperature of 97.7° F (36.5° C) is within the expected range of 97.6° F (36.4° C) to 99° F (37.2° C) for a newborn. Pale-pink to rust-colored staining in the diaper is caused by uric acid crystals from the immature kidneys; it is a common occurrence. A decrease in heart rate to 115 beats/min is within the expected range of 110 to 160 beats/min for a newborn.

An infant is born in the breech position and diagnosed with Erb palsy (Erb-Duchenne paralysis). What clinical manifestation supports this conclusion? Inability to turn the head to the unaffected side Absence of the grasp reflex on the affected side Absence of the Moro reflex on the unaffected side Flaccid arm with the elbow extended on the affected side

Flaccid arm with the elbow extended on the affected side Rationale With Erb-Duchenne paralysis there is damage to spinal nerves C5 and C6, which causes paralysis of the arm. The grasp reflex is intact because the fingers usually are not affected; if C8 is injured, paralysis of the hand results (Klumpke paralysis). There would be an absence of the Moro reflex only on the affected side. There is no interference with head turning; usually injury results from excessive lateral flexion of the head as the shoulder is born.

A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose mother: <p>A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose mother:</p> Has type 1 diabetes Has been hypertensive during pregnancy Was preeclamptic during the labor and birth Was a previous abuser of heroin and other opioids

Has type 1 diabetes Rationale Infants of diabetic mothers are at risk for respiratory distress syndrome as a result of delayed synthesis of surfactant caused by a high serum level of insulin. The infant of a mother with hypertension may be small for gestational age but not necessarily preterm and at risk for RDS. Preeclampsia does not predispose the full-term newborn to the development of RDS. The mother's use of heroin or other opioids does not necessarily predispose the newborn to RDS.

A nurse is caring for the newborn of a drug-addicted mother with suspected cytomegalovirus disease. What does the nurse suspect was the cause of the disease? Handling a cat litter box Drinking contaminated water Having sex with many partners Eating inadequately cooked meat

Having sex with many partners Rationale Cytomegalovirus has been recovered from semen, vaginal secretions, urine, feces, and blood; it is commonly found in clients who are HIV positive. Drug use can decrease sexual inhibitions and judgment. Toxoplasmosis can be contracted from contaminated cat litter. Contaminated water is associated with hepatitis type A. Toxoplasmosis can be contracted from inadequately cooked meat.

A newborn who has remained in the hospital because the mother had a cesarean birth is to be tested for phenylketonuria (PKU) on the morning of discharge. What should the nurse explain to the mother about the purpose of PKU testing? It detects thyroid deficiency. It reveals possible brain damage. It is used to measure protein metabolism. It identifies chromosomal damage.

It is used to measure protein metabolism. Rationale Phenylalanine, an essential amino acid necessary for growth and Development; cannot be metabolized by infants with PKU; early diagnosis and treatment may prevent mental retardation. Tests for thyroid deficiency are done at the same time as PKU testing, but there is no relationship between thyroid deficiency and PKU. Recognition and treatment of PKU early in life can help prevent, not detect, brain damage. Chromosomal damage cannot be detected with a PKU test.

A parent of a preterm infant in the neonatal intensive care unit, asks a nurse why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they: Perspire excessively, causing a constant loss of body heat Have a smaller body surface area than full-term newborns Lack the subcutaneous fat that usually provides insulation Have a limited ability to produce antibodies against infections

Lack the subcutaneous fat that usually provides insulation Much of a full-term infant's birth weight (almost a third) is gained during the last month of gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves as insulation; the preterm infant did not have enough time to grow in the uterus and therefore has little of this insulating layer. Preterm infants do not shiver or sweat. The preterm infant has a relatively larger surface area per body weight than does a term infant. Depressed antibody production is unrelated to maintenance of body temperature.

What does the nursing care for an infant with necrotizing enterocolitis (NEC) include? Diluting the formula mixture Measuring abdominal girth every 2 hours Giving half-strength formula by gavage feeding Administering oxygen 10 minutes before each feeding

Measuring abdominal girth every 2 hours Rationale Prolonged gastric emptying occurs with NEC; an increase in abdominal girth of greater than 1 cm in 4 hours is significant and requires immediate intervention. Formula feedings are stopped and the infant is given parenteral therapy. Administering oxygen 10 minutes before each feeding will have no therapeutic value for an infant with NEC.

What should the nurse tell a new mother will be delayed until her newborn is 36 to 48 hours old? Vitamin K injection Test for blood glucose level Screening for phenylketonuria Test for necrotizing enterocolitis

Screening for phenylketonuria Rationale In 36 to 48 hours the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of a specific liver enzyme, can result in excessive levels of phenylalanine in the bloodstream and brain, resulting in cognitive impairment; early detection is essential to prevent this. The infant will have a vitamin K injection soon after birth to prevent bleeding problems. Blood is withdrawn from the heel soon after birth to test for hypoglycemia. Necrotizing enterocolitis is a disorder that can affect preterm infants. It is not identified with the use of a test.

A male born at 28 weeks' gestation weighs 2 lb 12 oz. What characteristic does the nurse expect to observe? Staring eyes Absence of lanugo Descended testicles Transparent red skin

Transparent red skin is expected because of the absence of subcutaneous fat tissue. Preterm infants born nearer to term have open, staring eyes. Preterm infants generally are born with large amounts of lanugo, which begins to thin just before term and by 40 weeks is found only on the shoulders, back, and upper arms. The preterm infant's scrotum is small and the testicles usually are high in the inguinal canal.

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent? Radiation Convection Conduction Evaporation

4 Evaporative heat loss is a result of the conversion of moisture into vapor, which is avoided when the newborn is dried.

What characteristic does the nurse anticipate in an infant born at 32 weeks' gestation? Barely visible areolae and nipples Ear pinnae that spring back when folded Definite creases of the infant's palms and soles A zero-degree angle on the square window sign

Rationale Breast tissue is not palpable in a newborn of less than 33 weeks' gestation. The ear pinnae spring back in an infant at 36 weeks' gestation. Creases of the palms and soles are not clearly defined until after the 37th week of gestation. A zero-degree square window sign is present in an infant at 40 to 42 weeks' gestation.

While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond? 1 "Take another look. They seem fine to me." 2 "It's all right. Most babies have crossed eyes." 3 "This is expected. Your baby is trying to focus." 4 "You're right. I'll contact your health care provider."

3 "This is expected. Your baby is trying to focus." Newborns' eye movements are uncoordinated, and the eyes may appear crossed as they try to focus. As the eye muscles mature, the apparent strabismus disappears. Stating that the baby's eyes seem fine discounts the mother's concern and is demeaning. Although it is true that the baby's eyes are crossed, the mother should be given an explanation for the apparent strabismus. Telling the mother that she is right and that the health care provider must be contacted is misinformation that will increase the mother's anxiety.

A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus? Contact precautions are necessary. It occurs during sexual intercourse. It can be acquired during a vaginal birth. Protection is provided by way of maternal immunity.

3. It can be acquired during a vaginal birth. Rationale Herpes virus infection can be fatal to a newborn, and the infant should be admitted to the neonatal intensive care unit. Although contact precautions are necessary, herpes infection can occur during sexual intercourse, and protection is conferred on the fetus by the mother, these statements are not relevant in meeting the needs of this neonate who has been exposed to herpes virus during the birthing process.

The nurse observes several dark round areas on a newborn's buttocks on a dark-skinned neonate. How should this observation be documented? Stork bites Forceps marks Mongolian spots Ecchymotic areas

3. Mongolian Spots Mongolian spots are bluish-black areas of pigmentation commonly found on the back and buttocks of dark-skinned newborns; they are benign and fade gradually over time. Stork bites are short red marks commonly found near the base of the neck of the newborn. Forceps marks are red and have a distinctive imprint on the face and head matching the configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the extravasation of blood into subcutaneous tissue.

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

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

A mother is breastfeeding her newborn. She asks when she may switch the baby to a cup. The nurse concludes that the mother understands the teaching about feeding when she says she will start to introduce a cup after the baby reaches: 4 months 6 months 12 months 16 months

6 months Rationale: Around 6 months of age infants are able to swallow independently of sucking, and a cup may be introduced. Introducing a cup at 4 months is inappropriate because the infant does not have the ability to swallow independently of sucking at this age. Between 9 and 12 months of age, infants can swallow four or five times consecutively and hold and carry a cup to the mouth; introduction of a cup at the age 6 of months makes weaning easier at 9 to 12 months of age. Sixteen months is too late to introduce a cup; by this time the child has teeth and sucking on a bottle will promote the development of caries, as well as a preference for milk over solid foods.

A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy? 1 Stimulates the liver to dispose of the bilirubin 2 Breaks down the bilirubin into a conjugated form 3 Facilitates the excretion of bilirubin by activating vitamin K 4 Dissolves the bilirubin, allowing it to be excreted by the skin

Breaks down the bilirubin into a conjugated form Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces. Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by way of the skin.

The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother (IDM) is by performing a heel stick blood test on the newborn. What does this test determine? a-Blood acidity b-Glucose tolerance c-Serum glucose level d-Glycosylated hemoglobin level

C) Serum glucose level Obtaining a blood glucose level is a simple, cost-effective method of testing newborns for suspected hypoglycemia. Although the acidity of the blood will indicate whether the newborn has metabolic acidosis as a result of hypoglycemia, it is more important to determine whether the newborn has hypoglycemia so it can be corrected before acidosis develops. The glucose tolerance test and glycosylated hemoglobin level test are not used in newborns.

Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed because the mother does not have an infection. The nurse explains that it protects the newborn from: Chlamydia and gonorrhea Syphilis and toxoplasmosis Rubella and retrolental fibroplasia Cytomegalovirus and varicella zoster

Chlamydia and gonorrhea Rationale The antibiotic ointment is administered prophylactically to prevent the development of ophthalmia neonatorum, which may be contracted during a vaginal birth to a mother with gonorrhea, chlamydia, or both infections. Syphilis and toxoplasmosis are contracted by the fetus in utero, not during birth Rubella is contracted by the fetus in utero. The term "retrolental fibroplasia" has been replaced by the term "retinopathy of prematurity." It is a complex disorder that affects the retinal vessels of preterm infants, causing blindness. Cytomegalovirus and varicella zoster are contracted by the fetus in utero during various stages of pregnancy, not during birth.

A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. What test result should the nurse anticipate for this infant? Increased Po 2 Lowered HCO 3 Decreased Pco 2 Decreased blood pH

Decreased blood pH Rationale In addition to increased Pco 2, hypoxia from inadequate oxygen/carbon dioxide exchange leads to anaerobic metabolism with an accumulation of acid by-products; both lower blood pH. Po 2 is decreased because inadequate lung surface area is available for diffusion of gases. Acidosis, not alkalosis, is present; bicarbonate will be normal or increased in the body's attempt to compensate. Pco 2 increases because inadequate lung surface area is available for the diffusion of gases.

After a spontaneous vaginal delivery the client expresses concern because the newborn has a red rash with small papules on the face, chest, and back. What condition does the nurse recognize? Harlequin sign Vernix caseosa Nevus flammeous Erythema toxicum

Erythema toxicum Erythema toxicum is a benign, generalized, transient rash that is a reaction to the new environment in which a neonate finds itself. It disappears after short time after birth. It is not the harlequin sign, which is dilation of blood vessels on one side of the body with red on one side, and white skin on the other. It is not vernix caseosa, which is a thick, white, greasy substance that protects the skin in utero. It is not nevus flammeous, or portwine stain, a reddish-purple capillary angioma below the dermis.

A newborn experiences a hypothermic period while being bathed and having clothing changed. Once the hypothermic episode has been identified and treated, what is the next nursing action? Feeding the infant Requesting a complete blood count Monitoring the infant for hyperthermia Allowing the infant to rest undisturbed

Feeding the infant Rationale: A newborn who experiences a hypothermic episode responds by becoming hypoglycemic; providing calories will increase the blood glucose level. If the hypothermic period is treated adequately, hyperthermia is not expected to develop. The blood count will not change during a transient hypothermic episode. Allowing the infant to rest undisturbed will result in a delay in meeting the newborn's need for an increase in blood glucose.

A neonate has phenylketonuria (PKU). What information should the nurse include in a discussion with the parents when explaining what caused their infant's problem? Failure to pass meconium Inborn error of metabolism Severe eczematous skin rash Presence of an extra chromosome

Inborn error of metabolism Rationale A heel stick to draw blood to screen for inborn errors of metabolism, such as PKU, is required in most states in the United States; because affected newborns appear healthy at birth, this test is performed after several days of milk ingestion. The test is necessary for the early detection of PKU so that it can be treated before brain damage occurs. Meconium ileus may occur if the newborn has cystic fibrosis, an intestinal obstruction, or an imperforate anus. A skin rash is not a sign of PKU. Trisomy is a chromosomal anomaly, the most common of which results in Down syndrome.

While showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection because: Wharton jelly is no longer present It contains exposed tissue and blood It is touched by diapers, blankets and clothing Newborns do not have immunity to cord infections

It contains exposed tissue and blood Rationale Exposed tissue and blood in an area that is moist, warm, and dark make an excellent culture medium, so it is important to keep the umbilical area clean and dry. Wharton jelly is present and provides a protective barrier. The diaper is kept below the level of the umbilicus. Although the site may be touched by clothing, this usually is not a source of bacterial infection. Newborns do have resistance to infections because they carry antibodies from the mother.

What does the nurse expect the size of a newborn to be if the mother had inadequately controlled type 1 diabetes during her pregnancy? Average for gestational age, term Small for gestational age, preterm Large for gestational age, postterm Large for gestational age, near term

Large for gestational age, near term Newborns of diabetic mothers may be large for gestational age because hyperglycemia in the mother precipitates hyperinsulinism in the fetus, resulting in excess deposits of fetal fat; these infants are usually born at or before term and are large, not average or small, for gestational age. Diabetic mothers with advanced vascular and renal disease may give birth to infants who are small for gestational age. Because of the risk for fetal death, women with diabetes should give birth before the 40th week of gestation, either by way of induction of labor or, if necessary, by cesarean birth.

The nurse is reassessing a newborn who had an axillary temperature of 97° F (36° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next? Placing the newborn under a radiant warmer in the nursery Checking the newborn for a wet diaper and then continue the skin-to-skin contact Leaving the newborn in skin-to-skin contact and rechecking the temperature in 1 hour Double-wrapping the newborn in warm blankets and returning the newborn to a crib by the mother's bedside

Placing the newborn under a radiant warmer in the nursery Rationale The newborn's temperature should be kept in the normal range of 97.7° F to 99.5° F (36.5° C to 37.5° C ). A hypothermic temperature that has not improved in an hour with the use of skin-to-skin contact requires additional measures. The infant should be placed under a radiant warmer for a short time until the temperature returns to the normal range. Continuing skin-to-skin contact would not resolve the problem of hypothermia. Double-wrapping the newborn in warm blankets and leaving the newborn at the bedside would not be an adequate means of resolving the hypothermia.

The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth to: Promote the synthesis of prothrombin Facilitate the growth of intestinal flora Limit an increase in the serum bilirubin level Decrease the level of calciferol until the kidneys have matured

Promote the synthesis of prothrombin Rationale Vitamin K stores are almost absent in the newborn because the intestinal flora that produce this vitamin are not present; vitamin K is an essential precursor of prothrombin, which is part of the clotting mechanism. The intestinal flora develop as the newborn is exposed to extrauterine living conditions. An increased serum bilirubin level may occur in the newborn because of the rapid breakdown of red blood cells and the immature liver's inability to conjugate such large amounts; it is not related to vitamin K. A newborn's kidneys operate at a functional level appropriate to the needs of a healthy newborn, and kidney maturity and calciferol are not related to vitamin K.

After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn? Protecting the sac with moist sterile gauze Removing buccal mucus and administering oxygen Placing name bracelets on both the mother and infant Transferring the newborn to the neonatal intensive care unit

Protecting the sac with moist sterile gauze Rationale Preventing infection and trauma is the priority; rupture of the sac may lead to meningitis. The Apgar scores are 9 and 10 at 1 and 5 minutes, respectively; oxygen is not needed. Placement of name bracelets on both mother and infant may be done before the infant leaves the birthing room; the priority is care of the infant's sac. The infant's sac must be protected before the infant is transferred to the neonatal intensive care unit.

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele located at the fourth lumbar vertebra (L4). What is the priority nursing intervention while the infant is awaiting surgery? Increasing nutritional intake Promoting sensory stimulation Providing meticulous skin care Performing range-of-motion exercises

Providing meticulous skin care Skin care is essential to prevent rupture of the sac and subsequent infection. There is no need to increase nutrition; there are no data to confirm that the infant is malnourished. Although sensory stimulation is important, it is not the priority. Exercises are not indicated at this time; they may be implemented after surgery.

A health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time? Bringing the infant as requested before she changes her mind Describing how the infant looks before bringing the infant to her Staying with her after bringing the infant to help her verbalize her feelings. Showing the mother pictures of the birth defects, then bringing the infant to her.

Rationale Allowing the client time to talk about her feelings and staying with her when she sees the infant for the first time are measures that will provide support, acceptance, and understanding. Bringing the infant to the mother as requested does not allow the mother adequate time to prepare to see her infant. Anomalies are difficult to describe accurately in words, especially when the mother has not been given time to express her feelings. Showing pictures may not be helpful, and discussion of treatment is premature.

What does the nurse expect concerning the alveoli in the lungs of a 28-week-gestation neonate? They have a tendency to collapse with each breath. There usually is a sufficient supply of pulmonary surfactant. Although apparently mature they cannot absorb adequate oxygen. Oxygen is not released into the circulation because they overinflate.

Rationale Alveolar collapse occurs because of a lack of pulmonary surfactant to overcome surface tension in the alveoli. Surfactant is present in sufficient amounts when the birth is closer to term. Fetal alveoli mature closer to term, around 35 to 36 weeks. The alveoli tend to collapse and may stay collapsed, resulting in atelectasis.

How does the nurse provide kangaroo care to a preterm infant? Co-bed the newborn with the parent. Keep the newborn wrapped in warm blankets. Encourage the mother to breastfeed the newborn. Keep the newborn in skin-to-skin contact with the parent.

Rationale Kangaroo care means keeping the newborn in skin-to-skin contact with the parent to promote thermoregulation and prevent heat loss from the newborn. Kangaroo care does not involve co-bedding the newborn with the parent, which is not a recommended practice. Nor does kangaroo care involve keeping the newborn wrapped in warm blankets or encouraging the mother to breastfeed.

A nurse plans to weigh a newborn. What is the most appropriate way to obtain the newborn's weight? Placing the naked infant on the scale Removing the infant's clothes except for the diaper before weighing Weighing the infant's clothes and then subtracting that weight from the clothed infant's weight Having the mother hold the infant while on an adult scale and subtracting the mother's weight from the combined weight

Rationale Placing the naked infant on the scale is the most accurate method of weighing an infant because it removes all variables that could influence the weight. Removing the infant's clothes except for the diaper before weighing will result in an inaccurate measurement because the diaper and its contents have mass, which will add to the measurement. Weighing the infant's clothes and then subtracting that weight from the infant's weight adds an unnecessary step to the procedure. An adult scale does not have the fine increments that are needed to obtain an accurate weight for an infant.

How should the nurse assess a newborn's grasp reflex? By putting direct pressure along the sole of the newborn's foot By jarring the crib and watch the movement of the newborn's hands By pressing the examining fingers against the palms of the newborn's hands By holding the body upright and allowing the newborn's feet to touch a surface

Rationale Pressing the examiner's fingers against the palms should elicit the grasp reflex of the newborn's hands. Putting direct pressure along the sole of the newborns' foot will cause the toes to hyperextend with dorsiflexion of the big toe (Babinski reflex). Jarring the crib will elicit symmetric abduction and extension of the arms with the thumb and forefingers forming a C, followed by adduction of the arms and finally a return of the arms to a relaxed position (Moro reflex). Holding the body upright and allowing the newborn's feet to touch a surface will elicit alternating flexion and extension of the feet that simulates walking (stepping reflex).

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first? <p>During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?</p> Report this finding Administer nasal oxygen Lower the head of the bassinette Remove secretions from the pharynx

Remove secretions from the pharynx An increase in mucus production is expected during the second reactive period; mucus should be removed either by swiping the oral cavity with a gloved finger or with the use of an aspiration device. Reporting this finding is unnecessary; identifying and treating human responses is within the scope of nursing practice. Oxygen administration is useless if mucus is blocking the respiratory passages. Although lowering the head of the bassinet may help secretions drain, the newborn cannot remove secretions that block respirations.

During assessment of a newborn, a practitioner diagnoses cephalhematoma and informs the parents. The mother asks why her baby's head looks different. What does the nurse take into consideration before responding in terms that the mother will understand? Edema of soft tissue over the scalp is a result of pressure during labor. Overlapped fetal scalp bones are a result of the head's conforming to the shape of the pelvic outlet. Swelling that is confined to one part of the scalp is caused by hemorrhage beneath the periosteum. Widening of the sutures between the scalp bones is caused by a partial blockage of cerebrospinal fluid drainage.

Swelling that is confined to one part of the scalp is caused by hemorrhage beneath the periosteum. Rationale A cephalhematoma occurs during labor when the rim of the pelvis exerts pressure on the fetal occiput, causing bleeding between the cranial bone and the periosteum; the hematoma does not cross the suture line. A diffuse pattern of edema above the periosteum is caput succedaneum; it results from an even distribution of pressure on the presenting part. Overlap of fetal bones occurs during the second stage of labor, when the fetus' head molds to the shape of the birth canal. When there is a blockage of cerebrospinal fluid, the circumference of the head is larger than expected (hydrocephalus).

How should a nurse screen the newborn of a diabetic mother for hypoglycemia?

Testing heel blood with the use of a glucose-oxidase strip Rationale Glucose-oxidase strips are used by nurses to screen infants for hypoglycemia. The glucose tolerance test and serum glucose determination are not used to screen newborns for hypoglycemia. Fasting blood glucose levels are not used routinely to screen newborns for hypoglycemia.

The parents of a newborn ask the nurse about several areas of deep-blue coloring on their baby's lower back and buttocks. The nurse's response is based on the information that: These areas usually are normal and will fade within the first year. Color changes represent transient mottling that occurs when the baby is cold. These are characteristic of the harlequin color change that occurs when the newborn lies on the side. Discolorations are probably bruises requiring observation of the infant for the development of jaundice.

These areas usually are normal and will fade within the first year. Rationale Areas of deep-blue coloring on the skin, often seen on the lower back and buttocks, are called Mongolian spots . Mongolian spots are a variation within the norm and disappear in the first year. Mottling caused by cold covers the entire body. The harlequin color change is not purple or blue and involves an entire half of the body. In this newborn these are expected findings; if the baby were light skinned, the possibility of bruises should be investigated.

A nurse is preparing a pregnant client for an amniocentesis. What should nursing care include? Encouraging her to void before the test Reminding her to get a good night's sleep Instructing her to stop drinking fluids after midnight Giving her a mild enema when she arrives for the test

Encouraging her to void before the test Rationale A full bladder may obstruct visualization of the uterus, and the bladder may be punctured accidentally when the needle is inserted. The amount of rest the client gets will not influence the procedure. Fluid intake should not be restricted. The colon is behind the uterus and, even if full, will not interfere with the test.

A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, a nurse identifies them as: Milia Lanugo Whiteheads Mongolian spots

white sebaceous glands on face- Milia

A potentially dangerous pregnancy complication characterized by high blood pressure. high blood pressure protein in urine swelling in hands in feet

preeclampsia

A new mother who has begun breastfeeding asks for assistance removing the baby from her breast. What should the nurse teach her? "Pinch the baby's nostrils gently to help release the nipple." "Let the baby nurse as long as desired without interruption." "Pull your nipple out of the baby's mouth when the baby falls asleep." "Insert your finger in the corner of the baby's mouth to break the suction."

"Insert your finger in the corner of the baby's mouth to break the suction." Rationale Inserting a finger into the corner of the baby's mouth is painless and will help prevent damage to the mother's nipple. Pinching the baby's nostrils is somewhat cruel; breaking suction with a finger is less traumatic. The mother may need to remove the baby from the breast before the baby is ready to let go, and the mother should be taught how to do this. Pulling without first breaking the suction may inflict trauma on the nipple.

A nurse withholds methylergonovine maleate (Methergine) from a postpartum client. What clinical finding supports the withholding of the medication? Urine output of 50 mL/hr Third-degree perineal laceration Blood pressure of 160/90 mm Hg Respiratory rate of 12 breaths/min

Blood pressure of 160/90 mm Hg Rationale Methylergonovine maleate can cause hypertension and should not be given to a client with an increased blood pressure. Urine output of 50 mL/hr is an expected finding in a healthy adult. Perineal lacerations are not related to methylergonovine maleate (Methergine) use. Methylergonovine maleate does not affect respiration.

An infant has surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant? Frequent crying Bulging fontanels Change in vital signs Difficulty with feeding

Bulging fontanels After closure, spinal fluid may accumulate and reach the brain, increasing intracranial pressure (ICP) and causing the fontanels to bulge. Frequent crying may be a typical pattern for the neonate; it does not, in and of itself, indicate changes in ICP. Changes in vital signs are not among the early signs of increasing ICP in an infant. Difficulty with feeding can indicate changes in ICP but is not one of the first signs.

How does the nurse know whether a client is in true labor? Contractions occur every 10 minutes with no change in frequency over 2 hours, and the cervix is closed. Contractions are not evident; the cervix is dilated 3 cm and 50% effaced, and there is no change after 4 hours of staying out of bed. Contractions occur every 5 to 10 minutes; the cervix is dilated 2 cm and 75% effaced, and dilation has increased to 3 cm in 2 hours. Contractions are irregular, occurring every 10 to 15 minutes; the cervix is dilated one fingertip and is 50% effaced, and there is no change with 4 hours of bedrest.

Contractions occur every 5 to 10 minutes; the cervix is dilated 2 cm and 75% effaced, and dilation has increased to 3 cm in 2 hours. Rationale Progressive cervical dilation and regular contractions that become progressively closer and increase in intensity are indications of true labor . The other options are not indications of true labor.

A nonstress test is scheduled for a client with preeclampsia. During the nonstress test the nurse concludes that if nonperiodic accelerations of the fetal heart rate occur with fetal movement, this probably indicates: Fetal well-being Fetal head compression Uteroplacental insufficiency Umbilical cord compression

Fetal well-being Rationale Nonperiodic accelerations with fetal movement indicate fetal well-being. Early decelerations are associated with fetal head compression. Late decelerations are associated with uteroplacental insufficiency. Variable decelerations are associated with cord compression.

A nurse has learned that infants born to very young mothers are at risk for neglect or abuse primarily because an adolescent characteristically:

Is involved in seeking her own identity Rationale Adolescent parents are still involved in the developmental stage of resolving their own self-identity; they have not sequentially matured to intimacy and generativity, making nurturing of another difficult. Although adolescents usually do not plan for their pregnancies, it is not the primary reason that their infants are at risk for neglect or abuse. Although adolescents may have difficulty anticipating their infants' needs, it is not the primary reason that their infants are at risk for neglect or abuse. Although adolescents may resent the responsibilities involved in childrearing, it is not the primary reason that their infants are at risk for neglect or abuse.

The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent future problems. What must the nurse consider before responding? Most important is diagnosis within 2 days after birth. Most important is the institution of a corrective formula soon after birth. It depends on whether phenylpyruvic acid is found in the urine 1 week after birth. It depends on the level of phenylalanine found in the blood immediately after birth.

Most important is the institution of a corrective formula soon after birth. Rationale Adherence to a diet low in phenylalanine is necessary for optimal physical growth and little or no adverse effect on mental development; a restricted diet that is instituted late will not reverse brain damage. Detection cannot occur until the infant has taken milk or formula that contains phenylalanine for 24 hours and metabolites have accumulated in the blood; behaviors indicating mental retardation and central nervous system involvement are usually evident by about 6 months of age in the untreated infant. Phenylpyruvic acid in the urine is an intermediate product of the metabolism of phenylalanine in the body. It is related to compliance with the prescribed diet after the diagnosis is made. There is no phenylalanine in the blood at birth; it first becomes measurable after the infant ingests milk or formula.

A nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. What part of the foot is the best site to use for the puncture? Big toe Foot pad Inner sole Outer heel

Outer heel (The outer heel is well perfused and heals quickly. The big toe, foot pad, and inner sole are all inappropriate sites from which to obtain a blood specimen from a newborn.)

A newborn male is admitted to the nursery. He weighs 10 lb 2 oz, which is 2 lb more than the birthweight of any of his siblings. What should the nurse do in relation to the baby's weight? Document the findings Place him in a heated crib Delay starting oral feedings Perform serial glucose readings

Perform serial glucose readings

At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action? Suctioning the mouth Administering oxygen Notifying the practitioner Inserting an endotracheal tube

1 Suctioning the mouth To maintain a patent airway and promote respiration and gaseous exchange, the nurse must remove mucus from the newborn's mouth and pharynx. If the airway is obstructed, oxygenation is useless; suctioning is the priority. The practitioner should be notified if oral suctioning does not clear the airway. Insertion of an endotracheal tube is an emergency measure that may be required if the nurse's initial action does not clear the airway.

A client who is in labor is admitted 30 hours after her membranes ruptured. For what condition does the nurse anticipate that the client is most at risk? 1. Cord prolapse 2. Placenta previa 3. Chorioamnionitis 4. Abruptio placentae

3 The risk of developing chorioamnionitis (intra-amniotic infection) is increased with prolonged rupture of the membranes; foul-smelling fluid is a sign of infection. 1 A prolapsed cord usually occurs shortly after the membranes rupture, not 1½ days later. 2 This is an abnormally implanted placenta; it is unrelated to ruptured membranes. 4 Premature separation of the placenta is unrelated to ruptured membranes. (Nugent 366) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examinat

A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate? 20 to 40 breaths/min 30 to 60 breaths/min 60 to 80 breaths/min 70 to 90 breaths/min

30 to 60 breaths/min Rationale After respiration is established, the normal neonate respiratory rate ranges from 30 to 60 breaths/min with short periods of apnea. Twenty breaths per minute is bradypnea. A respiratory rate faster than 60 breaths/min is tachypnea.

A nurse who is monitoring the blood glucose level of the term infant of a diabetic mother (IDM) identifies a blood glucose level of 48 mg/dL. What should the nurse do? Check the cord serum glucose level. Initiate oral feedings of 10% dextrose in water. Secure a prescription for an IV infusion of 50% dextrose. Continue to monitor the blood glucose level per policy.

Continue to monitor the blood glucose level per policy. Rationale A reading of 48 mg/dL is within the expected blood glucose range for a neonate (40-60 mg/dL) and requires no measures other than continued monitoring for the next 24 hours. Heel sticks are adequate for monitoring the blood glucose level of a neonate. Oral feedings of 10% dextrose in water are administered if the neonate's blood glucose level is low. Administering 50% dextrose intravenously will cause hyperglycemia in the neonate.

Two days after birth a neonate's head circumference is 16 inches (40 cm) and the chest circumference is 13 inches (32.5 cm). What does the nurse infer from these measurements? Microcephaly Narrow chest Enlarged head Expected head size

Enlarged head Rationale The enlarged head may indicate hydrocephalus. Average head circumference in the healthy newborn is 13.2 to 14 inches (33 to 35 cm), about 1 inch (2.5 cm) larger than the chest circumference. Microcephaly indicates that the head is smaller than expected, not larger. The chest circumference of 13 inches (32.5 cm) is expected in a healthy newborn. The head size is not within expected limits; it is too large.

A mother who is formula feeding her 1-month-old infant asks the nurse whether any vitamin or mineral supplements are required. The nurse bases the reply on the knowledge that infants who are fed with ready-to-use formula do require a supplement.

Fluoride

A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70 mm Hg, pulse of 90 beats/min, respiratory rate of 22 breaths/min, fetal heart rate of 132 beats/min. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, what problem does the nurse suspect? <p>A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70 mm Hg, pulse of 90 beats/min, respiratory rate of 22 breaths/min, fetal heart rate of 132 beats/min. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, what problem does the nurse suspect?</p> Preterm labor Uterine inertia Placenta previa Abruptio placentae

Placenta previa -A nontender uterus and bright-red bleeding are classic signs of placenta previa ; as the cervix dilates, the overlying placenta separates from the uterus and begins to blee

A nurse determines that a newborn is in respiratory distress. Which signs confirm respiratory distress in the newborn? (Select all that apply.) Crackles Cyanosis Wheezing Tachypnea Retractions

Rationale Cyanosis occurs because of inadequate oxygenation. Tachypnea is a compensatory mechanism to increase oxygenation. Retractions occur in an effort to increase lung capacity. Crackles occur in the healthy newborn. Wheezing in the newborn is benign.

At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? (Select all that apply.) Long nails Wrinkled skin Edematous skin Abundant body hair Obvious blood vessels in the skin

Rationale The longer the nails, the more mature the infant. Wrinkled skin is found in a postterm infant who has been exposed to amniotic fluid for too long; the skin is thick, parchmentlike, wrinkled, and peeling. Edematous skin is a characteristic of the preterm infant. Abundant body hair, known as lanugo, is another characteristic of the preterm infant. Obvious blood vessels in the skin are characteristic of the preterm infant because the skin is thin and translucent.

A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13 oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The client complains, "This pain in my vaginal and rectum is excruciating, and my vagina feels so full and heavy." What does the nurse suspect as the cause of the pain? Full bladder Vaginal hematoma Infected episiotomy Enlarged hemorrhoid

Vaginal hematoma Rationale A vaginal hematoma caused by fetal head pressure during the birthing process can result in severe pain. Bladder distention causes abdominal, not perineal, discomfort. Although the episiotomy may cause pain, it should not be excruciating; it is too early for an infection to have developed. Although hemorrhoids may cause perineal discomfort, they should not cause the vagina to feel full and heavy.

A thin 24-year-old woman who runs 10 miles each week asks the nurse for advice about preventing osteoporosis. Which vitamin and other dietary supplement should the nurse recommend?

Vitamin D and calcium citrate

What is a nurse's most important concern when caring for a client with a ruptured tubal pregnancy? <p>What is a nurse's <b>most</b> al pregnancy?</p> Infection Hypervolemia Protein deficiency Diminished cardiac output

dimished cardiac output

A mother whose newborn infant son has a cleft lip and palate asks how to feed her baby because he has difficulty suckling. What information should the nurse provide concerning safe feeding technique for this infant? "Because he tires easily, it's best to have him lying in bed while he is being fed." "Hold him in a horizontal position and feed him slowly to help prevent aspiration." "Try using a soft nipple with an enlarged opening so he can get the milk through a chewing motion." "Give him brief rest periods and frequent burpings during feedings so he can get rid of swallowed air."

"Give him brief rest periods and frequent burpings during feedings so he can get rid of swallowed air." Rationale Cleft lip and palate, a congenital defect, prevents the infant from creating a tight seal with the lips to facilitate suckling. As a result, the infant swallows large amounts of air when feeding. The mother should be taught to provide frequent rest periods and to burp the infant often to expel excess air in the stomach. Infants with cleft lip and palate should be held upright during feedings. Newborn infants cannot chew and do not make chewing movements.

A nurse decides on a teaching plan for a new mother and her infant. What should the plan include? A schedule for teaching infant care A demonstration and explanation of infant care A discussion of mothering skills presented in a nonthreatening manner Emotional support and that will foster dependence on the nurse's expertise

B) Showing by example and explanation how to care for the infant Rationale Teaching the mother by example is a nonthreatening approach that allows her to proceed at her own pace. Learning does not occur on a schedule; questions must be answered as they arise. New mothers need demonstration of appropriate mothering skills, not just a discussion. Although emotional support is required, the plan should encourage independent caregiving.

A pregnant woman tells a nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and that she is taking a prescribed supplement. She asks the nurse what foods contain folic acid (folate) so she may add them to her diet in its natural form. Which foods should the nurse recommend? (Select all that apply.) Beef and fish Milk and cheese Chicken and turkey Black and pinto beans Enriched bread and pasta

Black and pinto beans Enriched bread and pasta Rationale Legumes contain large amounts of folate , as do enriched grain products. Beef and fish do not contain an adequate amount of folate. Milk and cheese do not contain adequate amounts of folate; nor does fowl.

A client arrives at the clinic in preterm labor, and terbutaline (Brethine) is prescribed. For what therapeutic effect should the nurse monitor the client? Increased blood pressure and pulse Reduction of pain in the perineal area Gradual cervical dilation as labor progresses Decreased frequency and duration of contractions

Decreased frequency and duration of contractions Rationale Terbutaline sulfate (Brethine) is a β-mimetic that acts on the smooth muscles of the uterus to reduce contractility, which in turn inhibits dilation and the frequency and duration of contractions. Although terbutaline may increase blood pressure and pulse, this is a side, not a therapeutic, effect requiring frequent assessments. Terbutaline is not an analgesic. It should stop cervical dilation rather than increase it.

What should the nurse's initial discussion include to best help new parents understand tA nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include? he unique characteristics of a newborn?

Expected movements and behaviors

A client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. What priority intervention for the infant can the nurse anticipate implementing upon delivery? Stimulating crying Administering oxygen Putting a moist saline dressing on the cord stump Providing for suctioning of the oropharynx as the head emerges

Providing for suctioning of the oropharynx as the head emerges Rationale The color of the amniotic fluid is indicative of meconium staining; the practitioner must therefore prepare for the potential fetal aspiration of meconium. The newborn should not be stimulated to cry until the airway has been cleared of meconium . Oxygen is administered only after a patent airway is established and if needed. Putting a moist saline dressing on the cord stump is unnecessary because there is no indication that umbilical cord blood or a transfusion is needed.

A pregnant client is experiencing nausea and vomiting. The nurse determines that this discomfort: Is always present during early pregnancy Will disappear when lightening occurs Is a common response to an unwanted pregnancy May be related to an increased human chorionic gonadotropin level

Rationale An increased level of human chorionic gonadotropin, or hCG, may cause nausea and vomiting, but the exact reason is unknown. Some pregnant women do not experience nausea and vomiting. Lightening occurs at the end of the third trimester; nausea and vomiting usually cease at the end of the first trimester. Nausea and vomiting are unrelated to whether a pregnancy is desired or unwanted.

A nurse assesses a new mother who is breastfeeding. The client asks how to care for her nipples. What should the nurse recommend? Putting lanolin cream on the nipples after breastfeeding Applying vitamin E gel to the nipples before breastfeeding Using soap and water to clean the breasts and nipples at least once a day Spreading breast milk on the nipples after the feeding and allowing them to air dry

Spreading breast milk on the nipples after the feeding and allowing them to air dry Rationale Breast milk is a natural lubricant for the nipples and obviously is not toxic for the infant. Products containing lanolin or vitamin E are not advised because they may be ingested by the infant. Soap should not be used on the nipples because it has a drying effect, which may precipitate cracking of the nipples.

Immediately after the third stage of labor a nurse administers the prescribed oxytocin (Pitocin) infusion. Why is this medication administered? To help the uterus contract To lessen uterine discomfort To aid in the separation of the placenta For the stimulation of breast milk production

To help the uterus contract Rationale Oxytocin (Pitocin) given after the third stage of labor will stimulate the uterus to contract and remain contracted. Oxytocin does not have an analgesic effect. It is administered after the placenta is expelled (third stage of labor). Prolactin, not oxytocin, stimulates milk production.

A nurse is teaching a class about childbearing and contraceptive options. The nurse explains that fertilization of the ovum by the sperm occurs at a specific time. When does it occur? As the ovum leaves the ovary When one sperm penetrates the wall of the ovum When the ovum reaches the endometrium of the uterus As one sperm prevents the ovum from moving along the tube

When one sperm penetrates the wall of the ovum Rationale Fertilization occurs when one sperm penetrates one ovum, producing a viable zygote. Fertilization occurs in a fallopian tube, not when the ovum is expelled from the ovary or in the uterus. After the sperm penetrates the ovum in a fallopian tube, the impregnated ovum travels down the tube to the uterus.

A nurse is admitting a pregnant client who has mitral valve stenosis to the high-risk unit. What prophylactic medication does the nurse anticipate administering during the intrapartum period? Diuretic Antibiotic Cardiotonic Anticoagulant

antibiotic Rationale Clients who have mitral valve stenosis are administered prophylactic antibiotic therapy to minimize the development of streptococcal infections that may cause endocarditis. A diuretic will probably be used if heart failure develops. A cardiotonic will probably be used if heart failure develops. An anticoagulant will probably be used if thrombophlebitis or atrial fibrillation develops.

A client is taking a progesterone oral contraceptive (minipill). The nurse instructs the client to take one pill daily during the: Five days of the ovulatory cycle Latter part of the ovulatory cycle First week of the menstrual cycle Entire menstrual cycle

entire menstral cycle Rationale Maintenance of serum progesterone levels keeps cervical mucus thick and hostile to sperm at all times. Telling the client to take the pills for five days of the ovulatory cycle is inaccurate information; the pill must be taken throughout the menstrual cycle. Whereas progesterone oral contraceptives (minipills) must be taken throughout the cycle, combined estrogen and progesterone oral contraceptives are taken during the second, third, and fourth weeks of the cycle. Fertility drugs are often taken during the first part of the cycle to encourage ovulation, not for contraception.

A nurse is observing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider? Flaring nares Acrocyanosis Heartbeat of 140 beats/min Respirations of 40 beats/min

flaring of nose Rationale Preterm neonates are prone to respiratory distress ; flaring nares are a compensatory mechanism in a neonate with respiratory distress syndrome, the body's attempt to lessen resistance of narrow nasal passages and increase oxygen intake. Acrocyanosis is not related to respiratory distress but is caused by vasomotor instability; this is an expected occurrence in the newborn. A heartbeat of 140 beats/min is an expected finding in the newborn. A respiratory rate of 40 breaths/min is an expected finding in the newborn.

After the birth of a neonate, a parent asks, "What is that white substance over the baby's body?" The nurse initially responds:

"It's expected, and it's called vernix caseosa."

A nurse in a family planning clinic determines that a client understands the discussion about using a cervical cap with a spermicide when the client states that after intercourse, a cervical cap must be left in place for at least: 1. 6 hours 2. 5 hours 3. 3 hours 4. 2 hours

6 hrs The cervical cap , used in conjunction with a spermicide that remains active for 6 hours, provides the most effective contraceptive result. Leaving the barrier in for 2, 3, or 5 hours does not give the spermicide adequate time to work and increases the likelihood of contraceptive failure.

A nurse is performing the Ortolani test on a newborn. Which finding indicates a positive result? Dorsiflexion, then fanning Hypertonia and jitteriness An arched back and crying An audible click on abduction

An audible click on abduction As the head of the femur moves within the acetabulum, sometimes there is an audible click when there is developmental dysplasia of the hip. Dorsiflexion followed by fanning is associated with the Babinski test. Hypertonia and jitteriness is a neurological finding. An arched back and crying is opisthotonic posturing.

A small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect? Hypovolemia Hypoglycemia Hypercalcemia Hypothyroidism

Hypoglycemia Rationale SGA infants may exhibit signs of hypoglycemia, especially during the first 2 days of life, because of depleted glycogen stores and inhibited gluconeogenesis. Decreased blood pressure, pallor with cyanosis, tachycardia, retractions, lethargy, and a weak cry are signs of hypovolemia. Hypercalcemia is uncommon in newborns. These signs are unrelated to hypothyroidism; signs of hypothyroidism are difficult to identify in the newborn.

What is the safest and most reliable birth control method for the nurse to recommend to a client with type 1 diabetes?

diaphragm with spermicidal gel A diaphragm with a spermicidal gel, if used correctly, offers a low risk of conception and a high degree of reliability, and it is the safest contraceptive method for a person with type 1 diabetes. A vaginal sponge may be used by a woman with type 1 diabetes, but it is less reliable than the diaphragm with spermicidal gel. Even a low-dose oral contraceptive increases the risk for vascular complications, and women with type 1 diabetes are already at risk for vascular complications. The rhythm method is not reliable because menses during the postpartum and lactation periods are often irregular; condoms can fail and must be used correctly and consistently throughout sexual intercourse.

uterine atony

inability of the uterus to contract effectively

A nurse who is admitting a newborn to the nursery observes a fetal scalp monitor site on the scalp. For what complication should the nurse monitor this newborn? Injury Infection Feeding problems Respiratory distress

infection Rationale The monitor site represents a break in the integrity of the scalp, which allows access by microorganisms. There is no further risk for injury. A fetal scalp monitor site does not interfere with feeding. A fetal scalp monitor site does not affect respirations.

A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong? "You seem very concerned. I don't see anything unusual." "Your baby appears to have a problem. I'll notify the pediatrician." "The swelling and discharge will go away. It's nothing to worry about." "The swelling and discharge are expected. They're a response to your hormones."

"The swelling and discharge are expected. They're a response to your hormones." This response emphasizes that the findings are to be expected and explains why they occur; this may relieve the client's anxiety. Claiming not to see anything unusual denies that there is anything to explain to the mother and is somewhat belittling. Calling the pediatrician is not necessary; these findings are expected. The comment that the swelling and discharge will go away tells the mother that the findings are expected but provides no explanation and is somewhat belittling.

Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the laboratory report reveals: A pH of 7.35 A potassium level of 4.6 mEq/L An increased Paco 2 of 55 mm Hg An arterial O 2 pressure of 80 mm Hg

3 An increased Paco2 of 55 mm Hg Rationale In respiratory acidosis the pH decreases and the carbon dioxide level increases. A pH of 7.35 is within the expected range of 7.32 to 7.49 for a neonate. A potassium level of 4.6 mEq/L is within the expected range of 3.5 to 5 mEq/L. The arterial oxygen level may or may not change with acidosis.

A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. Eleven hours after birth, the infant's skin appears yellow. What is the most likely cause? Neonatal sepsis Rh incompatibility Physiological jaundice ABO incompatibility

ABO incompatibility Rationale There is an apparent ABO incompatibility because the mother is O and the infant is B; incompatibility can cause jaundice within the first 24 hours. The information provided does not indicate neonatal sepsis. Rh incompatibility is not a factor because the mother is Rh positive. Jaundice in the first 24 hours is not physiological; it is pathological.

A nurse is caring for a client with preeclampsia who is receiving intravenous magnesium sulfate therapy. What antidote should the nurse have readily available? Adrenaline Hydrocortisone Potassium iodide Calcium gluconate

Calcium gluconate is the antidote for magnesium sulfate toxicity. Adrenaline is a vasoconstrictor and is not used as an antidote for magnesium sulfate toxicity. Hydrocortisone is a steroid and is not used to counteract magnesium sulfate toxicity. Potassium iodide is not the antidote for magnesium sulfate toxicity. Potassium iodide inhibits the secretion of thyroid hormone and decreases the vascularity of the thyroid gland.

During the discharge examination of a 2-day-old newborn, the nurse observes an edematous area confined to the right side of the scalp. How should the nurse document this condition? Molding Hydrocephalus Cephalhematoma Caput succedaneum

Cephalhematoma Cephalhematoma is a collection of blood beneath the periosteum of the skull bone; the blood mass does not cross the suture line and is confined to one side of the head. It is reabsorbed within 3 to 6 weeks. Molding is overlapping of the cranial bones or shaping of the fetal head to accommodate and conform to the bony and soft parts of the mother's birth canal during labor; it resolves within 3 days. Hydrocephalus is an enlargement of the entire head (macrocephaly) caused by an abnormal enlargement of the cerebral ventricles and skull, which results from an obstruction in the flow of cerebral spinal fluid. Caput succedaneum is an edematous swelling of the scalp that extends across the suture line; it resolves within 3 to 4 days.

A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn? In utero through the placenta In the postpartum period through breast milk During birth through contact with the maternal vagina After the birth through a blood transfusion given to the mother

In utero through the placenta Rationale Toxoplasmosis is caused by a parasitic protozoon that is acquired from inadequately cooked contaminated food or through handling of infected cat feces; the most common form of transmission to the newborn is by way of placental perfusion when in utero. There is no evidence that toxoplasmosis is transmitted in breast milk. The newborn does not contract toxoplasmosis from the maternal genital tract during the birth process. There is no evidence that toxoplasmosis is transmitted in blood transfused into the mother.

A nurse is caring for a client in active labor. What positions should the nurse encourage the client to assume to help promote comfort during back labor? (Select all that apply.) Prone Sitting Supine Lateral Knee-chest

Rationale The sitting position relieves back pain because it removes pressure from the back. The lateral position relieves back pain because it removes pressure from the back. The knee-chest position may help relieve back pain because it removes pressure from the back. The prone position is almost impossible to assume because of the size of the uterus; also, it cannot be maintained because it impedes fetal monitoring. Low back pain is aggravated when the client is in the supine position because of increased pressure from the fetus on the lumbar and sacral regions.

What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include? Examining for a cleft palate Testing for congenital syphilis Assessing the infant for muscle hypotonicity Inspecting the soles for maculopapular lesions

Testing for congenital syphilis

Although a client in labor is prepared and plans to participate in the labor and birth process, she states that she is in severe discomfort. The nurse administers the prescribed butorphanol (Stadol). Which phase of labor is the safest time for the nurse to administer this medication? Early phase Active phase Transition phase Expulsion phase

active Rationale Respiratory depression of the newborn will not occur if the medication is given during the active phase; it should not be given when birth is expected to occur within 2 hours. The level of pain during the early phase can usually be managed with other strategies such as breathing techniques or diversion; giving an opioid early in labor may slow the progress of labor. An opioid should be avoided in the 2 hours preceding birth; giving it to a client in the transition phase can cause respiratory depression in the newborn. Giving the medication when birth is imminent is contraindicated because it may cause respiratory depression in the newborn; the mother's level of consciousness will be altered as well, making it difficult for her to cooperate with requests for her to push.

A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1 rating at one minute? Color Heart rate Respirations Reflex irritability

color Because of inadequate peripheral circulation at birth there is acrocyanosis (body pink, hands and feet blue), which merits 1 point for color. This is a common occurrence in a healthy newborn. The fetal heart rate ranges from 110 to 160 beats/min; a newborn heart rate of more than 100 beats/min is expected in a healthy newborn and merits 2 points. An adequate respiratory rate is evidenced by crying, which is expected in a healthy newborn and merits 2 points. Reflex irritability is represented by crying, which is expected in a healthy newborn and merits 2 points

endometritis

inflammation of the inner (lining) of the uterus (endometrium) factors that contribute to increased risk for puerperal infection, which are: poor nutritional status, anemia, vaginal infection with group B streptococcus, and diabetes.

The mother of a pregnant teenager asks the nurse how her daughter could have been so foolish because birth control had been discussed with her many times. How should the nurse respond? "Apparently your daughter wasn't listening to you." "You should have made sure that her boyfriend understood birth control, too." "Teenagers often fail to use birth control because they forget to discuss it with their sexual partners." "Although teenagers can intellectually discuss birth control, they often don't believe that they will become pregnant."

"Although teenagers can intellectually discuss birth control, they often don't believe that they will become pregnant." Rationale Teenagers are capable of cognitively understanding the risks of unprotected sex but often believe themselves invulnerable, which leads to risk-taking behaviors. Stating that the daughter was not listening to the mother does not help the mother understand her daughter's behavior and may precipitate increased hostility toward the daughter. Stating that the mother should have made sure that the daughter's boyfriend understood birth control could precipitate feelings of guilt and does not help the mother understand her daughter's behavior. Sexual activity may be impulsive and therefore not conducive to discussion; also, adolescents, who are developing their sense of sexuality, may feel too insecure to raise this discussion.

A pregnant client in the third trimester tells the nurse in the prenatal clinic that she has heartburn after every meal. What explanation should the nurse give about the cause of the heartburn? "The cardiac sphincter relaxes and allows acid to be regurgitated." "In pregnancy, gastric motility increases, causing a burning sensation." "In pregnancy, gastric pH increases, causing acid to enter the esophagus." "In pregnancy, the pyloric sphincter relaxes, allowing acid to enter the intestine."

"The cardiac sphincter relaxes and allows acid to be regurgitated." Rationale Relaxation of the cardiac sphincter, resulting in regurgitation of acid, causes heartburn (pyrosis) during the second half of pregnancy. Delayed emptying of stomach contents because of decreased gastric motility and displacement of the stomach because of uterine enlargement contribute to the problem. Gastric motility is decreased during pregnancy. When gastric pH increases, gastric juices become more alkaline, leaving little or no acid to be regurgitated into the esophagus. The pyloric sphincter does not relax, and acid does not pass into the small intestine.

While caring for a client during labor, the nurse remembers that the second stage of labor: Ends at the time of birth Ends as the placenta is expelled Begins with the transition phase of labor Begins with the onset of strong contractions

1. Ends at the time of birth Rationale The second stage of labor starts with full cervical dilation and ends with the birth of the infant. The third stage of labor begins after birth, continues until the separation of the placenta from the uterine wall, and ends with the expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occurs during the active phase of the first stage of labor.

What complication should a nurse be alert for in a client receiving an oxytocin (Pitocin) infusion to induce labor? 1. Intense pain 2. Uterine tetany 3. Hypoglycemia 4. mbilical cord prolapse 2. Uterine tetany

2. Uterine tetany Rationale Because oxytocin (Pitocin) promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise. Intense pain can be associated with strong uterine contractions; this is not a complication. Hypoglycemia is unrelated to uterine contractions. Umbilical cord prolapse is not likely to occur when induction of labor is initiated.

The four essential components of labor are powers, passageway, passenger, and psyche. Passageway refers to the bony pelvis. What type of pelvis is considered the most favorable for a vaginal delivery? Android Anthropoid Gynecoid Platypelloid

A gynecoid pelvis is considered most favorable for a vaginal birth because the inlet allows the fetus room to pass. The gynecoid pelvis is considered the typical female pelvis. An android pelvis, which has a heart shape, is considered a male pelvis. The fetus often gets stuck. The anthropoid pelvis is elongated, with a roomy anterior posterior dimension and a narrower transverse diameter than the gynecoid pelvis. Although delivery is possible with this type of pelvis, it is less likely to be successful. The platypelloid pelvis is flat, with a compressed oval shape as the middle opening, instead of an open circle like the gynecoid pelvis. This is a rare type of pelvis.

A nurse is counseling a pregnant client with iron-deficiency anemia about when and how to take supplemental iron. What time of day and with what drink is iron absorption most efficient? Dinnertime with water Bedtime with a milkshake After lunch with cranberry drink Before breakfast with orange juice

Before breakfast with orange juice Rationale Iron should be taken before breakfast, on an empty stomach, to permit maximal absorption; ascorbic acid enhances the absorption of iron. Iron should not be taken with or after meals. Iron should not be taken with milk, which may interfere with its absorption.

A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 and she has 2+ protein in her urine and edema of the hands and face. Which signs or symptoms are suggestive that HELLP syndrome is developing? (Select all that apply.) Headache Constipation Abdominal pain Vaginal bleeding Flulike symptoms

Headache, abdominal pain, and flulike symptoms are all indications of increasing severity of preeclampsia and HELLP syndrome. Constipation is not related to preeclampsia; neither is vaginal bleeding.

A nurse is caring for a client who is receiving IV magnesium sulfate for preeclampsia. At 37 weeks' gestation she gives birth to an infant weighing 4 lb. What clinical finding in the newborn may indicate magnesium sulfate toxicity?

Hypotonia Rationale: Hypotonia occurs with magnesium sulfate toxicity because of skeletal and smooth muscle relaxation. Pallor, tremor, and tachycardia are not signs of magnesium sulfate toxicity.

A nurse is observing a newborn's respiratory rate. What clinical findings indicate that the rate is within the expected range? Regular, thoracic, 40 to 60/min Irregular, thoracic, 30 to 60/min Regular, abdominal, 40 to 50/min Irregular, abdominal, 30 to 60/min

Irregular, abdominal, 30 to 60/min Rationale The expected breathing pattern is abdominal and irregular in rhythm and depth (alternating between shallow and deep); the expected rate ranges from 30 to 60 breaths/min. Newborns' respirations are irregular and abdominal.

A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by: Oxidization of fatty acids Shivering when chilled Metabolism of brown fat Increased muscular activity

Metabolism of brown fat Rationale Metabolism of brown fat releases energy and increases heat production in the newborn. Fatty acids are byproducts of the breakdown of brown fat. Shivering is the mechanism of heat production for an adult, not for a newborn. Increased muscular activity will not be successful unless there is an abundance of brown fat.

The fetus of a woman in labor is at +1 station. At what place in the pelvic area does the nurse conclude that the presenting part is located? 1Not yet engaged 2Entering the pelvic inlet 3Below the ischial spines 4Visible at the vaginal opening

Rationale A +1 station indicates that the fetal presenting part is 1 cm below the ischial spines, which are the points of engagement. Entrance of the pelvic inlet is designated as 0 station or as a negative number. The head must be at +3 to +5 to be visible at the vaginal opening.

Assign an Apgar score to this infant: heart rate 110, crying vigorously, moves all extremities, cries when suctioned, blue extremities with pink body. Record your answer using a whole number.

Rationale A heart rate above 100 beats/min scores 2 points , vigorous crying scores 2 points, moving all extremities scores 2 points, reflex irritability scores 2 points, and blue extremities with a pink body scores 1 point, for a total Apgar score of 9.

The nurse is caring for a couple after the birth of their first child. What should the nurse tell the family to do when their infant is exhibiting the behavior demonstrated in the picture?

"This is the time when the baby is likely to be most responsive to you." Rationale The picture is consistent with the quiet/alert stage of an infant's sleep/wake cycle , during which the infant is most responsive to people talking and most observant of others' faces. Leaving an infant alone during the quiet/alert stage is not using this time to its best advantage. An infant is sensitive to circumoral sensation; a hand in the mouth does not necessarily indicate hunger.

A client at 37 weeks' gestation gives birth to a healthy boy. While inspecting her newborn in the birthing room, the client becomes concerned and asks, "What's this sticky white stuff all over him?" How should the nurse respond? "It's a secretion from the baby's fat cells called milia." "This is vernix. It helps protect the baby while he's in the uterus." "Your baby was born several weeks early, so we expect to see this." "It's nothing to be concerned about. Most newborns are covered with it."

"This is vernix. It helps protect the baby while he's in the uterus." Rationale A factual response will allay the mother's concern. Vernix caseosa is a cheesy white substance that covers the fetus and confers protection from the amniotic fluid while the fetus is in utero. Most of it disappears by 40 weeks' gestation. Milia are white pinpoint dots (sebaceous glands) on the newborn's nose, chin, and forehead that disappear within a few weeks. The nurse should explain only what vernix is; referring to the infant as preterm may unnecessarily alarm the mother. Stating that the substance is nothing to be concerned about does not answer the mother's question, and vernix is not abundant on neonates born at term.

A client has just been told that she has cervical erosion. The nurse would expect to help explain that early treatment of the erosion can help prevent: <p>A client has just been told that she has cervical erosion. The nurse would expect to help explain that early treatment of the erosion can help prevent:</p> Cancer of the cervix Pelvic inflammatory disease Unexpected vaginal bleeding Additional cervical erosions

-Cancer of the cervix Erosion of the cervix frequently occurs at the columnosquamous junction, the most common site for carcinoma of the cervix. Treatment of cervical erosions does not prevent pelvic inflammatory disease; early onset of sexual intercourse (before 16 years of age), multiple sexual partners, and history of human papillomavirus (HPV) infection are risk factors for cancer of the cervix rather than consequences of precervical cancer. Metrorrhagia, abnormal bleeding from the uterus, may be present as erosion develops into carcinoma; however, spotting may be the earliest sign and will be eliminated when the cancer is treated. The goal of treatment of the erosion is to prevent cancer.

A nurse is caring for a client who has contracted a trichomonal infection. Which oral drug should the nurse anticipate that the health care provider will most likely prescribe? Penicillin G Gentian violet Nystatin (Mycostatin) Metronidazole (Flagyl)

-Metronidazole (Flagyl) Metronidazole (Flagyl) is a potent amebicide. It is effective in eradicating the protozoan Trichomonas vaginalis. Penicillin is administered for its effect on bacterial, not protozoal, infections. Gentian violet is a local antiinfective that is applied topically; it may cause discoloration of the skin. It is effective against Candida albicans. Nystatin (Mycostatin) is an antifungal for infections caused by C. albicans.

A nurse is counseling a pregnant client who is a vegetarian. What should the nurse plan to do to ensure optimal nutrition during the pregnancy? 1 Refer the client to a dietitian to help plan her daily menu. 2 Encourage the client to join a group that teaches nutrition. 3 Explain that she needs to include meat in her diet at least once a day. 4 Advise the client that it is unhealthy to continue a vegetarian diet during pregnancy.

1 Refer the client to a dietitian to help plan her daily menu.

For what complication should the nurse specifically monitor a grand multipara who has just given birth? 1. Uterine atony 2. Bladder distention 3. Profuse diaphoresis 4. Hypertensive episodes

1. Uterine atony Grand multiparas have diminished uterine muscle tone as a result of the repeated distentions of pregnancy; consequently, the uterine muscles may not contract effectively during the fourth stage of labor. Bladder distention may occur in any postpartum clients; it is not specific to grand multiparas. Profuse sweating occurs in all postpartum clients; it is the body's attempt to excrete excess fluid accumulated during pregnancy. Hypertensive episodes may be indicative of chronic hypertension, which is not specific to grand multiparas.

A client at 39 weeks' gestation is admitted for induction of labor. Knowing that several medications are used to induce labor, a nurse identifies those that may be prescribed. (Select all that apply.) Oxytocin (Pitocin) Misoprostol (Cytotec) Ergonovine (Ergotrate) Carboprost (Hemabate) Dinoprostone (Prepidil

125 Oxytocin (Pitocin) is an oxytocic that triggers or augments uterine contractions; it is used for labor induction. Misoprostol (Cytotec) is a prostaglandin used for cervical ripening and labor induction. Dinoprostone (Prepidil) is used for cervical ripening to induce labor and is also used to induce abortion. Ergonovine (Ergotrate) is an oxytocic used in postpartum or postabortion hemorrhage. Carboprost (Hemabate) is a prostaglandin used to treat postpartum hemorrhage; it is also used to induce abortion.

A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? (Select all that apply.) Mitral valve Foramen ovale Pulmonary veins Ductus arteriosus Pulmonary arteries

2 . Foramen ovale 4 . Ductus arteriosus **If the foramen ovale fails to close, the infant will have an atrial septal defect. If the ductus arteriosus fails to close, the pressure in the lungs and heart will be abnormal, resulting in chronic heart disease. The mitral valve, pulmonary veins, and pulmonary arteries do not change after birth.

What findings occur with supine hypotensive syndrome? (Select all that apply.) Reflex tachycardia Feeling of faintness Increased cardiac output Increased venous pressure Increased diastolic pressure Decreased systolic pressure

2 Feeling of faintness 4 Increased venous pressure 6 Decreased systolic pressure Rationale Compression of the vena cava hinders venous return, which in turn results in a decrease in the systolic pressure, an increase of venous pressure in the legs, and decreased blood flow to the brain, causing the woman to feel faint. Blood pressure decreases when venous return is compromised. Supine hypotensive syndrome results in a reflex bradycardia. Cardiac output is decreased by half.

A client at 6 weeks' gestation who has type 1 diabetes is attending the prenatal clinic for the first time. The nurse explains that during the first trimester insulin requirements may decrease because: Body metabolism is sluggish in the first trimester. Morning sickness may lead to decreased food intake. Fetal requirements of glucose in this period are minimal. Hormones of pregnancy increase the body's need for insulin.

2 Morning sickness, a common occurrence during pregnancy, contributes to decreased food intake; the insulin dosage must be reduced to prevent hypoglycemia.

A client in labor is receiving an oxytocin (Pitocin) infusion. For which adverse reaction resulting from prolonged administration should the nurse monitor the client? <p>A client in labor is receiving an oxytocin (Pitocin) infusion. For which adverse reaction resulting from prolonged administration should the nurse monitor the client?</p> Change in affect Hyperventilation Water intoxication Increased temperature

3. Water intoxication Rationale Oxytocin (Pitocin) has an antidiuretic effect, acting to reabsorb water from the glomerular filtrate. Oxytocin does not alter the client's affect. Hyperventilation is caused by an inappropriate breathing pattern, not prolonged use of oxytocin. Fever occurs with infection or dehydration, not prolonged administration of oxytocin.

Which pregnant client does the nurse suspect is most likely to have placenta previa? 19 years old, gravida 1, para 0 30 years old, gravida 6, para 5 25 years old, gravida 2, para 1 40 years old, gravida 3, para 2

30 years old, gravida 6, para 5 Rationale Multiple past pregnancies can scar the endometrial lining, rendering it vulnerable to an abnormal implantation. Primigravidas are the least prone to placenta previa; the endometrium is receptive to implantation. Two pregnancies have not compromised the endometrium to the extent that an abnormal implantation is likely to occur. Age is not known to be a significant factor; also, three pregnancies should not have compromised the endometrium. had more then 4 pregancies

A client in active labor is rushed from the emergency department to the labor and birth suite screaming, "Knock me out!" Examination reveals that her cervix is dilated 9 cm. What should the nurse say while trying to calm the client? "I'll rub your back—that will help ease your pain." "You'll get a shot when you reach the birthing room." "I'm sure you're in pain, but try to bear with it for the baby's sake." "Medication may interfere with the baby's first breaths; keep breathing."

4 Analgesia crosses the placental barrier; because birth is imminent, it can cause respiratory depression in the newborn. Rationale Analgesia crosses the placental barrier ; when birth is imminent, it can cause respiratory depression in the newborn. The client is exhibiting fear and panic; a backrub at this time will not be effective and will probably be rejected. Stating that the client will get a shot when she reaches the birthing room is incorrect and provides false reassurance. Although acknowledging that the client is in pain is an empathic response, an explanation of why medication cannot be given is more appropriate in this situation.

During a childbirth class the nurse evaluates that the women understand how to use effleurage correctly when they are observed: 1. Rocking gently on their knees 2. Practicing panting to avoid pushing during labor 3. Taking deep breaths before imagined contractions 4. Massaging their abdomens gently with their fingertips

4 Effleurage is a gentle massage of the abdomen that is effective during the first stage of labor because it distracts the client from the discomfort of the contractions. 1 This is the pelvic rock; it is used during pregnancy to relieve backache. 2 This is a technique of breathing. 3 This is a technique of breathing. (Nugent 352) Nugent, Patricia M. Mosby's Review Questions for the NCLEX-RN® Examination, 7th Edition. Mosby, 2011. VitalBook file.

A local anesthetic (pudendal block) is administered to a client as second-stage labor begins. For what side effect does the nurse monitor for the client? Fewer contractions Depressed respirations Decreased blood pressure Accumulated respiratory secretions

A local anesthetic (pudendal block) is administered to a client as second-stage labor begins. For what side effect does the nurse monitor for the client? Correct3 Decreased blood pressure Mild reactions, including vertigo, dizziness, and hypotension, occur because of vasodilation resulting from direct action of these medications on the mother's pelvic blood vessels. The progress of labor is not affected by a local anesthetic administered during the second stage of labor. A local anesthetic does not affect the respiratory center in the central nervous system. Accumulated respiratory secretions are not caused by a local anesthetic administered during the second stage of labor.

A woman in labor hears the health care provider tell the nurse that the fetal lie is longitudinal. The mother asks the nurse what this means in relation to her labor and birth of the baby. How should the nurse respond? "A vaginal birth is possible." "We're anticipating a cesarean delivery." "It has no relevance to the labor and birth." "Labor probably will be long, and you might have back pain.

A longitudinal lie means that the fetus is lying parallel to the woman's spine; therefore vaginal birth is possible. A transverse, not longitudinal, lie might indicate that vaginal birth is unlikely, and cesarean birth is anticipated. The fetal lie will influence the labor and the birth of the fetus. A longitudinal lie does not indicate that the labor will be prolonged; however, if the fetal head is in the posterior occiput position, second-stage labor may be prolonged, accompanied by back pain.

A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. She tells the nurse that her membranes ruptured 26 hours ago. Assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action? Obtaining maternal vital signs Planning for an emergency birth Administering oxygen by way of nasal cannula Preparing for fetal scalp blood sampling

A prolonged period after the rupture of membranes and fetal tachycardia indicate the possibility of maternal infection; the maternal vital signs should be assessed for fever and increased pulse and respirations. Planning for an emergency birth is premature unless the fetal status deteriorates and intrauterine resuscitation efforts fail. Fetal heart rate accelerations indicate increased cardiac activity with adequate oxygenation; prolonged fetal decelerations warrant oxygen administration. Fetal scalp blood testing may be done after additional data are collected and the cause of the tachycardia is determined.

A nurse is checking the external fetal monitor of a client in active labor. Which fetal heart pattern indicates cord compression? Smooth, flat baseline tracings of 135 beats/min Abrupt decreases in fetal heart rate that are unrelated to the contractions Accelerations in the fetal heart rate of 10 beats/min above baseline Decelerations when a contraction begins that return to baseline when the contraction ends

Abrupt decreases in fetal heart rate that are unrelated to the contractions Rationale Abrupt decreases in fetal heart rate that are unrelated to the contractions are variable decelerations that indicate cord compression. These are most common during the second stage of labor and are considered benign unless the heart rate does not recover adequately. A flat baseline reading indicates decreased variability and may have many causes, but it is not related to cord compression. Fetal heart rate accelerations are not related to cord compression. Decelerations when a contraction begins that return to baseline when the contraction ends indicate head compression during contractions; they are an expected, benign finding.

A client who is pregnant for the first time expels the products of conception at 12 weeks' gestation. The client's blood type is Rh negative. What should the nurse anticipate concerning the administration of Rho(D) immune globulin (RhoGAM)? RhoGAM is not necessary if the fetus died in utero. Administer RhoGAM immediately after the miscarriage. Administer RhoGAM within 72 hours of the miscarriage. RhoGAM will not be needed because the gestation lasted less than 20 weeks.

Administer RhoGAM within 72 hours of the miscarriage. Rationale Rho(D) immune globulin (RhoGAM) should be given within 72 hours of a miscarriage or birth to have an effect on future pregnancies. RhoGAM is always indicated at the termination of a pregnancy, whether it is at term or before term and whether the fetus is alive or dead. It is not necessary to administer RhoGAM this early.

The nurse is caring for a first-time mother at her first prenatal visit. The client confides, "I'm not sure about all this." Which research-based knowledge guides a nurse regarding the emotional factors of pregnancy? A rejected pregnancy will result in a rejected infant. Ambivalence and anxiety about mothering are common. A mother's love usually develops in the first week after birth. An effective mother does not experience ambivalence and anxiety about mothering.

Ambivalence and anxiety about mothering are common. Rationale Because mothering is not an inborn instinct in human beings, almost all mothers, including multiparas, report some ambivalence and anxiety about their mothering ability. Frequently maternal feelings are bolstered by the sight of the infant. The time it takes to develop these feelings is specific to each individual. With some mothers it may take a much longer time. Ambivalent feelings are universal in response to a neonate.

One statement by a breastfeeding mother that indicates that the nurse's teaching about stimulating the let-down reflex has been successful is "I will: Take a cool shower before each feeding." Drink a couple of quarts of fat-free milk a day." Wear a snug-fitting breast binder day and night." Apply warm packs and massage my breasts before each feeding."

Apply warm packs and massage my breasts before each feeding." Rationale Applying warm packs and massaging the breasts before each feeding help dilate milk ducts, promote emptying of the breasts, and stimulate further lactation. Taking a cool shower before each feeding will contract the milk ducts and interfere with the let-down reflex. Heavy consumption of milk products is not required to stimulate the production of milk. Breast binders may inhibit lactation by fooling the body into thinking that milk secretion is no longer needed.

What is the best nursing intervention to minimize perineal edema after an episiotomy?

Applying ice packs Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides little or minimal perineal relief.

A client who is to undergo dilation and curettage, and conization of the cervix for cancer appears tense and anxious. What is the best approach for the nurse to support the client emotionally?

Asking whether something is troubling the client and whether she'd like to talk about it

What does a nurse expect to find when checking the vital signs of a client in the early postpartum period? Bradycardia with no change in respirations Tachycardia with a decrease in respirations Increased basal temperature with a decrease in respirations Decreased basal temperature with an increase in respirations

Bradycardia with no change in respirations Rationale In the postpartum period a slow pulse rate may result from a combination of factors, including decreased cardiovascular workload, emotional relief and satisfaction, and rest after labor and birth. Bradycardia is more likely; respirations generally are unchanged. The temperature may rise slightly, but usually respirations are unchanged.

A client in active labor becomes very uncomfortable and asks a nurse for pain medication. Nalbuphine (Nubain) is prescribed. How does this medication relieve pain? By producing amnesia By acting as a preliminary anesthetic By inducing sleep until the time of birth By acting on opioid receptors to reduce pain

By acting on opioid receptors to reduce pain Rationale Nalbuphine (Nubain) is classified as an opioid analgesic and is effective in relieving pain; it induces little or no newborn respiratory depression. Nalbuphine does not induce amnesia, act as an anesthetic, or induce sleep.

A nurse is teaching a prenatal class about the changes that occur during the second trimester of pregnancy. What cardiovascular changes should the nurse include?

Cardiac output increases Blood pressure decreases The heart is displaced upward.

Postpartal hemorrhage indicates loss of greater than 500 mL of blood after the end of the third stage of labor.

Causes of early postpartal hemorrhage include uterine atony (relaxation of the uterus), laceration of the genital tract, and retained placental fragments. Factors in Maureen's history that contribute to the potential for hemorrhage include: overdistention of the uterus due to a large infant, the trauma of a forceps delivery, a prolonged labor, and the use of oxytocin.

A client with severe preeclampsia is receiving an IV infusion of magnesium sulfate. The nurse remembers that magnesium sulfate is a: Hypotensive that relaxes smooth muscles Cholinergic that increases the release of acetylcholine Muscle relaxant that decreases the severity of uterine contractions Central nervous system depressant that blocks neuromuscular transmissions

Central nervous system depressant that blocks neuromuscular transmissions Rationale Eclamptic seizures may be prevented with the administration of IV magnesium sulfate, which is a central nervous system depressant. Although magnesium sulfate is a neuromuscular sedative that relaxes smooth muscle and decreases blood pressure, it is not considered an antihypertensive and is not given for that purpose. Magnesium sulfate decreases, not increases, the quantity of acetylcholine. Decreased uterine contractions are not associated with magnesium sulfate administration.

A nurse determines that a newborn has a cephalhematoma. What did the nurse note? <p>A nurse determines that a newborn has a cephalhematoma. What did the nurse note?</p> Ridges where the cranial bones overlap Edema involving the scalp over the occipital area Pulsation of the cerebral arteries in the anterior and posterior fontanels Bleeding between the parietal bone and periosteum confined within the suture line

Cephalhematoma is a collection of blood localized between the periosteum and the bony cranium caused by the rupture of blood vessels during the birth process; it does not cross suture lines. Overriding sutures cause ridges, not swelling. Edema involving the scalp over the occipital area is a description of caput succedaneum, which results from pressure on the occiput during labor; it is outside the periosteum and spreads throughout the scalp. Pulsations may be seen and palpated in the anterior fontanel, but they are not related to a cephalhematoma.

A neonate is tested for phenylketonuria (PKU) after formula feedings are initiated. The nurse explains to the parents that this is done to prevent: Failure to thrive Cognitive Impairment Growth restriction Specific food allergies

Cognitive Impairment Rationale Screening for PKU facilitates early diagnosis and treatment, which can prevent cognitive impairment. Although children with untreated PKU do have problems with physical growth and may exhibit failure to thrive, the major purpose of the test is to prevent the development of cognitive impairment. Telling the parent that this test is performed to prevent specific food allergies is not accurate because this is not a test for food allergies; it tests for an inborn error of metabolism, PKU.

Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer? <p>Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer?</p> Clopidogrel (Plavix) Warfarin (Coumadin) Continuous infusion of heparin Intermittent doses of a low molecular weight heparin

Continuous infusion of heparin Rationale Heparin is the medication of choice during the acute phase of a deep vein thrombosis; it prevents conversion of fibrinogen to fibrin and of prothrombin to thrombin. Clopidogrel (Plavix) is a platelet aggregate inhibitor and is used to reduce the risk of a brain attack. Warfarin (Coumadin), a long-acting oral anticoagulant, is started after the acute stage has subsided; it is continued for 2 to 3 months. A low molecular weight heparin (e.g., enoxaparin [Lovenox]) is not administered during the acute stage; it may be administered later to prevent future deep vein thromboses.

A 24-year-old client complains to the nurse in the women's health clinic that her breasts become tender before her menstrual period. What should the nurse recommend that the client do 1 week before an expected menses? Take salt tablets daily Increase protein intake Eliminate daily exercise Decrease caffeine intake

Decrease caffeine intake Rationale The client is exhibiting one symptom of premenstrual syndrome (PMS); eliminating food and beverages containing caffeine can limit breast swelling. Salt intake should be reduced premenstrually to limit the development of edema. Increased protein intake is unnecessary if the client is eating a nutritious diet. Exercise should be increased before the menstrual period to help ease the symptoms of PMS.

A 37-year-old client with endometriosis visits the women's health clinic because she has dysmenorrhea and dyspareunia. What is a description of dysmenorrhea? Pain with menses Endometrial hyperplasia Bleeding between menses Heavy bleeding with menses

Dysmenorrhea is defined as pain with menses. Endometrial hyperplasia results from anovulation and persistent estrogen stimulation. Bleeding between menses is metrorrhagia. Heavy bleeding with menses is menorrhagia.

Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For what condition should the nurse assess the newborn? Cardiac defect Kidney disorder Diabetes mellitus Esophageal atresia

Esophageal atresia Rationale: Esophageal atresia is associated with hydramnios. Cardiac defects are not associated with hydramnios. Kidney disorders are associated with oligohydramnios, not hydramnios. Diabetes in the newborn is not associated with hydramnios.

A nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On what information about pregnant women with diabetes should the nurse base the response? Taking exogenous insulin stimulates fetal growth. Consuming more calories covers the insulin secreted by the fetus. Extra circulating glucose causes the fetus to acquire fatty deposits. Fetal weight gain increases as a result of the common response of maternal overeating.

Extra circulating glucose causes the fetus to acquire fatty deposits. Rationale It is difficult to maintain maternal normoglycemia throughout pregnancy; excess glucose passes into the fetus, in whom it is converted to fat. The problem is excess glucose, which is why exogenous insulin must be administered. Although all pregnant women consume extra calories to meet the increased metabolism associated with pregnancy, fetal insulin does not pass from the fetus to the mother. Stating that fetal weight gain increases because pregnant women commonly overeat is a stereotypical statement; not all clients with diabetes overeat.

The nurse is caring for a group of postpartum clients. Which factor puts a client at increased risk for postpartum hemorrhage? Breastfeeding in the birthing room Receiving a pudendal block for the birth Having a third stage of labor that lasts 10 minutes Giving birth to a baby weighing 9 lb 8 oz

Giving birth to a baby weighing 9 lb 8 oz Rationale The chance of postpartum hemorrhage is five times greater with large infants because uterine contractions may be impaired after the birth. Early breastfeeding will stimulate uterine contractions and lessen the chance of hemorrhage. Having a pudendal block for the birth does not contribute to postpartum hemorrhage, because the anesthetic for a pudendal block does not affect uterine contractions. Ten minutes is a short third stage; a prolonged third stage of labor, 30 minutes or more, may lead to postpartum hemorrhage.

The nurse is teaching a prenatal class to expectant mothers in their first trimester of pregnancy. In addition to discussing the need for 0.6 mg/day of folic acid replacement, which dietary choice that is high in folic acid should the nurse recommend? One egg Slice of bread Half cup of corn Half cup of cooked spinach

Half cup of cooked spinach A half cup of cooked spinach provides 100 mcg of folic acid per serving. One egg, a slice of bread, and half a cup of corn each provides only 20 mcg per serving.

Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL. The nurse explains that what the infant has is physiological jaundice, a benign condition, caused by: <p>Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL. The nurse explains that what the infant has is physiological jaundice, a benign condition, caused by:</p> Immature liver function An inability to synthesize bile An increased maternal hemoglobin level A high hemoglobin and low hematocrit level

IMMATURE LIVER FUNCTION Rationale Jaundice occurs because of the expected physiological breakdown of fetal red blood cells and the inability of the newborn's immature liver to conjugate the resulting bilirubin. Breastfed neonates are more prone to physiological jaundice because of diminished calorie and fluid intake in the 3 days before milk production reaches normal volume. Conjugation and excretion, not synthesis of bile, are compromised because of the immature liver. The mother's hemoglobin level is unrelated to the newborn's; the mother and the fetus had separate circulations. Newborns usually have high hemoglobin and high hematocrit levels.

A client at 36 weeks' gestation exhibits oligohydramnios. What newborn complication should the nurse anticipate? <p>A client at 36 weeks' gestation exhibits oligohydramnios. What newborn complication should the nurse anticipate?</p> Spina bifida Imperforate anus Tracheoesophageal fistula Intrauterine growth restriction (IUGR)

Intrauterine growth restriction (IUGR) Rationale Oligohydramnios is associated with IUGR; risk factors for IUGR include inadequate maternal nutrition and other high-risk conditions such as diabetes and preeclampsia. Spina bifida does not affect amniotic fluid volume; it is associated with an increased alpha-fetoprotein level. Imperforate anus does not affect amniotic fluid volume. Tracheoesophageal fistula is often associated with polyhydramnios, which is excessive amniotic fluid.

A client in the 38th week of gestation exhibits a slight increase in blood pressure. The health care provider advises her to remain in bed at home in a side-lying position. The client asks why this is important. What is the nurse's response regarding the advantage of this position? It increases blood flow to the fetus. Decreases intra-abdominal pressure. It increases the mean arterial pressure. It prevents the development of thrombosis.

It increases blood flow to the fetus. Rationale The side-lying position decreases blood pressure and moves the gravid uterus off the great vessels of the lower abdomen, increasing venous return, improving cardiac output, and promoting kidney and placental perfusion. The side-lying position does not influence intra-abdominal pressure. While a pregnant woman is on bedrest the blood pressure decreases. The side-lying position does not prevent thrombosis; bedrest and immobility may increase the risk of thrombosis.

A pregnant client interested in childbirth education asks how the Lamaze method differs from the Read method. What should the nurse explain about the Lamaze method? It is an easier method to teach and learn. It provides relaxation and techniques that can be used during labor. It is a natural approach based on childbirth without pain. It avoids the use of pain-relieving medications during labor.

It provides relaxation and techniques that can be used during labor. Rationale There is much to be learned and practiced so that the client can vary the breathing and relaxation techniques of Lamaze through the stages of labor. The Read method can be quickly taught to an "unprepared" woman in labor. The Read method, not the Lamaze method, focuses on naturalness and denial of pain. Medication use is acceptable, if required, in the Lamaze method.

The nurse in the postpartum unit is teaching self-care to a group of new mothers. What color does the nurse teach them that the lochial discharge will be on the fourth postpartum day? <p>The nurse in the postpartum unit is teaching self-care to a group of new mothers. What color does the nurse teach them that the lochial discharge will be on the fourth postpartum day?</p> Dark red Deep brown Pinkish brown Yellowish white

Lochia serosa is the expected vaginal discharge between the third and 10th postpartum days; it is pinkish to brownish and consists of serous exudate, shreds of degenerating decidua, erythrocytes, leukocytes, cervical mucus, and numerous microorganisms. Lochia rubra is the expected vaginal discharge on the first 2 or 3 postpartum days; it is dark red and consists of epithelial cells, erythrocytes, leukocytes, shreds of decidua, and occasionally fetal meconium, lanugo, and vernix caseosa. Lochia is never dark brown. Lochia alba is the expected vaginal discharge about 10 days postpartum; it persists for 1 to 2 weeks. A creamy or yellowish color, it consists of leukocytes, decidual cells, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.

A client gives birth to a baby weighing 7 lb 2 oz and decides to breastfeed. The nurse is instructing the client regarding breastfeeding. What should the nurse tell the client to expect? 1 Weight loss will occur rapidly. 2 Lochial flow will be increased. 3 Uterine involution will be delayed. 4 Cold compresses will promote lactation

Lochial flow will be increased. Rationale Breastfeeding stimulates oxytocin release and uterine contractions, resulting in increased lochial flow. Weight loss may occur more slowly in the breastfeeding mother because of increased nutritional and caloric intake. The increased level of oxytocin and subsequent uterine contractions will enhance involution. Although cold compresses applied to the breasts may ease the discomfort of engorgement, they will also depress milk production. Warm compresses are preferred for the breastfeeding mother.

After a cesarean birth a nurse performs fundal checks every 15 minutes. The nurse determines that the fundus is soft and boggy. What is the priority nursing action at this time? Elevating the client's legs Massaging the client's fundus Increasing the client's oxytocin drip rate Examining the client's perineum for bleeding

Look for the word Boggy inorder to massage fundus Gentle massage stimulates muscle fibers, resulting in firming the tone of the fundus; it also helps expel any clots that may be interfering with contraction of the fundus. Elevating the client's legs will increase return of blood from the extremities but will not improve the tone of the client's fundus. Increasing the client's oxytocin drip rate will be done if uterine massage is ineffective. Examining the client's perineum for bleeding should not be the first action at this time; gentle massage to contract the fundus is the priority.

A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? (Select all that apply.) "My ears are ringing." "It gets better when I lie down." "Bright lights really bother my eyes." "It gets better as soon as I walk a while." "My head hurts more when I'm sitting watching TV." "My head hurts more when I'm lying on my side breastfeeding."

My ears are ringing." "It gets better when I lie down." "Bright lights really bother my eyes." My head hurts more when I'm sitting watching TV." Rationale Central nervous system irritation can cause auditory problems such as tinnitus. A headache resulting from spinal anesthesia usually occurs 24 to 72 hours after administration. Postural changes cause the diminished volume of cerebrospinal fluid to exert traction on pain-sensitive central nervous system structures. The client is most comfortable when lying flat. Central nervous system irritation can cause visual problems such as photophobia and blurred vision. This type of headache will worsen when the client is ambulatory or assumes an upright position.

The nurse teaches a pregnant client why she needs a folic acid supplement. Which neonatal disorder does folic acid prevent? Phenylketonuria Down syndrome Neural tube defects Erythroblastosis fetalis

Neural tube defects Rationale A folic acid supplement (0.4 mg/day) greatly reduces the incidence of fetal neural tube defects. Phenylketonuria is a genetic disorder that cannot be prevented by the action of folic acid. Down syndrome is a genetic disorder that cannot be prevented by the action of folic acid. Erythroblastosis fetalis is related to the Rh factor and is not prevented by the action of folic acid.

A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an α-fetoprotein test. She asks the nurse, "What does this test do?" The nurse bases the response on the knowledge that this test can reveal:

Neural tube defects Rationale The α-fetoprotein test can detect not only neural tube defects but also Down syndrome and other congenital anomalies. It is a screening test that affords a tentative diagnosis; confirmation requires more definitive testing. Anomalies of the kidneys, heart, and urinary tract are not revealed by the α-fetoprotein test.

A nurse in the newborn nursery is monitoring an infant for jaundice related to ABO incompatibility. What blood type does the mother usually have to cause this incompatibility? A B O AB

O Rationale Mothers with type O blood have anti-A and anti-B antibodies that are transferred across the placenta. This is the most common incompatibility because the mother is type O in 20% of all pregnancies. Blood types A, B, and AB usually are not a problem.

A client at 40 weeks' gestation is admitted to the birthing unit in labor. During the initial examination the nurse uses Leopold maneuvers to palpate the abdomen. The purpose of this intervention is to assess the: Station of the fetus Position of the fetus Duration of the contractions Frequency of the contractions

Position of the fetus

Women who become pregnant for the first time at a later reproductive age (35 years or older) are at risk for what complications? (Select all that apply.) Seizures Preterm labor Multiple gestation Chromosomal anomalies Bleeding in the first trimester

Preterm labor Multiple gestation Chromosomal anomalies Bleeding in the first trimester Rationale Increased risk for preterm labor is age associated; it occurs more commonly in older primigravidas and adolescents. Mature women have an increased incidence of multiple gestations as a result of fertility drug use and in vitro fertilization. After 35 years of age, mature women have an increased risk of having children with chromosomal abnormalities. Bleeding in the first trimester as a result of spontaneous abortion occurs more frequently in mature gravidas. Seizures are not seen more frequently in mature gravidas.

A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at -2. For what complication should the nurse assess when caring for this client? Vaginal bleeding Urinary tract infection Prolapse of the umbilical cord Meconium in the amniotic fluid

Prolapse of the umbilical cord Rationale A breech presentation results in a larger space between the cervix and the fetal sacrum than does a vertex presentation. When the client is a multipara, the muscle tone of the cervix may be relaxed; therefore the umbilical cord may prolapse and become compressed, leading to fetal hypoxia and potential fetal demise. Unless there are other complications, vaginal bleeding is not expected. A urinary tract infection is not related to a breech presentation. As the fetal sacrum is compressed during labor, meconium may be expelled; this is not a fetal life-threatening concern with a breech presentation.

What characteristics cause the nurse to suspect that a newborn has Down syndrome? (Select all that apply.)

Protruding tongue Epicanthal eye folds One transverse palmar crease

A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse whether there is any medication that can stop the contractions. What is the nurse's response? <p>A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse whether there is any medication that can stop the contractions. What is the nurse's response?</p> "An oxytocic." "An analgesic." "A corticosteroid." "A beta-adrenergic."

Rationale Beta-adrenergic medications are tocolytic agents that may halt labor, although only temporarily. Other tocolytics that may be used are magnesium sulfate, prostaglandin inhibitors, and calcium channel blockers. Oxytocin is a hormone that is secreted by the posterior pituitary gland; it stimulates contractions and is released after birth to initiate the let-down reflex. Analgesics do not halt preterm labor. Corticosteroids do not halt labor; they are used during preterm labor to accelerate fetal lung maturity, when birth is likely to occur within 24 to 48 hours.

What should the nurse explain to a newly pregnant client with cardiac disease? <p>What should the nurse explain to a newly pregnant client with cardiac disease?</p> Palpitations are expected as pregnancy progresses. Other cardiac medications will be substituted for digoxin. It is not safe to administer prophylactic penicillin during pregnancy. Maintenance dosages of cardiac medications will probably be increased.

Rationale During the second and third trimesters blood volume and cardiac output increase, placing a greater workload on the heart. Women with preexisting heart disease may require larger doses of cardiac medication to prevent cardiac decompensation. Palpitations may occur when the heart rate reaches 120 beats/min. A heart rate of more than 100 beats/min may be an indicator of cardiac decompensation; further assessment and treatment are required. Digoxin (Lanoxin) is a category C medication and is prescribed during pregnancy. Penicillin is a category B medication and is relatively safe to take during pregnancy.

The gravida 1 now para 1 woman delivered a 7-lb 6 oz female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks that the baby be picked up so she can take a nap. What behavior is the new mother demonstrating? <p>The gravida 1 now para 1 woman delivered a 7-lb 6 oz female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks that the baby be picked up so she can take a nap. What behavior is the new mother demonstrating?</p> Taking-in Letting-go Taking-hold Bonding failure

Rationale During the taking-in period the mother focuses on her needs rather than the baby's. During this period the mother needs to be "mothered" so she can assume the role of mother. The letting-go period is when the mother wants to take control and "mother" the infant. The taking-hold period is when the mother is anxious to learn about the infant and how to care for it. This mother shows positive behaviors, including smiling, kissing, and holding. There is no evidence of a failure to bond.

A nurse is caring for a client with placenta previa who is in labor. What action is most important for the nurse to take? Inserting an internal fetal monitor Performing frequent vaginal examinations Evaluating external blood loss by counting pads Monitoring for a decrease in the height of the fundus

Rationale Evaluating external blood loss by counting pads will indicate whether bleeding is progressing toward maternal or fetal compromise. Attempting to insert an internal fetal monitor is contraindicated because the placenta will be disturbed; an external fetal monitor should be applied. Vaginal examinations are contraindicated because they may stimulate more bleeding if the placenta is dislodged. The height of the fundus will increase, not decrease, as blood accumulates in the uterus.

A primigravida at 8 weeks' gestation is visiting the prenatal clinic for the first time. What should an examination reveal at this time? Lightening Quickening Goodell's sign Braxton Hicks sign

Rationale Goodell's sign, or softening of the cervix, occurs at 8 to 9 weeks' gestation. Lightening or settling of the fetal presenting part into the pelvis usually occurs about 2 weeks before the onset of labor in nulliparas. Quickening refers to fetal movement, usually perceived by the mother between the 16th and 20th weeks of gestation. Braxton Hicks (preparatory) contractions consist of intermittent cramp like contractions that start at the 16th week and grow stronger and more frequent as pregnancy progresses.

A client in labor is admitted with a suspected breech presentation. For what occurrence should the nurse be prepared? Uterine inertia Prolapsed cord Imminent birth Precipitate labor

Rationale The feet or buttocks do not block the cervical opening effectively, and the cord may slip through and be compressed. Uterine inertia may result from fatigue or cephalopelvic disproportion; it is not related to fetal position. When a fetus is in the breech presentation the labor is usually long and difficult. Rapid dilation and precipitate labor may occur with fetuses in the cephalic position as well as the breech position

A primigravida is admitted to the birthing unit in active labor. The fetus is in a breech presentation. What physiological response does the nurse expect during this client's labor? Heavy vaginal bleeding Fetal heart rate irregularities Greenish-tinged amniotic fluid Severe back pain with contractions

Rationale Greenish amniotic fluid is common in a breech presentation because the contracting uterus exerts pressure on the fetus' lower colon, forcing the expulsion of meconium. Mild bloody show is expected; a heavier flow is a deviation from the expected response and not a common finding with breech presentations. Fetal heart rate irregularities are not specific to a breech presentation. Severe back pain is more likely to occur when the fetus is in a cephalic presentation and the occiput is in the posterior position.

A nurse plans to evaluate a postpartum client's uterine fundus for involution. What should the nurse ask the client to do before this assessment? Drink fluids. Empty her bladder. Perform the Valsalva maneuver. Assume the semi-Fowler position.

Rationale Having the client empty her bladder will help ensure accurate assessment of fundal height. A full bladder may promote a boggy uterus and may elevate the uterus upward and toward the client's right side. There is no need to drink fluids before this assessment; however, the client should drink at least 2 L of fluid a day during the postpartum period. The Valsalva maneuver has no effect on the assessment of fundal height. Assessing the fundus while the client is in the semi-Fowler position will result in an inaccurate assessment. The bed should be flat, and the client should assume the supine position.

A primigravida at 34 weeks' gestation tells the nurse that she is beginning to experience some lower back pain. What should the nurse recommend that the client do? (Select all that apply.) Wear low-heeled shoes. Wear a maternity girdle during waking hours. Sleep flat on her back with her feet elevated. Perform pelvic tilt exercises several times a day. Take an ibuprofen (Motrin) tablet at the onset of back pain.

Rationale Low-heeled shoes help maintain her center of gravity to counterbalance the gravid uterus. Pelvic tilt exercises help relieve lower backaches, are easily learned, and can be done without any equipment. A maternity girdle is not routinely recommended. Sleeping flat during this stage of pregnancy decreases venous return, impedes respiration, and puts pressure on the vena cava, which can cause uteroplacental insufficiency. Nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) should be avoided during pregnancy, and the prescription of medications is beyond the scope of nursing practice.

Thirty minutes after a client gives birth, the nurse palpates the client's uterus. It is relaxed and the lochia is excessive. What is the nurse's initial action? Check vital signs Massage the uterus Notify the practitioner Elevate the foot of the bed

Rationale Massaging the uterus will induce uterine contraction and cause expulsion of clots; frequent massage should be continued to keep the uterus firm and inhibit bleeding. Pulse and blood pressure do not change significantly unless large amounts of blood are lost. If bleeding continues after the fundus is massaged, the practitioner should be notified. Placing the client in the Trendelenburg position is appropriate if the client is in shock, but the data do not indicate shock.

A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C); pulse, 70 beats/min; respirations, 18 breaths/min; and blood pressure, 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication may cause respiratory depression in the newborn? Naloxone (Narcan) Lorazepam (Ativan) Meperidine (Demerol) Promethazine (Phenergan)

Rationale Meperidine (Demerol) is an opioid that can cause respiratory depression in the neonate if administered less than 4 hours before birth. Naloxone (Narcan) is an opioid antagonist that reverses the effects of respiratory depression in the newborn. Lorazepam (Ativan) is a sedative; it does not cause respiratory depression in the newborn, but it does not relieve pain by itself. Promethazine (Phenergan) is a tranquilizer; it does not cause respiratory depression in the newborn. Promethazine does not relieve pain by itself.

A nurse is caring for a new mother who has a chlamydial infection. Which complications are associated with chlamydial infections in neonates? (Select all that apply.) Pneumonia Preterm birth Microcephaly Conjunctivitis Congenital cataracts

Rationale Pneumonia may develop in the newborn with a chlamydial infection; oral antibiotics such as erythromycin may be required. Preterm birth is a common complication of chlamydial infection. Ophthalmia neonatorum (neonatal conjunctivitis) is common in newborns whose mothers have chlamydial infection; ophthalmic antibiotic ointments are administered to all newborns prophylactically. Microcephaly is more likely to occur in newborns with severe infections of toxoplasmosis or cytomegalovirus. Cataracts may occur in a newborn whose mother had rubella during pregnancy. Pneumonia Preterm birth Conjunctivitis

When a nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. What is the most important measure for the nurse to take? Giving the infant to the mother Having the visitor step outside the room Verifying the infant's and mother's identification bands Asking the visitor whether the coughing and sneezing are caused by a cold

Rationale Protection of newborns from unnecessary exposure to microorganisms is the priority. Giving the infant to the mother should not be done until the mother and newborn's identification bands have been verified. Verifying the infant's and the mother's identification bands should be done after the visitor leaves the room. Asking the visitor whether the coughing and sneezing are caused by a cold is a discussion that should take place outside the room. The visitor should be asked to leave if indications of an infection are present.

While auscultating the lungs of a client admitted with severe preeclampsia, the nurse identifies crackles. What inference does the nurse make when considering the presence of crackles in the lungs? <p>While auscultating the lungs of a client admitted with severe preeclampsia, the nurse identifies crackles. What inference does the nurse make when considering the presence of crackles in the lungs?</p> Seizure activity is imminent. Pulmonary edema has developed. Bronchial constriction was precipitated by the stress of pregnancy. Impaired diaphragmatic function was caused by the enlarged uterus.

Rationale Pulmonary edema is associated with severe preeclampsia ; as vasospasms worsen, capillary endothelial damage results in capillary leakage into the alveoli. Crackles are not an indication of an impending seizure; signs of an impending seizure include hyperreflexia, developing or worsening clonus, severe headache, visual disturbances, and epigastric pain. Pregnancy does not precipitate bronchial constriction, although the hormones associated with pregnancy can cause nasal congestion. Impaired diaphragmatic function is a discomfort associated with pregnancy that may result in shortness of breath or dyspnea, not crackles.

A nurse is planning to teach a new mother about breastfeeding. What should the nurse consider before preparing the client to breastfeed? Oxytocin stimulates milk production. Suckling stimulates the release of oxytocin. Estrogen stimulates the secretion of lactogenic hormones. Placental separation stimulates the release of progesterone.

Rationale Suckling or nipple stimulation precipitates the release of oxytocin, which initiates the let-down reflex. The hormone prolactin stimulates milk production. Estrogen inhibits the secretion of lactogenic hormones. Placental separation triggers the hormonal changes of the postpartum period.

On her first postpartum day, a client asks the nurse whether her baby has had a test for phenylketonuria (PKU) yet. How should the nurse reply? "The test won't be done until your baby reaches 10 lb." "The test won't be done today because newborns have sluggish circulation." "The test won't be done until your baby has had enough milk for the results to be accurate." "The test won't be done today because a newborn's liver doesn't produce enough enzymes before 7 days."

Rationale The PKU test cannot be done until the newborn has ingested a high-phenylalanine (formula or breast milk) diet for at least 24 hours. The test may be performed with the newborn at any weight; the important factor is the ingestion of milk for at least 24 hours to obtain a reading. The sluggish circulation of the newborn is not the reason that the test is not being done at this time. Measurable enzymes are produced after the infant has ingested milk for at least 24 hours.

A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? (Select all that apply.) Thin upper lip Wide-open eyes Small upturned nose Larger-than-average head Smooth vertical ridge in the upper lip

Rationale The abnormal facies associated with FAS includes a thin upper lip (vermilion), a small upturned nose, and a smooth vertical ridge (philtrum) in the upper lip, all of which are distinctive in these infants. Infants with FAS have small eyes with epicanthic folds, rather than wide-open eyes, as well as microcephaly (head circumference less than the tenth percentile), rather than a larger-than-average head.

A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity? <p>A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?</p> Oxygen Naloxone Calcium gluconate Suction equipment

Rationale The antagonist of magnesium sulfate is calcium gluconate. Oxygen is ineffective if the action of magnesium is not reversed. Naloxone is unnecessary; it is an opioid antagonist. Suction equipment may be necessary if the client has excessive secretions after a seizure. The priority intervention is trying to prevent a seizure.

The parents of a newborn are told that their neonate may have Down syndrome and that additional diagnostic studies will be done to confirm this diagnosis. What procedure does the nurse expect to be performed? 1 Heel stick 2 Buccal smear 3 Urinary catheterization 4 Venous blood withdrawal

Rationale The cells in the buccal smear provide a pictorial analysis of chromosomes and show chromosomal abnormalities such as the trisomy found in Down syndrome. Blood from the heel stick is tested for inborn errors of metabolism such as phenylketonuria. Urine is not used to assess chromosomal aberrations; neither is venous blood.

The partner of a woman in labor is having difficulty timing the frequency of contractions and asks the nurse to review the procedure. How should contractions be timed? From the end of one contraction to the end of the next contraction From the end of one contraction to the beginning of the next contraction From the beginning of one contraction to the end of the next contraction From the beginning of one contraction to the beginning of the next contraction

Rationale The frequency of contractions is timed from the beginning of one contraction to the beginning of the next; this is the definition of one contraction cycle. The beginning, not the end, of a contraction is the starting point for timing the frequency of contractions. The time between the end of one contraction and the beginning of the next contraction is the interval between contractions. Timing from the beginning of one contraction to the end of the next contraction is too long a time frame and will produce inaccurate information.

A vaginal examination reveals that a client in labor is dilated 7 cm. Soon afterward she becomes nauseated and has the hiccups, and bloody show increases. What phase of labor does the nurse determine the client is entering? Latent Active Transition Early active

Rationale The transition phase is the most difficult phase of labor . Characterized by restlessness, irritability, nausea, and increased bloody show, it continues from 8 to 10 cm of dilation. The latent phase is early labor (1-4 cm of dilation). It is relatively easy to tolerate and the client generally is in control and not too uncomfortable. The active phase lasts from about 6 to 8 cm of dilation. It is difficult but is not accompanied by nausea, irritability, or an increase in bloody show. The early active phase lasts from about 4 to 6 of cm dilation. It is difficult but is not accompanied by nausea, irritability, or an increase in bloody show.

A client is receiving antibiotics and antifungal medications for the treatment of a recurring vaginal infection. What should the nurse encourage the client to do to compensate for the effect of these medications? Eat yogurt daily Avoid spicy foods Drink more fruit juices Take a multivitamin every day

Rationale Yogurt contains Lactobacillus acidophilus, which replaces the intestinal flora destroyed by antibiotics. The other options are not relevant to antibiotics or intestinal flora.

A client who is at risk for seizures as a result of severe preeclampsia is receiving an IV infusion of magnesium sulfate. What findings cause the nurse to determine that the client is showing signs of magnesium sulfate toxicity? (Select all that apply.) Proteinuria Epigastric pain Respirations of 10/min Loss of patellar reflexes Urine output of 40 mL/hr

Respirations of 10/min Loss of patellar reflexes Rationale A high level of magnesium sulfate may depress respirations; if respirations are fewer than 12 breaths/min, immediate treatment is warranted. Toxicity results in diminished flexes or an absence of them; hypertonic (hyperactive) reflexes are related to preeclampsia. Magnesium sulfate toxicity is not accompanied by proteinuria; proteinuria is a sign of preeclampsia. Epigastric pain is associated with severe eclampsia, not magnesium sulfate toxicity. Urine output of 40 mL/hr is an acceptable output; an output of less than 30 mL/hr may contribute to the development of a toxic level of magnesium.

A 37-year-old client with a nontender palpable breast mass has a questionable mammogram. She is undergoing further diagnostic tests to determine whether the mass is malignant. What information should the nurse take into consideration before planning health teaching for this client? Squamous cell carcinomas are neoplasms arising from glandular tissues. Results of a biopsy are necessary before a specific form of therapy is selected. Mammographies should be repeated to confirm the presence of malignancies. Waiting for several weeks before receiving confirmation of cancer is helpful to the client.

Results of a biopsy are necessary before a specific form of therapy is selected. Rationale The therapy selected depends on whether there is a malignancy and, if so, the type of cancer cells, the extent of nodal involvement, and the presence and extent of metastasis. Adenocarcinomas, not squamous cell carcinomas, arise from glandular tissue; squamous cell carcinomas arise from epithelial tissue. Only a biopsy will confirm the diagnosis of a malignancy. Waiting several weeks for a diagnosis is not advisable; an extended waiting period increases the client's stress and anxiety.

A nurse is observing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? (Select all that apply.) Sneezing Hyperactivity High-pitched cry Exaggerated Moro reflex Reduced deep tendon reflexes

Sneezing Hyperactivity High-pitched cry Rationale Neurological signs of withdrawal in a neonate of an opioid-addicted mother are manifested by sneezing. Other signs exhibited by neonates undergoing withdrawal are hyperactivity and jitteriness and a shrill, high-pitched cry. The Moro reflex usually becomes weaker as the signs of withdrawal become apparent. The deep tendon reflexes are exaggerated during opioid withdrawal.

A nurse is assessing a newborn with a myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus?

Tense fontanels, high-pitched cry, A defect in the lumbosacral area

When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse do to confirm that the membranes have ruptured?

Test the leaking fluid with nitrazine paper

A client at 16 weeks' gestation is scheduled for a sonogram followed by amniocentesis. The nurse instructs the client to drink 8 oz of fluid and not void before the sonogram. The nurse explains that this is done: To improve visualization of the fetus To hydrate the mother and increase circulation To hydrate the fetus and decrease fetal movement To replace fluid lost during the procedure

To improve visualization of the fetus Rationale A full bladder puts uterus in the optimal position for imaging because it raises the uterus out of the pelvis. Increased circulation is not required before a sonogram and amniocentesis. The purpose of increasing maternal fluid intake before the sonogram is not to hydrate the fetus or decrease fetal movement. After amniocentesis, hydration is encouraged to decrease uterine activity caused by the amniocentesis and support fluid volume.

What should the nurse do when an apnea monitor sounds an alarm 10 seconds after cessation of respirations? Assess for changes in skin color Use tactile stimuli on the chest or extremities Check the monitor for signs of a malfunction Resuscitate with a face mask and an Ambu bag

Use tactile stimuli on the chest or extremities The nurse applies tactile stimulation after confirming that respirations are absent; this action may be sufficient to reestablish respirations in the high-risk neonate with frequent episodes of apnea.

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department? Warming the newborn Clamping the umbilical cord Assessing maternal bleeding Monitoring expulsion of the placenta

Warming the newborn Rationale Immature thermoregulation necessitates warming the newborn to prevent neonatal hypothermia. The cord may be left intact until the newborn's temperature has stabilized, after which it may be clamped. It is too soon to evaluate the hemorrhagic condition of the mother; the placenta has not yet been expelled. The expulsion of the placenta is not a concern; it may not separate for 30 minutes.

When is it most important for a female client to know that a fetus may be structurally damaged by the ingestion of drugs? During early adolescence Throughout the entire pregnancy When she is planning to become pregnant At the beginning of the first trimester

When she is planning to become pregnant Rationale The greatest danger of drug-induced malformations is in the first trimester of pregnancy, during the period of organogenesis; because a woman may not know that she is pregnant, she should be aware of this possibility before becoming pregnant. Although adolescent girls may be made aware of the risk of damage to the fetus posed by drugs, it is not a priority concern at this time. Drugs should be avoided throughout pregnancy, but the first trimester (period of organogenesis) is the most critical. If the client is not aware of her pregnancy, it may be too late to discontinue drug use.

A nurse is teaching a prenatal class about smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching? Low birth weight Facial abnormalities Chronic lung problems Hyperglycemic reactions

low birth weight Rationale Smoking during pregnancy causes a decrease in placental perfusion, resulting in a newborn who is small for gestational age (SGA). Facial abnormalities and developmental restriction may occur if the woman ingests alcoholic drinks during pregnancy, resulting in fetal alcohol syndrome. Smoking during pregnancy and chronic lung problems in newborns are not related. Maternal smoking may result in a SGA neonate; these neonates may experience hypoglycemia, not hyperglycemia.

A newborn's birth was prolonged because the shoulders were very wide. With which reflex does the nurse anticipate a problem? Moro Plantar Babinski Stepping

moro Rationale A difficult birth because of broad fetal shoulders may result in a fractured clavicle, as evidenced by a knot or lump, limited arm movement, and a unilateral Moro reflex . Plantar reflex is unrelated to a difficult birth caused by a fetus with broad shoulders. Babinski reflex involves the feet; it is not related to a difficult birth caused by a fetus with broad shoulders. Stepping reflex involves the feet; it is not related to a difficult birth caused by a fetus with broad shoulders.

At 32 weeks' gestation a client undergoes ultrasound, which reveals a low-lying placenta. What complication should the nurse anticipate as the client's pregnancy approaches term? Sharp abdominal pain Painless vaginal bleeding Increased lower back pain Early rupture of membranes

painless vagina bleeding Rationale Because the process of effacement occurs in the latter part of pregnancy, placental separation from the uterus may occur, causing painless bleeding. There is pain with premature separation of a normally implanted placenta (abruptio placentae). Lower back pain is not associated with placenta previa. Rupture of membranes usually does not occur before the placenta starts to separate.

A mother asks the neonatal nurse why her infant must be monitored for hypoglycemia when her type 1 diabetes was in excellent control during her pregnancy. How should the nurse respond? "A newborn's glucose level drops after birth, so we're being especially cautious with your baby because of your diabetes." "A newborn's pancreas produces an increased amount of insulin during the first day of birth, so we're checking to see whether hypoglycemia has occurred." "Babies of mothers with diabetes do not have large stores of glucose at birth, so it's difficult for them to maintain the blood glucose level within an acceptable range." "Babies of mothers with diabetes have a higher -than -average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."

"Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop." Rationale The infant of a diabetic mother (IDM) produces a higher level of insulin in response to the increased maternal glucose level; after birth it takes several hours for the newborn to adjust to the loss of the maternal glucose. A healthy newborn's glucose level does not drop significantly after birth. A newborn's pancreas usually produces more insulin as a response to the maternal glucose level, but this response is not specific to the IDM. IDMs have the same glucose stores as other newborns; their responses to the loss of maternal glucose levels differ.

The mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. What is the nurse's best response? "A newborn's nerves are not mature enough for him to feel pain." "It's such a short procedure that the pain won't last long." "Your baby should have no memory of it, even if there is pain." "The health care provider will tell you how your baby's pain will be controlled."

"The health care provider will tell you how your baby's pain will be controlled." Rationale Each health care provider has a protocol for relieving the pain caused by circumcision, and the parent has the right to be informed before signing the consent form. Newborns do feel pain, although their nervous systems are not yet mature enough to localize it. The mother is concerned about her newborn's pain regardless of the duration of the procedure. Although the infant may have no memory of the pain, this statement does not address the mother's concern adequately.

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? (Select all that apply.) Cracked and peeling skin Long scalp hair and fingernails Red, puffy appearance of face and neck Vernix caseosa covering the back and buttocks Creases covering the neonate's full soles and palms

1 Cracked and peeling skin 2 Long scalp hair and fingernails 5 Creases covering the neonate's full soles and palms Rationale Dry, peeling skin is related to decreased vernix and prolonged immersion in amniotic fluid. Abundant scalp hair and long fingernails are characteristics of postmaturity . These findings are typically noted in a term newborn who is 2 to 3 weeks old. Creases on the entire soles and palms are typical of full-term maturity; preterm newborns have few sole and palm creases. A red, puffy appearance of face and neck is not a sign of postmaturity; neonates born to diabetic mothers usually have this appearance. Vernix is found on a newborn at about 38 weeks' gestation and disappears after 40 weeks' gestation.

A newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow, irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and has flaccid muscle tone. What Apgar score should the nurse assign to this neonate? <p>A newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow, irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and has flaccid muscle tone. What Apgar score should the nurse assign to this neonate?</p> 2 3 4 5

2. 3 **A heart rate of less than 100 beats/min = 1; slow and irregular respirations = 1; grimaces in response to suctioning = 1; flaccid muscle tone = 0; and cyanosis = 0. This infant's Apgar score is 3. A score of 2 is too low. A score of 4 is too high, as is a score of 5.

Jaundice develops in a newborn 72 hours after birth. What should the nurse tell the parents is the probable cause of the jaundice? 1. An allergic response to the feedings 2. The physiological destruction of fetal red blood cells 3. A temporary bile duct obstruction commonly found in newborns 4. The seepage of maternal Rh-negative blood into the neonate's bloodstream

2. The physiological destruction of fetal red blood cells After birth, fetal erythrocytes hemolyze, releasing into the circulation bilirubin , which the immature liver cannot metabolize as rapidly as it is produced, resulting in physiological jaundice. Jaundice is not an allergic response. Bile duct obstruction, which is not common in newborns, is not the cause of the jaundice. The newborn and mother have independent circulations, and Rh-negative blood does not enter the fetus's bloodstream. A problem may occur if the mother is sensitized, because her antibodies can enter the fetal circulation.

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication? Muscle irritability within 1 hour of birth Neurological signs during the first 24 hours Jaundice that develops in the first 12 to 24 hours Jaundice that develops between 48 and 72 hours after birth

3. Jaundice that develops in the first 12 to 24 hours Rationale The development of jaundice in the first 24 hours indicates hemolytic disease of the newborn. Neurological signs may or may not be present during the first 24 hours; they are dependent on the bilirubin level. Muscle irritability may or may not be present during the first 24 hours; usually it develops later. Serum bilirubin is expected to accumulate in the neonatal period because of the short life span of fetal erythrocytes, reaching a level of 7 mg/100 mL the second to third day when jaundice appears (physiological jaundice).

An infant born at 40 weeks' gestation weighs 6 lb 13 oz (3090 g). What category describes this neonate? Small for gestational age (SGA) and term SGA and preterm Appropriate for gestational age (AGA) and term AGA and preterm

Appropriate for gestational age (AGA) and term Rationale Birth between 38 and 42 weeks' gestation is considered term. At term, healthy neonates weigh between 5 lb 10 oz and 8 lb 6 oz (2300 to 3800 g). Although the birth took place between 38 and 42 weeks' gestation (term infant), an SGA infant weighs less than the expected range for the gestational age. A preterm infant is one born before 38 weeks' gestation; the infant's weight is within the expected range for 40 weeks' gestation. Although the infant's weight is appropriate for the gestational age of 40 weeks, the infant is not preterm, because birth occurred between 38 and 42 weeks' gestation.

How does a nurse identify possible developmental dysplasia of the hip (DDH) during a newborn assessment? Depressed dance reflex Limited adduction of the leg Asymmetry of the gluteal folds Shortened leg on the unaffected side

Asymmetry of the gluteal folds Rationale The gluteal folds should be symmetric, as should all planes and folds of the body. An abnormality of the hips will cause asymmetry, a shorter leg on the affected side, or both. The dance reflex is not affected in DDH . With DDH, abduction of the leg is usually limited at the hip. The leg on the affected, not unaffected, side appears to be shorter with DDH.

A nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. What value denotes a healthy infant? Less than 40% More than 75% Between 45% and 65% Between 65% and 75%

Between 45% and 65% Rationale The expected hematocrit level for a healthy newborn is between 45% and 65%. Less than 40% is below the expected level and is considered anemia. More than 75% is high and is considered polycythemia. Between 65% and 75% is above the expected range.

A client has chosen not to have her son circumcised. What instruction should be included in discharge teaching for the care of an uncircumcised neonate? Assess the penis daily for signs of bleeding. Apply petroleum jelly to the penis for 1 week. Pull the foreskin back once a day for 1 month. Clean the penis with warm water at each diaper change.

Clean the penis with warm water at each diaper change.

The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because caput succedaneum features scalp edema that: Becomes ecchymotic Crosses the suture line Increases after several hours Is tender in the surrounding area

Crosses the suture line Rationale Scalp edema that crosses the suture line is the sign that differentiates between these two conditions; with caput succedaneum the swelling crosses the suture line, whereas it does not in cephalhematoma. Bruising may occur in either condition.The swelling diminishes; if the swelling increases, the newborn will have to be observed for signs of increased intracranial pressure. Pain is not associated with either condition.

A nurse teaches a new mother about neonatal weight loss in the first 3 days of life. What does the nurse explain is the cause of this weight loss? An allergy to formula A hypoglycemic response Ineffective feeding techniques Excretion of accumulated excess fluids

Excretion of accumulated excess fluids Early weight loss occurs because excess fluid is lost, not body mass. Weight loss is expected; there are no data to support an allergic response. Weight loss is not related to hypoglycemia. Neither breast nor formula feeding will prevent the 10% weight loss that is expected in the first few days of life.

What nursing care is most important for a newborn with respiratory distress syndrome (RDS)? Keeping the infant in a warm environment Turning the infant frequently to prevent apnea Tapping the infant's toes to stimulate deep breathing Maintaining the infant's oxygen administration level at the same rate

Keeping the infant in a warm environment Rationale The infant is kept in a warm environment because any attempt by the infant's body to maintain body temperature further compromises physical status by increasing metabolic activity and oxygen demands. Increased physical activity will also increase oxygen demands. The amount of oxygen administered should vary with the infant's laboratory values.

A nurse instills an antibiotic ophthalmic ointment into a newborn's eyes. What condition does this medication prevent? Herpetic ophthalmia Retrolental fibroplasia Ophthalmia neonatorum Hemorrhagic conjunctivitis

Ophthalmia neonatorum Rationale Ophthalmia neonatorum is caused by gonorrheal and/or chlamydial infections present in the vaginal tract. It is preventable with the prophylactic use of an antibiotic ophthalmic ointment applied to the neonate's eyes. Herpes affects the neonate systemically. Retrolental fibroplasia (retinopathy of prematurity) occurs as a result of prolonged exposure to a too-high oxygen concentration. Hemorrhagic conjunctivitis is usually caused by rapid expulsion of the fetus' head from the vagina.

A new mother asks a nurse how to care for her baby's umbilical cord stump. What should the nurse teach the mother?

Provide sponge baths until the stump falls off. Rationale The infant is given sponge baths instead of being immersed in a tub of water because the moisture will retard drying of the cord stump and will delay its falling off. Drainage is indicative of infection; the cord stump should be dry. Moisture slows the drying process and promotes bacterial growth. Keeping the cord stump covered delays drying.

The parents of a newborn are concerned about red pinpoint dots on their infant's face and neck. How should the nurse explain the finding? They are obstructed sebaceous glands. They are excessive superficial capillaries. The cause is a decreased vitamin K level in the newborn. The cause is an increased intravascular pressure during birth.

The cause is an increased intravascular pressure during birth. Rationale Pressure exerted during the birth process causes increased intravascular pressure, which may result in petechiae caused by capillary rupture. Obstructed sebaceous glands are milia, which are white, not red. Superficial capillaries are intact capillaries. They are distinguished from petechiae if they disappear when the area is blanched. Bloody stools or oozing from the umbilicus are the most commons sign of vitamin K deficiency, not red pinpoint dots on an infant's face and neck.

The nurse concludes that a couple with a newborn with Erb palsy has an accurate understanding of the infant's prognosis. Which statement confirms this conclusion? "Surgery will correct the palsy." "This is a progressive disorder with no cure." ****"Recovery usually occurs in about 3 months." "Physical therapy will be necessary for 1 year."

The nerves that are stretched take about 3 months to recover from the trauma sustained during birth. Passive range-of-motion exercise and intermittent splinting performed by a trained family member will help facilitate recovery. Only in rare instances, when avulsion of the nerves results in permanent damage, is orthopedic or surgical intervention necessary. The paralysis is not progressive, and the prognosis is usually excellent. Physical therapy is necessary for about 3 months, not 1 year.

A client has a cesarean birth. The nurse monitors the newborn's respiration because infants subjected to cesarean birth are more prone to atelectasis. Why does this occur? The ribcage is not compressed, then released during birth. The sudden temperature change at birth causes aspiration. There is usually oxygen deprivation after a cesarean birth. There is no gravity during the birth to promote drainage from the lungs.

The ribcage is not compressed, then released during birth Rationale The release following compression of the chest during a vaginal birth is the mechanism for expansion of the newborn's lungs; because this does not occur during a cesarean birth, lung expansion may be incomplete and atelectasis may result. Temperature change is not implicated in aspiration. The infant is monitored closely to prevent oxygen deprivation. The newborn's head may be held lower than the chest to allow gravity to promote drainage from the lungs after a cesarean birth.

A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection? Deltoid muscle Rectus femoris Vastus lateralis Gluteus maximus

Vastus lateralis The vastus lateralis is the most appropriate muscle for a newborn's intramuscular injection because it is well developed and there is little danger of nerve injury. The deltoid muscle is too small for a newborn's intramuscular injection. The rectus femoris muscle is not used; it is not as large as the vastus lateralis in a newborn. The sciatic nerve in the newborn is near the outer aspect of the gluteus maximus and might be injured if this site were used for an injection.