Ricci Chapter 18 - Test Bank - 4th Edition, Ricci Chapter 17 - Test Bank - 4th Edition, Ricci Chapter 16 - Test Bank - 4th Edition

5. When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority? A. hypothermia B. impaired parenting C. deficient fluid volume D. risk for infection

Answer: A Rationale: The newborn's heart rate is slightly below the accepted range of 120 to 160 beats per minute; the respiratory rate is at the high end of the accepted range of 30 to 60 breaths per minute. However, the newborn's temperature is significantly below the accepted range of 97.7 to 99.7? (36.5 to 37.6?). Therefore, the priority problem area is hypothermia. There is no information to suggest impaired parenting. Additional information is needed to determine if there is deficient fluid volume or a risk for infection.

8. Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: A. habituation. B. motor maturity. C. orientation. D. social behaviors.

Answer: B Rationale: Motor maturity is evidenced by rhythmic, spontaneous movements. Habituation is manifested by the newborn's ability to respond to the environment appropriately. Orientation involves the newborn's response to new stimuli, such as turning the head to a sound. Social behaviors involve cuddling and snuggling into the arms of a parent.

18. A nurse is assessing a newborn who is about 4½ hours old. The nurse would expect this newborn to exhibit which behavior? Select all that apply. A. sleeping B. interest in environmental stimuli C. passage of meconium D. difficulty arousing the newborn E. spontaneous Moro reflexes

Answer: B, C Rationale: The newborn is in the second period of reactivity, which begins as the newborn awakens and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal newborn (Boxwell, 2010). Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period. In addition, motor activity and muscle tone increase in conjunction with an increase in muscular coordination. Spontaneous Moro reflexes are noted during the first period of reactivity. Sleeping and difficulty arousing the newborn reflect the period of decreased responsiveness.

27. When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes? A. gastrointestinal and hepatic B. urinary and hematologic C. respiratory and cardiovascular D. neurological and integumentary

Answer: C Rationale: Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

2. A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure? A. Offer warm blankets. B. Encourage the woman to void. C. Apply an ice pack to the site. D. Offer a warm sitz bath.

Answer: C Rationale: An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.

14. A postpartum woman is having difficulty voiding for the first time after giving birth. Which action would be least effective in helping to stimulate voiding? A. pouring warm water over her perineal area B. having her hear the sound of water running nearby C. placing her hand in a basin of cool water D. standing her in the shower with the warm water on

Answer: C Rationale: Helpful measures to stimulate voiding include placing her hand in a basin of warm water, pouring warm water over her perineal area, hearing the sound of running water nearby, blowing bubbles through a straw, standing in the shower with the warm water turned on, and drinking fluids.

8. Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage? A. multiparity, age of mother, operative birth B. size of placenta, small baby, operative birth C. uterine atony, placenta previa, operative procedures D. prematurity, infection, length of labor

Answer: C Rationale: Risk factors for postpartum hemorrhage include a precipitous labor less than three hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.

12. The nurse administers vitamin K intramuscularly to the newborn based on which rationale? A. Stop Rh sensitization. B. Increase erythropoiesis. C. Enhance bilirubin breakdown. D. Promote blood clotting.

Answer: D Rationale: Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the liver. Rho(D) immune globulin prevents Rh sensitization. Erythropoietin stimulates erythropoiesis. Phototherapy enhances bilirubin breakdown.

23. A nurse is preparing a class on newborn adaptations for a group of soon-to-be parents. When describing the change from fetal to newborn circulation, which information would the nurse include? Select all that apply. A. Decrease in right atrial pressure leads to closure of the foramen ovale. B. Increase in oxygen levels leads to a decrease in systemic vascular resistance. C. Onset of respirations leads to a decrease in pulmonary vascular resistance. D. Increase in pressure in the left atrium results from increases in pulmonary blood flow. E. Closure of the ductus venosus eventually forces closure of the ductus arteriosus.

Answer: A, C, D, E Rationale: When the umbilical cord is clamped, the first breath is taken, and the lungs begin to function. As a result, systemic vascular resistance increases and blood return to the heart via the inferior vena cava decreases. Concurrently with these changes, there is a rapid decrease in pulmonary vascular resistance and an increase in pulmonary blood flow (Boxwell, 2010). The foramen ovale functionally closes with a decrease in pulmonary vascular resistance, which leads to a decrease in right-sided heart pressures. An increase in systemic pressure, after clamping of the cord, leads to an increase in left-sided heart pressures. Ductus arteriosus, ductus venosus, and umbilical vessels that were vital during fetal life are no longer needed.

19. The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which description? A. scant B. light C. moderate D. large

Answer: B Rationale: The amount of lochia is described as light or small for an approximately 4-inch stain. Scant refers to a 1- to 2-inch stain of lochia; moderate refers to a 4- to 6-inch stain; and large or heavy refers to a pad that is saturated within 1 hour after changing.

16. Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chest circumference would be: A. 30 cm. B. 32 cm. C. 34 cm. D. 36 cm.

Answer: B Rationale: The newborn's chest should be round, symmetric, and 2 to 3 cm smaller than the head circumference. Therefore, this newborn's chest circumference of 31 to 32 cm would be normal.

17. The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location? A. just superior to the nipple, at the midsternum B. lateral to the midclavicular line at the fourth intercostal space C. at the fifth intercostal space to the left of the sternum D. directly adjacent to the sternum at the second intercostals space

Answer: B Rationale: The point of maximal impulse (PMI) in a newborn is a lateral to midclavicular line located at the fourth intercostal space.

15. The nurse is assessing a newborn's eyes. Which findings would the nurse identify as normal? Select all that apply. A. slow blink response B. able to track object to midline C. transient deviation of the eyes D. involuntary repetitive eye movement E. absent red reflex

Answer: B, C, D Rationale: Assessment of the eyes should reveal a rapid blink reflex, ability to track objects to the midline, transient strabismus (deviation or wandering of the eyes independently), searching nystagmus (involuntary repetitive eye movement), and a red reflex.

26. Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which factor in the newborn's history would the nurse identify as playing a role in this this condition? A. vaginal birth B. shortened labor C. central nervous system depressant during labor D. maternal hypertension

Answer: C Rationale: Transient tachypnea of the newborn occurs when the fetal liquid in the lungs is removed slowly or incompletely. This can be due to the lack of thoracic squeezing that occurs during a cesarean birth or diminished respiratory effort if the mother received central nervous system depressant medication. Prolonged labor, macrosomia of the fetus, and maternal asthma also have been associated with this condition.

6. The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal? A. Prevent cold stress. B. Increase surfactant levels in the lungs. C. Promote respiratory stability. D. Decrease the serum bilirubin level.

Answer: D Rationale: Jaundice reflects elevated serum bilirubin levels; phototherapy helps to break down the bilirubin for excretion. Phototherapy has no effect on body temperature, surfactant levels, or respiratory stability.

18. The nurse is inspecting the external genitalia of a male newborn. Which finding would alert the nurse to a possible problem? A. limited rugae B. large scrotum C. palpable testes in scrotal sac D. negative engorgement

Answer: A Rationale: The scrotum usually appears relatively large and should be pink in white neonates and dark brown in neonates of color. Rugae should be well formed and should cover the scrotal sac. There should not be bulging, edema(engorgement), or discoloration. Testes should be palpable in the scrotal sac and feel firm and smooth and be of equal size on both sides of the scrotal sac.

1. Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess? A. respiratory rate 45 breaths/minute, irregular B. costal breathing pattern C. nasal flaring, rate 65 breaths/minute D. crackles on auscultation

Answer: A Rationale: Typically, respirations in a 24-hour-old newborn are symmetric, slightly irregular, shallow, and unlabored at a rate of 30 to 60 breaths/minute. The breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60 breaths per minute, and crackles suggest a problem.

16. A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply. A. history of diabetes B. labor of 12 hours C. rupture of membranes for 16 hours D. hemoglobin level 10 mg/dL E. placenta requiring manual extraction

Answer: A, D, E Rationale: Risk factors for postpartum infection include history of diabetes, labor over 24 hours, hemoglobin less than 10.5 mg/dL, prolonged rupture of membranes (more than 24 hours), and manual extraction of the placenta.

10. Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when the Ortolani maneuver is performed. What would the nurse suspect? A. slipping of the periosteal joint B. developmental hip dysplasia C. normal newborn variation D. overriding of the pelvic bone

Answer: B Rationale: A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the area. This, along with uneven gluteal creases, suggests developmental hip dysplasia. These findings are not a normal variation and are not associated with slipping of the periosteal joint or overriding of the pelvic bone.

30. A nurse is teaching a new mother about her newborn's immune status. The nurse determines that the teaching was successful when the mother states which immunoglobulin as having crossed the placenta? A. IgA B. IgG C. IgM D. IgE

Answer: B Rationale: IgG is the major immunoglobulin and the most abundant, making up about 80% of all circulating antibodies. It is found in serum and interstitial fluid. It is the only class able to cross the placenta, with active placental transfer beginning at approximately 20 to 22 weeks' gestation. No other immunoglobulin crosses the placenta.

4. A nurse is observing a new mother interacting with her newborn. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn? A. "You have your daddy's eyes." B. "He looks like a frog to me." C. "Where did you get all that hair?" D. "He seems to sleep a lot."

Answer: B Rationale: Negative comments may indicate impaired bonding. Pointing out commonalities such as "daddy's eyes" and expressing pride such as "all that hair" are positive attachment behaviors. The statement about sleeping a lot indicates that the mother is assigning meaning to the newborn's actions, another positive attachment behavior.

3. When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is some soft bedding material, and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching for which reason? A. The newborn should not be sleeping on his back. B. Soft bedding material should not be in areas where infants sleep. C. The bulb syringe should not be kept in the bassinet. D. This newborn should be sleeping in a crib.

Answer: B Rationale: The nurse should instruct the mother to remove all fluffy bedding, quilts, stuffed animals, and pillows from the crib to prevent suffocation. Newborns and infants should be placed on their backs to sleep. Having the bulb syringe nearby in the bassinet is appropriate. Although a crib is the safest sleeping location, a bassinet is appropriate initially.

24. A nurse is describing the advantages and disadvantages of circumcision to a group of expectant parents. Which statement by the parents indicates effective teaching? A. "Sexually transmitted infections are more common in circumcised males." B. "The rate of penile cancer is less for circumcised males." C. "Urinary tract infections are more easily treated in circumcised males." D. "Circumcision is a risk factor for acquiring HIV infection."

Answer: B Rationale: The risk for penile cancer appears to be slightly lower for males who are circumcised. However, penile cancer is rare and other risk factors such as genital warts and HPV infection seem to play a larger role. Sexually transmitted infections are less common in circumcised males, but the risk is believed to be related more to behavioral factors than circumcision status. Circumcised males have a 50% lower risk of acquiring HIV infection. Urinary tract infections are slightly less common in circumcised boys. However, rates are low in both circumcised and uncircumcised boys and are easily treated without long-term sequelae.

7. The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rhpositive newborn based on the understanding that this drug will prevent her from: A. becoming Rh positive. B. developing Rh sensitivity. C. developing AB antigens in her blood. D. becoming pregnant with an Rh-positive fetus.

Answer: B Rationale: The woman who is Rh-negative and whose infant is Rh-positive should be given Rho(D) immune globulin within 72 hours after birth to prevent sensitization.

24. A nurse is preparing a presentation about ways to minimize heat loss in the newborn. Which measure would the nurse include to prevent heat loss through convection? A. placing a cap on a newborn's head B. working inside an isolette as much as possible. C. placing the newborn skin-to-skin with the mother D. using a radiant warmer to transport a newborn

Answer: B Rationale: To prevent heat loss by convection, the nurse would keep the newborn out of direct cool drafts (open doors, windows, fans, air conditioners) in the environment, work inside an isolette as much as possible and minimize opening portholes that allow cold air to flow inside, and warm any oxygen or humidified air that comes in contact with the newborn. Placing a cap on the newborn's head would help minimize heat loss through evaporation. Placing the newborn skin-to-skin with the mother helps to prevent heat loss through conduction. Using a radiant warmer to transport a newborn helps minimize heat loss through radiation.

22. After teaching a group of nurses during an in-service program about risk factors associated with postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which risk factors? Select all that apply. A. prolonged labor B. placenta previa C. null parity D. hydramnios E. labor augmentation

Answer: B, D, E Rationale: Risk factors for postpartum hemorrhage include precipitous labor less than 3 hours, placenta previa or abruption, multiparity, uterine overdistention such as with a large infant, twins, or hydramnios, and labor induction or augmentation. Prolonged labor over 24 hours is a risk factor for postpartum infection.

20. When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which area? A. superficial structures above the muscle B. through the perineal muscles C. through the anal sphincter muscle D. through the anterior rectal wall

Answer: C Rationale: A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only the skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

9. While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: A. molding. B. microcephaly. C. caput succedaneum. D. cephalhematoma.

Answer: C Rationale: Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of the skull.

13. The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as: A. harlequin sign. B. nevus flames. C. erythema toxicum. D. port wine stain.

Answer: C Rationale: Erythema toxicum (newborn rash) is a benign, idiopathic, generalized, transient rash that occurs in up to 70% of all newborns during the first week of life. It consists of small papules or pustules on the skin resembling flea bites. The rash is common on the face, chest, and back. One of the chief characteristics of this rash is its lack of pattern. It is caused by the newborn's eosinophils reacting to the environment as the immune system matures. Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. It gives a distinct midline demarcation, which is described as pale on the nondependent side and red on the opposite, dependent side. Nevus flammeus or port wine stain is a capillary angioma located directly below the dermis. It is flat with sharp demarcations and is purple-red. This skin lesion is made up of mature capillaries that are congested and dilated.

26. While observing the interaction between a newborn and the mother, the nurse notes the newborn nestling into the arms of the mother. The nurse identifies this as which behavior? A. habituation B. self-quieting ability C. social behaviors D. orientation

Answer: C Rationale: Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held. Self-quieting ability refers to newborns' ability to quiet and comfort themselves, such as by hand-to-mouth movements and sucking, alerting to external stimuli and motor activity. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Orientation refers to the response of newborns to stimuli, becoming more alert when sensing a new stimulus in their environment.

14. The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest? A. 38 breaths per minute B. 46 breaths per minute C. 54 breaths per minute D. 68 breaths per minute

Answer: D Rationale: After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). Thus a newborn with a respiratory rate below 30 or above 60 breaths per minute would require further evaluation.

11. A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn? A. symmetrical chest movements B. periodic breathing C. respirations of 40 breaths/minute D. sternal retractions

Answer: D Rationale: Sternal retractions, cyanosis, tachypnea, expiratory grunting, and nasal flaring are signs of respiratory distress in a newborn. Symmetrical chest movements and a respiratory rate between 30 to 60 breaths/minute are typical newborn findings. Some newborns may demonstrate periodic breathing (cessation of breathing lasting 5 to 10 seconds without changes in color or heart rate) in the first few days of life.

9. When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature? A. hearing B. touch C. taste D. vision

Answer: D Rationale: Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

29. The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism? A. evaporation B. conduction C. convection D. radiation

Answer: A Rationale: Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

7. After the birth of a newborn, which action would the nurse do first to assist in thermoregulation? A. Dry the newborn thoroughly. B. Put a hat on the newborn's head. C. Check the newborn's temperature. D. Wrap the newborn in a blanket.

Answer: A Rationale: Drying the newborn immediately after birth using warmed blankets is essential to prevent heat loss through evaporation. Then the nurse would place a cap on the baby's head and wrap the newborn. Assessing the newborn's temperature would occur once these measures were initiated to prevent heat loss.

6. A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates: A. normal progression of behavior. B. probable hypoglycemia. C. physiological abnormality. D. inadequate oxygenation.

Answer: A Rationale: From 30 to 120 minutes of age, the newborn enters the second stage of transition, that of sleep or a decrease in activity. More information would be needed to determine if hypoglycemia, a physiologic abnormality, or inadequate oxygenation was present.

28. A nurse is teaching a group of new parents about their newborns' sensory capabilities. The nurse would identify which sense as being well-developed at birth? A. hearing B. touch C. taste D. vision

Answer: A Rationale: Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Vision is the least mature sense at birth. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

13. When describing the neurologic development of a newborn to parents, the nurse would explain that it occurs in which fashion? A. head-to-toe B. lateral-to-medial C. outward-to-inward D. distal-caudal

Answer: A Rationale: Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center to outside) pattern.

15. A new mother asks the nurse, "Why has my baby lost weight since he was born?" The nurse integrates knowledge of which cause when responding to the new mother? A. insufficient calorie intake B. shift of water from extracellular space to intracellular space C. increase in stool passage D. overproduction of bilirubin

Answer: A Rationale: Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth, shifting of intracellular water to extracellular space, and insensible water loss. Stool passage and bilirubin have no effect on weight loss.

12. When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure? A. early parent-infant contact following birth B. expert medical care for the labor and birth C. good nutrition and prenatal care during pregnancy D. grandparent involvement in infant care after birth

Answer: A Rationale: Optimal bonding requires a period of close contact between the parents and newborn within the first few minutes to a few hours after birth. Expert medical care, nutrition and prenatal care, and grandparent involvement are not associated with the promotion of bonding.

1. A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take? A. Document the finding, as it is a normal finding at this time. B. Contact the primary care provider, as it indicates early DIC. C. Contact the primary care provider, as it is a first sign of postpartum eclampsia. D. Obtain a prescription for a CBC, as it suggests postpartum anemia.

Answer: A Rationale: Pulse rates of 60 to 80 beats per minute at rest are normal during the first week after birth. This pulse rate is called puerperal bradycardia.

11. A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex? A. Babinski B. tonic neck C. stepping D. plantar grasp

Answer: A Rationale: The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The tonic neck reflex is tested by having the newborn lie on his back and then turn his head to one side. The stepping reflex is elicited by holding the newborn upright and inclined forward with the soles of the feet on a flat surface. The plantar grasp reflex is elicited by placing a finger against the area just below the newborn's toes.

3. Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as: A. a good time to initiate breast-feeding. B. the period of decreased responsiveness preceding sleep. C. a sign that the infant is being overstimulated. D. evidence that the newborn is becoming chilled.

Answer: A Rationale: The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breastfeeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. None of the behaviors indicate overstimulation. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.

23. While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next? A. Document this as pseudo menstruation. B. Notify the primary care provider immediately. C. Obtain a culture of the discharge. D. Inspect for engorgement.

Answer: A Rationale: The nurse should assess pseudomenstruation, a vaginal discharge composed of mucus mixed with blood, which may be present during the first few weeks of life. This discharge requires no treatment. The discharge is a normal finding and thus does not need to be reported immediately. It is not an indication of infection. The female genitalia normally will be engorged, so assessing for engorgement is not indicated.

4. Assessment of a newborn reveals a heart rate of 180 beats per minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A. How many hours old is this newborn? B. How long ago did this newborn eat? C. What was the newborn's birthweight? D. Is acrocyanosis present?

Answer: A Rationale: The typical heart rate of a newborn ranges from 110 to 160 beats per minute with wide fluctuation during activity and sleep. Typically heart rate is assessed every 30 minutes until stable for 2 hours after birth. The time of the newborn's last feeding and his birthweight would have no effect on his heart rate. Acrocyanosis is a common normal finding in newborns.

15. The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which action would be a priority? A. placing the call light within her reach B. teaching her how the sitz bath works C. telling her to use the sitz bath for 30 minutes D. cleaning the perineum with the peri-bottle

Answer: A Rationale: Tremendous hemodynamic changes are taking place within the woman, and safety must be a priority. Therefore, the nurse makes sure that the emergency call light is within her reach should she become dizzy or lightheaded. Teaching her how to use the sitz bath, including using it for 15 to 20 minutes, is appropriate but can be done once the woman's safety is ensured. The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can be done once the woman's safety needs are met.

14. A nurse is conducting a refresher program for a group of nurses working in the newborn nursery. After teaching the group about variations in newborn head size and appearance, the nurse determines that the teaching was successful when the group identifies which variation as normal? Select all that apply. A. cephalhematoma B. molding C. closed fontanels D. caput succedaneum E. posterior fontanel diameter 1.5 cm

Answer: A, B, D Rationale: Normal variations in newborn head size and appearance include cephalhematoma, molding, and caput succedaneum. Microcephaly, closed fontanels, or a posterior fontanel diameter greater than 1 cm are considered abnormal.

20. A newborn is experiencing cold stress. Which findings would the nurse expect to assess? Select all that apply. A. respiratory distress B. decreased oxygen needs C. hypoglycemia D. metabolic alkalosis E. jaundice

Answer: A, C, E Rationale: Cold stress in the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production.

30. A new parent is talking with the nurse about feeding the newborn. The parent has chosen to use formula. The parent asks, "How can I make sure that my baby is getting what is needed?" Which response(s) by the nurse would be appropriate? Select all that apply. A. "Make sure to use an iron-fortified formula until your baby is about 1 year old." B. "Start giving your baby fluoride supplements now so your baby develops strong teeth." C. "Since you are not breastfeeding, your baby needs a baby multivitamin each day." D. "Your baby gets enough fluid with formula, so you do not need to give extra water." E. "It is important to give your baby vitamin D each day."

Answer: A, D, E Rationale: Fluid requirements for the newborn and infant range from 100 to 150 mL/kg daily. This requirement can be met through breastfeeding or bottle feeding. Additional water supplementation is not necessary. Adequate carbohydrates, fats, protein, and vitamins are achieved through consumption of breast milk or formula. Iron-fortified formula is recommended for all infants who are not breastfed from birth to 1 year of age. The breastfed infant draws on iron reserves for the first 6 months and then needs iron-rich foods or supplementation added at 6 months of age. All infants (breastfed and bottle fed) should receive a daily supplement of 400 International Units of vitamin D starting within the first few days of life to prevent rickets and vitamin D deficiency. It is also recommended that fluoride supplementation be given to infants not receiving fluoridated water after the age of 6 months.

29. Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate? A. Assess the newborn's gestational age. B. Rewarm the newborn gradually. C. Observe the newborn every hour. D. Notify the primary care provider if the temperature goes lower.

Answer: B Rationale: A newborn's temperature is typically maintained at 97.7° F to 99.7° F (36.5° C to 37.5° C). Since this newborn's temperature is significantly lower, the nurse should institute measures to rewarm the newborn gradually. Assessment of gestational age is completed regardless of the newborn's temperature. Observation would be inappropriate because lack of action may lead to a further lowering of the temperature. The nurse should notify the primary care provider of the newborn's current temperature since it is outside normal parameters.

17. The nurse observes the stool of a newborn who has begun to breastfeed. Which finding would the nurse expect? A. greenish black, tarry stool B. yellowish-brown, seedy stool C. yellow-gold, stringy stool D. yellowish-green, pasty stool

Answer: B Rationale: After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. Meconium stool is greenish black and tarry. The last development in the stool pattern is the milk stool. Milk stools of the breastfed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically soursmelling. The milk stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor.

1. A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description? A. The cardiac murmur heard at birth disappears by 48 hours of age. B. Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. C. Heart rate remains elevated after the first few moments of birth. D. Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed.

Answer: B Rationale: Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life. With the first breath, PVR decreases, and the heart rate initially increases but then decreases to 120 to 130 bpm after a few minutes. The ductal murmur will go away in 80+% of infants by 48 hours. Rhonchi caused by retained amniotic fluid is an abnormal finding and would not be expected.

29. After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify which concept as reflecting the enduring nature of their relationship, one that involves placing the infant at the center of their lives and finding their own way to assume the parental identity? A. reciprocity B. commitment C. bonding D. attachment

Answer: B Rationale: Commitment refers to the enduring nature of the relationship. The components of this are twofold: centrality and parent role exploration. In centrality, parents place the infant at the center of their lives. They acknowledge and accept their responsibility to promote the infant's safety, growth, and development. Parent role exploration is the parents' ability to find their own way and integrate the parental identity into themselves. The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.

11. A nurse is preparing a couple and their newborn for discharge. Which instructions would be most appropriate for the nurse to include in discharge teaching? A. introducing solid foods immediately to increase sleep cycle B. demonstrating comfort measures to quiet a crying infant C. encouraging daily outings to the shopping mall with the newborn D. allowing the infant to cry for at least an hour before picking him or her up

Answer: B Rationale: Discharge teaching typically would focus on several techniques to comfort a crying newborn. The nurse needs to emphasize the importance of responding to the newborn's cues, not allowing the infant to cry for an hour before being comforted. Information about solid foods is inappropriate for a newborn because solid foods are not introduced at this time. The mother and newborn need rest periods. Therefore, daily outings to a shopping mall would be inappropriate. Information about newborn sleep-wake cycles and measures for sensory enrichment and stimulation would be more appropriate.

10. A nurse is reviewing the policies of a facility related to bonding and attachment with newborns. Which practice would the nurse identify as needing to be changed? A. allowing unlimited visiting hours on maternity units B. offering round-the-clock nursery care for all infants C. promoting rooming-in D. encouraging infant contact immediately after birth

Answer: B Rationale: Factors that can affect attachment include separation of the infant and parents for long times during the day, such as if the infant was being cared for in the nursery throughout the day. Unlimited visiting hours, rooming-in, and infant contact immediately after birth promote bonding and attachment.

5. After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A. presence of lochia serosa B. frequent scant voidings C. fundus firm, below umbilicus D. milk filling in both breasts

Answer: B Rationale: Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.

5. A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate? A. "You probably took iron during your pregnancy and that is what causes this type of stool." B. "This is meconium stool and is normal for a newborn." C. "I'll take a sample and check it for possible bleeding." D. "This is unusual, and I need to report this to your pediatrician. "

Answer: B Rationale: Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.

7. During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: A. milia. B. Mongolian spots. C. stork bites. D. birth trauma.

Answer: B Rationale: Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Milia are unopened sebaceous glands frequently found on a newborn's nose. Stork bites are superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling, and possible deformity.

26. A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how much should my newborn drink at each feeding?" The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding? A. 1 to 2 ounces B. 2 to 4 ounces C. 4 to 6 ounces D. 6 to 8 ounces

Answer: B Rationale: Newborns need about 108 cal/kg or approximately 650 cal/day (Dudek, 2010). Therefore, a newborn will need to 2 to 4 ounces to feel satisfied at each feeding.

22. A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern? A. hemoglobin 19 g/dL B. platelets 75,000/μL C. white blood cells 20,000/mm3 D. hematocrit 52%

Answer: B Rationale: Normal newborn platelets range from 150,00 to 350,000/μL. Normal hemoglobin ranges from 17 to 23g/dL, and normal hematocrit ranges from 46% to 68%. Normal white blood cell count ranges from 10,000 to 30,000/mm3.

28. A nurse is conducting a class for pregnant women who are in their third trimester. The nurse is reviewing information about the emotional changes that occur in the postpartum period, including postpartum blues and postpartum depression. After reviewing information about postpartum blues, the group demonstrates understanding when they make which statement about this condition? A. "Postpartum blues is a long-term emotional disturbance." B. "Getting some outside help for housework can lessen feelings of being overwhelmed." C. "The mother loses contact with reality." D. "Extended psychotherapy is needed for treatment."

Answer: B Rationale: Postpartum blues require no formal treatment other than support and reassurance because they do not usually interfere with the woman's ability to function and care for her infant. Nurses can ease a mother's distress by encouraging her to vent her feelings and by demonstrating patience and understanding with her and her family. Suggest that getting outside help with housework and infant care might help her to feel less overwhelmed until the blues ease. Provide telephone numbers she can call when she feels down during the day. Making women aware of this disorder while they are pregnant will increase their knowledge about this mood disturbance, which may lessen their embarrassment and increase their willingness to ask for and accept help if it does occur.

20. A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents make which statement? A. "We can put a tiny bit of lotion on his skin, and then rub it in gently." B. "We should avoid using any kind of baby powder." C. "We need to bathe him at least four to five times a week." D. "We should clean his eyes after washing his face and hair."

Answer: B Rationale: Powders should not be used, because they can be inhaled, causing respiratory distress. If the parents want to use oils and lotions, have them apply a small amount onto their hand first, away from the newborn; this warms the lotion. Then the parents should apply the lotion or oil sparingly. Parents need to be instructed that a bath two or three times weekly is sufficient for the first year because too frequent bathing may dry the skin. The eyes are cleaned first and only with plain water; then the rest of the face is cleaned with plain water.

25. A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's: A. finger. B. heel. C. scalp vein. D. umbilical vein.

Answer: B Rationale: Screening tests for genetic and inborn errors of metabolism require a few drops of blood taken from the newborn's heel. The finger, scalp vein, or umbilical vein are inappropriate sites for the blood sample.

18. The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse interprets this finding as indicating which amount of blood loss? A. 10 mL B. 10 to 25 mL C. 25 to 50 mL D. over 50 mL

Answer: B Rationale: The amount of lochia is described as light or small for an approximately 4-inch stain and indicates a blood loss of 10 to 25 mL. Scant refers to a 1- to 2-inch stain of lochia and approximately 10 mL of blood loss; moderate refers to a 4- to 6-inch stain, suggesting a 25 to 50 mL blood loss; and large or heavy refers to a pad that is saturated within 1 hour after changing, indicating over 50 mL blood loss.

22. A nurse is teaching a postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching? A. "We can put him in the tub to bathe him once the cord falls off and is healed." B. "The cord stump should change from brown to yellow." C. "Exposing the stump to the air helps it to dry." D. "We need to call the primary care provider if we notice a funny odor."

Answer: B Rationale: The cord stump should change color from yellow to brown or black. Therefore the parents need additional teaching if they state the color changes from brown to yellow. Tub baths are avoided until the cord has fallen off and the area is healed. Exposing the stump to the air helps it to dry. The parents should notify their primary care provider if there is any bleeding, redness, drainage, or foul odor from the cord stump.

21. A nurse is observing a postpartum client interacting with her newborn and notes that the mother is engaging with the newborn in the en face position. Which behavior would the nurse be observing? A. mother placing the newborn next to bare breast B. mother making eye-to-eye contact with the newborn C. mother gently stroking the newborn's face D. mother holding the newborn upright at the shoulder

Answer: B Rationale: The en face position is characterized by the mother interacting with the newborn through eye-to-eye contact while holding the newborn. Bonding is a vital component of the attachment process and is necessary in establishing parent-infant attachment and a healthy, loving relationship. During this early period of acquaintance, mothers touch their infants in a characteristic manner. Mothers visually and physically "explore" their infants, initially using their fingertips on the infant's face and extremities and progressing to massaging and stroking the infant with their fingers. This is followed by palm contact on the trunk. Eventually, mothers draw their infant toward them and hold the infant. Kangaroo care refers to skin-to-skin contact between the mother and newborn.

12. The nurse is teaching a group of parents about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed? A. "The newborn's skin and that of an adult are similar in thickness." B. "The newborn's sweat glands function fully, just like those of an adult." C. "Skin development in the newborn is not complete at birth." D. "The newborn has fewer fibrils connecting the dermis and epidermis."

Answer: B Rationale: The newborn has sweat glands, like an adult, but full adult functioning is not present until the second or third year of life. The newborn and adult epidermis is similar in thickness and lipid composition, but skin development is not complete at birth. Fewer fibrils connect the dermis and epidermis in the newborn when compared with the adult.

25. After teaching an in-service program to a group of nurses working in newborn nursery about a neutral thermal environment, the nurse determines that the teaching was successful when the group identifies which process as the newborn's primary method of heat production? A. convection B. nonshivering thermogenesis C. cold stress D. bilirubin conjugation

Answer: B Rationale: The newborn's primary method of heat production is through nonshivering thermogenesis, a process in which brown fat (adipose tissue) is oxidized in response to cold exposure. Convection is a mechanism of heat loss. Cold stress results with excessive heat loss that requires the newborn to use compensatory mechanisms to maintain core body temperature. Bilirubin conjugation is a mechanism by which bilirubin in the blood is eliminated.

30. A woman gave birth to a healthy term neonate today at 1330. It is now 1430 and the nurse has completed the client's assessment. At which time would the nurse next assess the client? A. 1445 B. 1500 C. 1530 D. 1830

Answer: B Rationale: The woman is in her second hour postpartum. Typically, the nurse would assess the woman every 30 minutes. In this case, this would be 1500. During the first hour, assessments are usually completed every 15 minutes. After the second hour, assessments would be made every 4 hours for the first 24 hours and then every 8 hours.

25. After teaching a postpartum woman about breastfeeding, the nurse determines that the teaching was successful when the woman makes which statement? A. "I should notice a decrease in abdominal cramping during breast-feeding." B. "I should wash my hands before starting to breastfeed." C. "The baby can be awake or sleepy when I start to feed him." D. "The baby's mouth will open up once I put him to my breast."

Answer: B Rationale: To promote successful breastfeeding, the mother should wash her hands before breast feeding and make sure that the baby is awake and alert and showing hunger signs. In addition, the mother should lightly tickle the infant's upper lip with her nipple to stimulate the infant to open the mouth wide and then bring the infant rapidly to the breast with a wide-open mouth. The mother also needs to know that her afterpains will increase during breastfeeding.

10. The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? A. evaporation B. conduction C. convection D. radiation

Answer: B Rationale: Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

24. A nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breastfeeding. Which information would the nurse most likely include? Select all that apply. A. resumption of sexual intercourse about two weeks after birth B. possible experience of fluctuations in sexual interest C. use of a water-based lubricant to ease vaginal discomfort D. use of combined hormonal contraceptives for the first three weeks E. possibility of increased breast sensitivity during sexual activity

Answer: B, C, E Rationale: Typically, sexual intercourse can be resumed once bright-red bleeding has stopped and the perineum is healed from an episiotomy or lacerations. This is usually by the third to the sixth week postpartum. Fluctuations in sexual interest are normal. In addition, breastfeeding women may notice a let-down reflex during orgasm and find that breasts are very sensitive when touched by the partner. Precoital vaginal lubrication may be impaired during the postpartum period, especially in women who are breastfeeding. Use of water-based gel lubricants can help. The Centers for Disease Control and Prevention recommend that postpartum women not use combined hormonal contraceptives during the first 21 days after birth because of the high risk for venous thromboembolism (VTE) during this period.

27. A nurse is observing a postpartum woman and her partner interact with the their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which behavior? Select all that apply. A. frequently ask for the newborn to be taken from the room B. identify common features between themselves and the newborn C. refer to the newborn as having a monkey-face D. make direct eye contact with the newborn E. refrain from checking out the newborn's features

Answer: B, D Rationale: Positive behaviors that indicate attachment include identifying common features and making direct eye contact with the newborn. Asking for the newborn to be taken out of the room, referring to the newborn as having a monkey-face, and refraining from checking out the newborn's features are negative attachment behaviors.

3. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed? A. ferrous sulfate B. methylergonovine C. docusate D. bromocriptine

Answer: C Rationale: A stool softener such as docusate may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.

21. A group of nurses are reviewing information about the changes in the newborn's lungs that must occur to maintain respiratory function. The nurses demonstrate understanding of this information when they identify which event as occurring first? A. expansion of the lungs B. increased pulmonary blood flow C. initiation of respiratory movement D. redistribution of cardiac output

Answer: C Rationale: Before the newborn's lungs can maintain respiratory function, the following events must occur: respiratory movement must be initiated; lungs must expand, functional residual capacity must be established, pulmonary blood flow must increase, and cardiac output must be redistributed.

2. The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? A. to aid in maturing the newborn's sucking reflex B. to encourage the development of maternal antibodies C. to facilitate maternal-infant bonding D. to enhance the clearing of the newborn's respiratory passages

Answer: C Rationale: Breastfeeding can be initiated immediately after birth. This immediate mother- newborn contact takes advantage of the newborn's natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn's temperature, blood glucose level, and respiratory rate. It is not associated with maturing the sucking reflex, encouraging the development of maternal antibodies, or aiding in clearing of the newborn's respiratory passages.

6. A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction by the nurse would be most appropriate to aid in relieving her discomfort? A. "Express some milk from your breasts every so often to relieve the distention." B. "Remove your bra to relieve the pressure on your sensitive nipples and breasts." C. "Apply ice packs to your breasts to reduce the amount of milk being produced." D. "Take several warm showers daily to stimulate the milk let-down reflex."

Answer: C Rationale: For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the woman who was breastfeeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.

28. The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation? A. respiratory rate of 54 breaths/minute B. abdominal breathing C. nasal flaring D. acrocyanosis

Answer: C Rationale: Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54 breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal findings.

23. A postpartum woman who is breastfeeding tells the nurse that she is experiencing nipple pain. After teaching the woman about possible suggestions, the nurse determines that more teaching is needed when the woman makes which statement? A. "I use a mild analgesic about 1 hour before breastfeeding." B. "I apply expressed breast milk to my nipples." C. "I apply glycerin-based gel to my nipples." D. "My baby latches on."

Answer: C Rationale: Nipple pain is difficult to treat, although a wide variety of topical creams, ointments, and gels are available to do so. This group includes beeswax, glycerin-based products, petrolatum, lanolin, and hydrogel products. Many women find these products comforting. Beeswax, glycerin-based products, and petrolatum all need to be removed before breastfeeding. These products should be avoided in order to limit infant exposure because the process of removal may increase nipple irritation. Mild analgesics such as acetaminophen or ibuprofen are considered relatively safe for breastfeeding mothers. Applying expressed breast milk to nipples and allowing it to dry has been suggested to reduce nipple pain. Usually the pain is due to incorrect latch-on and/or removal of the nursing infant from the breast. Early assistance with breastfeeding to ensure correct positioning can help prevent nipple trauma. In addition, applying expressed milk to nipples and allowing it to dry has been suggested to result in less nipple pain for many women.

21. A new mother who is breastfeeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate? A. "If he seems content after feeding, that should be a sign." B. "Make sure he drinks at least 5 minutes on each breast." C. "He should wet between 6 to 10 diapers each day." D. "If his lips are moist, then he's okay."

Answer: C Rationale: Soaking 6 to 10diapers a day indicates adequate hydration. Contentedness after feeding is not an indicator for adequate hydration. Typically a newborn wakes up 8 to 12 times per day for feeding. As the infant gets older, the time on the breast increases. Moist mucous membranes help to suggest adequate hydration, but this is not the best indicator.

9. When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The nurse refers to this process by which term? A. reciprocity B. engrossment C. bonding D. attachment

Answer: C Rationale: The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.

13. Which method would be most effective in evaluating the parents' understanding about their newborn's care? A. Demonstrate all infant care procedures. B. Allow the parents to state the steps of the care. C. Observe the parents performing the procedures. D. Routinely assess the newborn for cleanliness.

Answer: C Rationale: The most effective means to evaluate the parents' learning is to observe them performing the procedures. Parental roles develop and grow through interaction with their newborn. The nurse would involve both parents in the newborn's care and praise them for their efforts. Demonstrating the procedures to the parents and having the parents state the steps are helpful but do not guarantee that the parents understand them. Assessing the newborn for cleanliness would provide little information about parental learning.

17. A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem? A. lochia rubra with a fleshy odor B. respiratory rate of 16 breaths per minute C. temperature of 101° F (38.3° C) D. pain rating of 2 on a scale from 0 to 10

Answer: C Rationale: Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range. Some women experience a slight fever, up to 100.4º F (38º C), during the first 24 hours. A temperature above 100.4º F (38º C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Foul-smelling lochia or lochia with an unexpected change in color or amount, shortness of breath, or respiratory rate below 16 or above 20 breaths per minute would also be a cause for concern. The goal of pain management is to have the woman's pain scale rating maintained between 0 to 2 points at all times, especially after breast-feeding.

27. A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which suggestions would the nurse include in the teaching? Select all that apply. A. Supplement with iron if the woman is breastfeeding. B. Provide supplemental water intake with feedings. C. Feed the newborn every 2 to 4 hours during the day. D. Burp the newborn frequently throughout each feeding. E. Use feeding time for promoting closeness.

Answer: C, D, E Rationale: Most newborns are on demand feeding schedules and are allowed to feed when they awaken. When they go home, mothers are encouraged to feed their newborns every 2 to 4 hours during the day and only when the newborn awakens during the night for the first few days after birth. Newborns swallow air during feedings, which causes discomfort and fussiness. Parents can prevent this by burping them frequently throughout the feeding. Feeding is also more than an opportunity to get nutrients into the newborn. It is also a time for closeness and sharing. Iron supplementation is recommended for infants who are bottle-fed. Fluid requirements for the newborn and infant do range from 100 to 150 mL/kg daily. This requirement can be met through breast or bottle feedings. Thus, additional water supplementation is not necessary.

4. The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: A. have a smaller body surface compared to body mass. B. lose more body heat when they sweat than adults. C. have an abundant amount of subcutaneous fat all over. D. are unable to shiver effectively to increase heat production.

Answer: D Rationale: Newborns have difficulty maintaining their body heat through shivering and other mechanisms. They have a large body surface area relative to body weight and have limited sweating ability. Additionally, newborns lack subcutaneous fat to provide insulation.

19. A nurse is assessing a newborn and observes the newborn moving his head and eyes toward a loud sound. The nurse interprets this as which behavior? A. habituation B. motor maturity C. social behavior D. orientation

Answer: D Rationale: Orientation refers to the response of newborns to stimuli. It reflects newborns' response to auditory and visual stimuli, demonstrated by their movement of head and eyes to focus on that stimulus. Habituation is the newborn's ability to process and respond to visual and auditory stimuli—that is, how well and appropriately he or she responds to the environment. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Social behaviors include cuddling and snuggling into the arms of the parent when the newborn is held.

2. A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. Which factor would the nurse integrate into the response? A. newborn being placed prone after feeding B. limited ability of digestive enzymes C. underdeveloped pyloric sphincter D. relaxed cardiac sphincter

Answer: D Rationale: The cardiac sphincter and nervous control of the stomach is immature, which may lead to uncoordinated peristaltic activity and frequent regurgitation. Placement of the newborn is unrelated to regurgitation. Most digestive enzymes are available at birth, but they are limited in their ability to digest complex carbohydrates and fats; this results in fatty stools, not regurgitation. Immaturity of the pharyngoesophageal sphincter and absence of lower esophageal peristaltic waves, not an underdeveloped pyloric sphincter, also contribute to the reflux of gastric contents.

16. The nurse observes the stool of a newborn who is being bottle-fed. The newborn is 2 days old. What would the nurse expect to find? A. greenish black, tarry stool B. yellowish-brown, seedy stool C. yellow-gold, stringy stool D. yellowish-green, pasty stool

Answer: D Rationale: The milk stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor. After breast-feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. Meconium stool is greenish black and tarry. The last development in the stool pattern is the milk stool. Milk stools of the breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically sour-smelling.

8. While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first? A. Alert the primary care provider stat, and turn the newborn to her right side. B. Administer oxygen via facial mask by positive pressure. C. Lower the newborn's head to stimulate crying. D. Aspirate the oral and nasal pharynx with a bulb syringe.

Answer: D Rationale: The nurse's first action would be to suction the oral and nasal pharynx with a bulb syringe to maintain airway patency. Turning the newborn to her right side will not alleviate the blockage due to secretions. Administering oxygen via positive pressure is not indicated at this time. Lowering the newborn's head would be inappropriate.

19. When assessing a newborn's reflexes, the nurse strokes the newborn's cheek, and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive? A. palmar grasp reflex B. tonic neck reflex C. Moro reflex D. rooting reflex

Answer: D Rationale: The rooting reflex is elicited by stroking the newborn's cheek. The newborn should turn toward the side that was stroked and should begin to make sucking movements. The palmar grasp reflex is elicited by placing a finger on the newborn's open palm. The baby's hand will close around the finger. Attempting to remove the finger causes the grip to tighten. The tonic neck reflex is elicited by having the newborn lie on the back and turning the head to one side. The arm toward which the baby is facing should extend straight away from the body with the hand partially open, whereas the arm on the side away from the face is flexed and the fist is clenched tightly. Reversing the direction to which the face is turned reverses the position. The Moro reflex is elicited by placing the newborn on his or her back, supporting the upper body weight of the supine newborn by the arms using a lifting motion without lifting the newborn off the surface. The arms are released suddenly, the newborn will throw the arms outward and flex the knees, and then the arms return to the chest. The fingers also spread to form a C.