womens health final exam chap 23, 24, 25, 34, 35, 36, 37

Following birth, the nurse assigns an Apgar score of 10 at 1 minute to a newborn. How would the nurse explain this score? a. An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth. b. An infant having no difficulty adjusting to extrauterine life and needing no further testing. c. A prediction of a future free of neurologic problems. d. An infant in severe distress that needs resuscitation.

a A score of 10 at 1 minute of life indicates excellent transition to extrauterine life; however, the assessment needs to be repeated at 5 minutes of life. An infant in need of resuscitation has a very low Apgar score. Apgar scores do not predict neurologic outcome but are useful for describing the newborn's transition to extrauterine environment.

A nurse is caring for a preterm infant in the nursery setting. Why would the nurse anticpate that a preterm infants would be more likely to become septic? a. IgG level is directly proportional to gestational age. b. Serum complement levels are adequate. c. Immune function is suppressed because of increased IgG levels. d. IgG and IgA levels are adequate at birth.

a IgG levels are directly proportional to gestational age, being decreased in preterm infants, and reflect immune function. Levels of IgG and IgA are not adequate at birth and require time to become optimal. Serum complement levels are decreased at birth in preterm infants.

The condition hypospadias encompasses a wide range of penile abnormalities. Which information should the nurse provide to the anxious parents of an affected newborn? a. Mild cases involve a single surgical procedure. b. Repair is performed as soon as possible after birth. c. No correlation exists between hypospadia and testicular cancer. d. Infant should be circumcised.

a Mild cases of hypospadias are often repaired for cosmetic reasons, and repair involves a single surgical procedure, enabling the male child to urinate in a standing position and to have an adequate sexual organ. These infants are not circumcised; the foreskin will be needed during the surgical repair. Repair is usually performed between 1 and 2 years of age. A correlation between hypospadias and testicular cancer exists; therefore, these children will require long-term follow-up observation.

An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. What would the nurse identify as being the most likely cause of the tremors? a. Hypoglycemia. b. Seizures. c. Birth injury. d. Hypocalcemia.

a The description is indicative of a macrocosmic infant. Hypoglycemia is common in the infant with macrosomia. The tremors are jitteriness that is associated with hypoglycemia. Other signs of hypoglycemia are apnea, tachypnea, and cyanosis.

Which factor would the nurse identify as contributing to depletion of weight and metabolic stores in the high risk newborn? a. Phototherapy b. Frequent breast feedings c. Bathing d. Core temperature within normal range

a The use of phototherapy could lead to insensible heat loss and as a result lead to decreased weight and metabolic stores in the high risk newborn. Frequent breastfeedings and bathing would not have these effects. Maintaining a core temperature would help maintain weight and metabolic stores in the high risk newborn.

A nurse is reviewing the concept of birth injuries. Which factors would the nurse identify so as to predispose an infant to birth injuries? (Select all that apply.) a. Vacuum-assisted birth b. Multip between the ages of 25 and 30 c. Vertex presentation d. Application of an internal fetal scalp electrode

a, d, The use of an internal fetal scalp electrode could result in a scalp injury, which would be evident upon birth. The use of vacuum extraction could lead to a birth injury. Very young age (less than 16) and older age (more than 35) in a primipara are more likely to predispose an infant to birth injuries. Vertex presentation is a normal finding and as such would not typically lead to a birth injury.

A nurse is reviewing the clinical diagnosis of cleft lip and palate. Which environmental factors would the nurse identify as being causative? (Select all that apply.) a. Maternal cigarette smoking b. Alcohol consumption c. Antibiotic use in pregnancy d. Use of some anticonvulsant medications e. Female gender

a,b,d, Factors associated with the potential development of cleft lip or palate are maternal infections, alcohol consumption, radiation exposure, corticosteroid use, use of some anticonvulsant medications, male gender, Native-American or Asian descent, and maternal smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate.

A nurse is caring for an infant with suspected sepsis. Which priority intervention would the nurse implement? a. Electronic monitoring of vital signs b. Intravenous access c. Administration of oxygen d. Recorded intake and output

b Establishing intravenous access for the administration of antibiotics would be a priority intervention. The other actions described might be required but are not the priority intervention.

A pregnant client is receiving a selective serotonin reuptake inhibitor(SSRI) to treat depression. Which medication would the nurse identify as being associated with cardiac defects during pregnancy? a. Citalopram b. Paroxetine c. Sertraline d. Fluoxetine

b The American College of Obstetricians and Gynecologists (ACOG) has issued a recommendation that paroxetine be avoided both during pregnancy and in women considering pregnancy. There have also been reports linking paroxetine to other abnormalities, such as omphalocele, craniosynostosis, and anencephaly. The absolute risk of any congenital abnormality associated with use of citalopram, fluoxetine, or sertraline is small.

The nurse is caring for an infant with Developmental Dysplasia of the Hip (DDH). Which clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Telescoping of the affected limb b. Positive Ortolani click c. Negative Babinski sign d. Trendelenburg sign e. Unequal gluteal folds

b, e A positive Ortolani test and unequal gluteal folds are clinical manifestations of DDH observed from birth to 2 to 3 months of age. A negative Babinski sign, Trendelenburg sign, and telescoping of the affected limb are not clinical manifestations of DDH.

A nurse is working with clients who have experienced a perinatal loss. Which statements would not be advisable for the nurse to use as a basis for therapeutic discussion? (Select all that apply.) a. "You wanted a boy anyway, so now you have another chance" b. "I'm sorry" c. "I am sad for you" d. This must be hard for you" e. "You're young, you can have other children"

b,c,d "This must be hard for you," "I'm sorry," and "I am sad for you" are acceptable statements following perinatal loss. "You're young, you can have other children" and "You wanted a boy anyway, so now you have another chance" would not be considered therapeutic.

A nurse is discussing with an obese client potential long-term consequences of infant feeding practices. Which method should the nurse identify to the client as having a decreased risk for the development of childhood obesity for the infant? a. Lower-calorie infant formula. b. An on-demand feeding schedule. c. Breastfeeding. d. Smaller, more frequent feedings.

c Breastfeeding is the best prevention strategy for decreasing childhood and adolescent obesity. Breastfeeding also helps the woman return to her prepregnant weight sooner.All breastfed infants should be fed on demand. Use of lower-calorie formula is an inappropriate strategy that does not meet the infant's nutritional needs. Breastfeeding is the most appropriate choice for infant feeding. Smaller feedings are not necessary. Infants should continue to be fed every 2 to 3 hours in the newborn period.

A nurse is reviewing intrapartum risk factors that would lead to the development of neonatal sepsis. Which of the following would the nurse not consider to be a factor? a. Meconium aspiration b. Mechanical ventilation c. Chorioamnionitis d. Galactosemia

c Chorioamnionitis would be considered to be an intrapartum risk factor. The other conditions described are neonatal risk factors.

For diagnostic and treatment purposes, nurses should know the birth weight classifications of high risk infants. What description would the nurse identify for an infant who was categorized as an extremely low birth weight (ELBW)infant? a. Dependent on the gestational age. b. Less than 1500 g. c. Less than 1000 g. d. Less than 2000 g.

c ELBW is defined as less than 1000 g. At such weights, problems are so numerous that ethical issues regarding when to treat arise. Less than 1500 g is the designation for very low birth rate (VLBW). Less than 2000 g is less than LBW but too high for VLBW. Gestational age is a factor with weight in the condition of the preterm birth, but it is not part of the birth weight categorization.

To explain hemolytic disorders in the newborn to new parents, the nurse who cares for the newborn population must be aware of the physiologic characteristics related to these conditions. What would the nurse identify as being the most common cause of pathologic hyperbilirubinemia? a. Postmaturity b. Hepatic disease c. Hemolytic disorders d. Congenital heart defect

c Hemolytic disorders in the newborn are the most common cause of pathologic hyperbilirubinemia (jaundice). Although hepatic damage, prematurity, and congenital heart defects may cause pathologic hyperbilirubinemia, they are not the most common causes.

The nurse is assessing a newbown and discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver. What should be the priority action taken by the nurse? a. Informs the parents and physician that molding has not taken place. b. Tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. c. Alerts the physician that the infant has a dislocated hip. d. Suggests that if the condition does not change, surgery to correct vision problems might be needed.

c The Ortolani maneuver is a technique for checking hip integrity. Unequal movement suggests that the hip is dislocated. The physician should be notified. The statement in B is inappropriate and may result in unnecessary anxiety for the new parents. Molding refers to movement of the cranial bones and has nothing to do with the infant's hips.

A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is: a. hearing b. taste c. smell d. vision

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

The nurse taught new parents the guidelines to follow regarding the bottle feeding of their newborn who will be using formula from a can of concentrate. Which action if observed by the nurse would indicate that the parents correctly understand the nurse's instruction? a. Warm formula in a microwave oven for a couple of minutes prior to feeding. b. Add some honey to sweeten the formula and make it more appealing to a fussy newborn. c. Adjust the amount of water added according to weight gain pattern of the newborn. d. Wash the top of can and can opener with soap and water before opening the can.

d Washing the top of the can and can opener with soap and water before opening the can of formula is a good habit for parents to get into to prevent contamination. Directions on the can for dilution should be followed exactly and not adjusted according to weight gain to prevent nutritional and fluid imbalances. Honey is not necessary and could contain botulism spores. The formula should be warmed in a container of hot water because a microwave can easily overheat it.

Most congenital anomalies of the central nervous system(CNS)result from defects in the closure of the neural tube during fetal development. Which factor would the nurse identify has having the most impact on this process? a. Maternal folic acid deficiency b. Maternal diabetes c. Maternal use of anticonvulsant d. Socioeconomic status

a All of these environmental influences may affect the development of the CNS. Maternal folic acid deficiency has a direct bearing on the failure of neural tube closure. As a preventative measure, folic acid supplementation (0.4 mg/day) is recommended for all women of childbearing age.

A nurse is performing screening and providing education to parents regarding the treatment of developmental dysplasia of the hip (DDH). Which intervention should the nurse perform? a. Carefully monitor infants for DDH at follow-up visits. b. Explain to the parents the need for serial casting. c. Teach double or triple diapering for added support. d. Be able to perform the Ortolani and Barlow tests.

a Because DDH often is not detected at birth, infants should be carefully monitored at follow-up visits. The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. Double or triple diapering is not recommended because it promotes hip extension, thus worsening the problem. Serial casting is recommended for clubfoot, not DDH.

A nurse is providing teaching relative to TORCH infections to a group of pregnant women. Which TORCH infection could be contracted by the infant because the mother owned a cat? a. Toxoplasmosis b. Parvovirus B19 c. Varicella-zoster d. Rubella

a Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning a cat's litter box. The infection is passed through the placenta. The varicella-zoster virus is responsible for chickenpox and shingles. Approximately 90% of childbearing women are immune. During pregnancy, infection with parvovirus can result in abortion, fetal anemia, hydrops, intrauterine growth restriction (IUGR), and stillbirth; this virus is spread by vertical transmission, not by felines. Since vaccination for rubella was begun in 1969, cases of congenital rubella infection have been reduced significantly. Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in periodic outbreaks of rubella (German measles).

A mother expresses fear about changing her infant's diaper after he is circumcised. What should the nurse teach the mother about providing caring for the infant upon discharge? a. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. b. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. c. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. d. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.

a Gentle cleansing with warm water, not wipes, and application of petroleum jelly at each diaper change are appropriate care for an infant who has had a circumcision. If bleeding occurs, gentle pressure should be applied to the site of the bleeding with a sterile gauze square. Yellow exudate covers the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudate should not be removed.

With regard to the classification of neonatal bacterial infection, nurses should be aware that: a. Health care-associated infection can be prevented by effective handwashing; early-onset infection cannot. b. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher. c. The clinical sign of a rapid, high fever makes infection easier to diagnose. d. Congenital infection progresses slower than health care-associated infection.

a Handwashing is an effective preventive measure for late-onset (health care-associated) infections because these infections come from the environment around the infant. Early-onset (congenital) infections are caused by the normal flora at the maternal vaginal tract. Congenital (early-onset) infections progress more rapidly than health care-associated (late-onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult.

While caring for the newborn, the nurse must be alert for any signs of cold stress. Which finding should the nurse anticpate? a. Increased respiratory rate b. Decreased activity level c. Hyperglycemia d. Shivering

a In an infant who is cold, the respiratory rate rises in response to the increased need for oxygen. Signs of cold stress include increased activity level and crying (increased basal metabolic rate [BMR] and heat production). A cold infant is at risk for hypoglycemia as the glucose stores are depleted. Newborns are unable to shiver as a means to increase heat production.

The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Which statement should the maternity identify as correct? a. A common practice among Mexican women is known as las dos cosas. b. Muslim cultures do not encourage breastfeeding because of modesty concerns. c. Latino women born in the United States are more likely to breastfeed. d. East Indian and Arab women believe that cold foods are best for a new mother.

a Las dos cosas refers to combining breastfeeding and commercial infant formula. It is based on the belief that combining the two feeding methods gives the mother and infant the benefits of breastfeeding along with the additional vitamins from formula. In the Muslim culture, breastfeeding for 24 months is customary; Muslim women may, however, choose to bottle-feed formula or expressed breast milk while in the hospital. Latino women born in the United States are less likely to breastfeed. East Indian and Arab women believe that hot foods, such as chicken and broccoli, are best for the new mother. The cultural descriptor hot has nothing to do with the temperature or spiciness of the food.

The nurse is assessing the respiratory system of a newborn. Which statement should the nurse be aware of with regard to the respiratory development of the newborn? a. Crying increases the distribution of air in the lungs. b. Seesaw respirations are no cause for concern in the first hour after birth. c. Newborns must expel the fluid at uterine life from the respiratory system within a few minutes of birth. d. Newborns are instinctive mouth breathers.

a Respirations in the newborn can be stimulated by mechanical factors such as changes in intrathoracic pressure resulting from the compression of the chest during vaginal birth. With birth, the pressure on the chest is released, helping draw air into the lungs. The positive pressure created by crying helps keep the alveoli open and increases distribution of air throughout the lungs. Newborns continue to expel fluid for the first hour of life. They are natural nose breathers and may not have the mouth-breathing response to nasal blockage for 3 weeks. Seesaw respirations instead of normal abdominal respirations are not normal and should be reported.

A nurse is providing care for a mother who has abused (or is abusing) alcohol and for her infant. Which statement would the nurse identify as being accurate? a. Alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. b. Two thirds of newborns with fetal alcohol syndrome (FAS) are boys. c. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time. d. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over.

a Some learning problems do not become evident until the child is in school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident with growth, the mental capacities never become normal.

The nurse is providing discharge instructions related to the baby's respiratory system. Which statement should the nurse not include as part of discharge teaching? a. Don't let the infant sleep on his or her back. b. Avoid loose bedding, waterbeds, and beanbag chairs. c. Prevent exposure to people with upper respiratory tract infections. d. Keep the infant away from secondhand smoke.

a The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. Infants are vulnerable to respiratory infections, so infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding, and furniture that can trap them.

A nurse must administer erythromycin ophthalmic ointment to a newborn after birth. Which action shoud the nurse include when administering the medication? a. Cleanse eyes from inner to outer canthus before administration if necessary. b. Flush eyes 10 minutes after instillation to reduce irritation. c. Apply directly over the cornea. d. Instill within 15 minutes of birth for maximum effectiveness.

a The newborn's eyes should be cleansed if necessary before the administration of erythromycin ointment. Instillation of the ointment can be delayed for up to 2 hours to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. Erythromycin ointment should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation.

A nurse is working with a client who is grieving over the loss of a stillborn. Which statement would the nurse identify as correct with regard to the emotional state of grief? a. Time limit for grief experiences is variable among individuals. b. Aspects of grief occur simultaneously across family units. c. It represents a linear process. d. It is a static concept applied to loss.

a There is no prescribed time limit for the expression of grief. Grief is a dynamic concept involving complex emotions. The expression of grief is individualized and may not occur simultaneously across family units. The process of grief represents an iterative process.

A nurse is preparing to weight a newborn. Which action should the nurse include as part of the procedure? a. Weigh the newborn at the same time each day for accuracy. b. Place a sterile scale paper on the scale for infection control. c. Keep a hand on the newborn's abdomen for safety. d. Leave its diaper on for comfort.

a Weighing a newborn at the same time each day allows for the most accurate weight. The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above, not on, the abdomen for safety.

A nurse is reviewing concepts related to infants of diabetic mothers. Which factor would the nurse identified as increasing the risk of complications for infants of diabetic mothers? a. Duration of maternal disease b. Hemoglobin A1c level of 7 prior to pregnancy c. Glycemic control d. Hemoglobin A1c level of 7

a the duration and severity of maternal disease are significant factors in increasing the risk for complications in infants of diabetic mothers. Glycemic control would be a positive factor indicating that blood glucose levels were maintained within normal range. A hemoglobin A1c level of 7 is within normal range.

A nurse is reviewing the occurrence of hematologic problems in preterm infants. Which of the following processes or findings would the nurse identify as leading to an increase in hematologic problems? (Select all that apply.) a. Prolonged Prothrombin time (PT)time b. Decrease in size of red blood cells c. Decreased capillary fragility d. Decreased red blood cell survival time e. Decrease in erythropoiesis

a,d,e Prolonged PT reflects an increased tendency to bleed in preterm infants. Decrease in red blood cell survival time is seen in such infants. So is decreased functional ability of erythropoietin, which limits red blood cell synthesis. One sees an increase in the size of red blood cells in preterm infants, which affects their survival time. Increased capillary fragility also occurs in preterm infants.

A nurse is reviewing concepts of hemolytic disease of the newborn. Which statement would the nurse identify as being most accurate? a. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. b. The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth. c. Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother. d. Exchange transfusions are frequently required in the treatment of hemolytic disorders.

b An indirect Coombs' test may be performed on the mother a few times during pregnancy. Only the Rh-positive child of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers infrequently are needed because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

A Gravida III, Para 0 is concerned about the potential outcome for this pregnancy because all of her prior pregnancies have resulted in stillborn deliveries. Which diagnostic test would the nurse identify to assess for fetal well-being now that her pregnancy is at 32 weeks gestation? a. Chorionic villi sampling (CVS) b. Ultrasound c. Kleihauer-Betke test d. Contraction stress test (CST)

b An ultrasound could be used to determine fetal well-being. The Kleihauer-Betke test is a blood test to evaluate for the presence of fetal blood in maternal circulation; there is no evidence to support the use of this test at this time. CVS testing is typically done earlier in the pregnancy, between 10 and 12 weeks. There is no evidence to support the use of a CST at this time; determination of fetal well-being would first be evaluated with a nonstress test.

A nurse is taking care of a newborn who was diagnosed with a diaphragmatic hernia. Which nursing diagnosis would the nurse identify as being the most appropriate? a. Potential for infection b. Potential for reduced gas exchange c. Potential for attachment problems d. Inadequate nutrition

b Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. Although inadequate nutriton may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. The nutritional needs of this infant may be a clearly identified need. However, at this time the nurse should be most concerned about the potential for reduced gas exchange. This infant has a potential for infection, especially once the surgical repair has been performed. The extent of the herniation may have hindered normal development of the lungs in utero, resulting in respiratory distress.

A nurse is reviewing lab results related to Rh factor. Which infant would the nurse identify as being most likely to express Rh incompatibility? a. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor b. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor c. Infant who is Rh negative and a mother who is Rh negative d. Infant who is Rh positive and a mother who is Rh positive

b If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, then all the offspring of this union will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. Only the Rh-positive offspring of an Rh-negative mother are at risk. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, a 50% chance exists that each infant born of this union will be Rh positive, and a 50% chance exists that each will be born Rh negative. No risk for incompatibility exists if both the mother and the infant are Rh positive.

A nursing student is reviewing concepts related to infant feeding. Which statement should the nurse identify as being correct concerning tandem feeding? a. Supplementing breastfeeding with bottle feeding to maintain adequate weight gain. b. Breastfeeding an infant and an older sibling during the same period. c. Using both breasts to nurse the baby. d. Adequate nutritional stores for the mother and infant

b In tandem feeding, a mother nurses both an infant and an older child during the same period.

The nurse is instructing a family how to care for their infant in a Pavlik harness to treat Developmental Dysplasia of the Hip (DDH). What information should the nurse include in the teaching? a. Apply lotion or powder to minimize skin irritation. b. Return to the clinic every 1 to 2 weeks. c. Place a diaper over the harness, preferably using an absorbent disposable diaper. d. Remove the harness several times a day to prevent contractures.

b Infants have a rapid growth pattern. Therefore, the child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness, and the harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

A nurse providing care to preterm infants should understand that nasogastric and orogastric tubes are used to: a. Provide oxygen and ventilation. b. Feed the infants. c. Help maintain body temperature. d. Replace surfactants.

b Nasogastric and orogastric tubes are used in gavage feeding, providing breast milk or formula directly to an infant unable to nipple feed. To help maintain body temperature, preterm infants should be placed on warmers. Oxygen, continuous positive airway pressure (CPAP), and a ventilator are used for O2 and ventilation. Surfactants are not replaced by using nasogastric or orogastric tubes.

A nurse administers Vitamin K to the newborn post delivery. The nurse understands that the reason for this medication to be given is? a. Reduce bilirubin levels. b. Enhance the ability of blood to clot. c. Stimulate the formation of surfactant. d. Increase the production of red blood cells.

b Newborns have a deficiency of vitamin K until intestinal bacteria that produce it are formed. Vitamin K is required for the production of certain clotting factors. Vitamin K does not reduce bilirubin levels, increase the production of red blood cells, or stimulate the formation of surfactant.

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. What information should the nurse provide to the parents regarding the presence of petechiae? a. Should always be further investigated. b. Are benign if they disappear within 48 hours of birth. c. Usually occur with forceps delivery. d. Result from increased blood volume.

b Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. They usually occur with a breech presentation vaginal birth, although in this case they are soft-tissue injury resulting from the nuchal cord at birth. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae may also result from decreased platelet formation.

A nurse examining a newborn infant notes that the infant is jaundiced. Which observation would lead the nurse to continue to monitor but not to intervene and contact the physician? a. Infant is being bottle fed and within the first 24 hours of life. b. Jaundice appeared on the third day of life. c. Jaundice appeared within the first 24 hours of life. d. Preterm infant who is 12 hours old.

b Physiologic jaundice can be seen in a large percentage of newborns, 60% of term and 80% of preterm, but typically resolves without immediate intervention. The critical factor here is the time of appearance, being within the first 24 hours of life. Jaundice appearing at this time is considered pathological and requires further investigation. The timing in C combined with prematurity also requires further investigation.

A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturation values of 80%. The prescribed saturation value is 92%. What is the most appropriate nursing action? a. Continue with the admission process to ensure that a thorough assessment is completed. b. Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. c. Notify the parents that their infant is not doing well. d. Continue to observe and make no changes until the saturations are 75%.

b The actions described in A are appropriate nursing interventions to assist in optimal O2 saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained at more than 92%, and the nurse should delay other tasks to stabilize the infant. The action described in D is not appropriate. Further assessment and intervention are warranted prior to determination of fetal status.

A nurse is providing umbilical cord care to a newly delivered infant. What information should the nurse be aware of? a. The cord clamp is removed at cord separation. b. The stump can easily become infected. c. The average cord separation time is 5 to 7 days. d. A nurse noting bleeding from the vessels of the cord should immediately call for assistance.

b The cord stump is an excellent medium for bacterial growth. If bleeding occurs, the nurse should first check the clamp (or tie) and apply a second one; if the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

The nurse is assigned a home care visit of a 5-day-old infant for the treatment of jaundice. A thorough assessment is completed, and a health history is obtained. Which sign or symptom if observed by the nurse indicates that the infant may be displaying the initial phase of encephalopathy? a. Fever and seizures b. Hypotonia, lethargy, and poor suck c. High-pitched cry d. Severe muscle spasms (opisthotonos)

b The early and most subtle symptoms of bilirubin encephalopathy include hypotonia, lethargy, poor suck, and a depressed or absent Moro reflex. Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or an arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase of encephalopathy. Medical attention is immediately necessary. Symptoms may progress from the subtle indications of the first phase to fever and seizures in as few as 24 hours. Only approximately one half of these infants survive, and those that do will have permanent sequelae, including auditory deficiencies, intellectual deficits, and movement abnormalities.

A pregnant client who is at term has been informed that her fetus has died and has been admited to the obstetric unit. When developing a plan of care, the nurse would focus on which priority measure? a. Providing the client with phone numbers so as to make funeral arrangements. b. Incorporating perinatal palliative care into the client's plan of care. c. Including case management to participate in the client's care when she is admitted to the hospital. d. Referral to a perinatologist.

b The incorporation of a perinatal palliative care plan would be the priority intervention at this time to help the client and family members deal with the tragedy of the situation. At this point, a referral to a perinatologist would not be necessary because the determination has already been made that the fetus is dead. Although case management may be included in the plan of care and phone numbers may be provided to the client regarding funeral arrangements, these actions are not the priority measure.

A nurse is assisting a breastfeeding mother with positioning of the baby. Which finding should the nurse be aware of? a. While supporting the head, the mother should push gently on the occiput. b. Whatever the position used, the infant is held in direct skin with the mother. c. Women with perineal pain and swelling prefer the modified cradle position. d. The cradle position is usually preferred by mothers who had a cesarean birth.

b The infant inevitably faces the mother, belly to belly and should be in direct skin contact. The football position usually is preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head, because doing so might cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.

A client tells the nurse about the funeral arrangements for her newborn son. The client is thereby providing the nurse with information about: a. Expression of loss. b. Mourning process. c. Family reaction. d. Grief process.

b The mourning process is reflected by traditions and rituals such as the funeral arrangements. The grief process represents the emotional expression of loss. The expression of loss is related to the meaning of perception. Providing information related to funeral arrangements is not an indicator of family reaction.

A nurse has provided client teaching to a breastfeeding mother. Which action if observed by the nurse would indicate the need for further instruction? a. Puts her finger into newborn's mouth before removing breast. b. Leans forward to bring breast toward the baby. c. Holds breast with four fingers along bottom and thumb at top. d. Stimulates the rooting reflex and then inserts nipple and areola into newborn's open mouth.

b To maintain a comfortable, relaxed position, the mother should bring the baby to the breast, not the breast to the baby. The mother would need further demonstration and teaching to correct the ineffective action. The other actions described are correct.

A nurse is reviewing the concept of weaning with regard to infant care. Which statement should the nurse identify as correct? a. Abrupt weaning is easier than gradual weaning. b. Weaning can be mother or infant initiated. c. Weaning should proceed from breast to bottle to cup. d. The feeding of most interest should be eliminated first.

b Weaning is initiated by the mother or the infant. With infant-led weaning, the infant moves at his or her own pace in omitting feedings, which leads to a gradual decrease in the mother's milk supply. In mother-led weaning, the mother decides which feedings to drop. Infants can be weaned directly from the breast to a cup. Bottles are usually offered to infants younger than 6 months. If the infant is weaned prior to 1 year of age, iron-fortified formula rather than cow's milk should be offered. The feeding of least interest to the baby or the one through which the infant is likely to sleep should be eliminated first. Every few days thereafter the mother drops another feeding. Gradual weaning over a period of weeks or months is easier for both the mother and the infant than an abrupt weaning.

The birth weight of a breastfed newborn was 8 lb, 4 oz. On the third day the newborn's weight is 7 lb, 12 oz. Which action should the nurse take based on this finding? a. Notify the physician because the newborn is being poorly nourished. b. Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs. c. Suggest that the mother switch to bottle feeding because breastfeeding is ineffective in meeting newborn needs for fluid and nutrients. d. Refer the mother to a lactation consultant to improve her breastfeeding technique.

b Weight loss of 8 oz falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 oz. The infant is not undernourished, and the physician does not need to be notified. Breastfeeding is effective, and bottle feeding does not need to be initiated at this time.

The most widespread use of postnatal testing for genetic disease is the routine screening of newborns for inborn errors of metabolism (IEM). Which conditions would the nurse identify as being metabolic disorders? (Select all that apply.) a. Rubella b. Galactosemia c. Hemoglobinopathy d. Phenylketonuria (PKU) e. Cytomegalovirus (CMV)

b, c, d PKU is an IEM that can be diagnosed with newborn screening. Galactosemia is a metabolic defect that falls under the category of an IEM. Sickle cell disease and thalassemia are hemoglobinopathies that can be detected by newborn screening. CMV and rubella cannot be detected by newborn screening and are not metabolic disorders; rather, they are viruses contracted by the fetus.

Following a vaginal delivery, the client tells the nurse that she intends to breastfeed her infant but she is very concerned about returning to her prepregnancy weight. On the basis of this interaction, the nurse would advise the client that: (Select all that apply.) a. She should join Weight Watchers as soon as possible to ensure adequate weight loss. b. Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. c. If breastfeeding, she should regulate her fluid consumption in response to her thirst level. d. If she decreases her calorie intake by 100-200 calories a day she will lose weight more quickly. e. Weight loss diets are not recommended for women who breastfeed.

b, c, e Weight loss diet plans are not recommended for women who are breastfeeding because they can lead to depletion of reserves and nutrient stores and decreased milk production. Breastfeeding mothers need to increase their caloric intake by 400-500 calories/day to ensure adequate nutritional stores and milk production. Breastfeeding women lose weight faster postpartum than women who bottle feed their infants. Regulating fluid consumption in response to her thirst level will ensure that a breastfeeding woman has adequate hydration without overhydration.

A nurse is reviewing possible etiologies for hyperbilirubinemia in the newborn. Which findings would the nurse expect to lead to increased bilirubin levels in the newborn? (Select all that apply.) a. Cord clamped immediately following delivery of newborn b. Initiation of newborn feedings delayed following birth c. Twin-to-twin transfusion syndrome d. Hyperglycemia e. Meconium passed after 24 hours

b,c,e Delay in passage of meconium or in newborn feedings could lead to increased bilirubin levels because of increased enterohepatic circulation. Twin-to-twin transfusion syndrome could lead to increased bilirubin levels as a result of an increased amount of hemoglobin. An increase in bilirubin levels would be seen if cord clamping were delayed following birth. Hypoglycemia could lead to increased bilirubin levels because of alterations in hepatic function and perfusion.

A nurse is examining a newborn male, who is estimated to be 39 weeks of gestation. Which physical finding should the nurse anticipate to be present? a. Abundant lanugo over his entire body. b. Ability to move his elbow past his sternum. c. Testes descended into the scrotum. d. Extended posture when at rest.

c A full-term male infant has both testes descended into his scrotum and rugae appear on the anterior portion. A full-term infant's good muscle tone results in a more flexed posture when at rest. A full-term infant exhibits only a moderate amount of lanugo, usually on the shoulders and back. Preterm infants have an abundance of lanugo over the entire body. The muscle tone of a full-term newborn prevents him from being able to move his elbow past midline.

Which priority action implemented by the nurse would be most beneficial in helping a couple deal with fetal loss following the delivery of a stillborn? a. Provide a quiet environment for the couple for several hours restricting any visitors or family members. b. Allow all family members to come in immediately after the delivery to console the couple. c. Allow the parents to hold and view the baby following delivery if they so request. d. Take a photograph of the stillborn prior to the client's discharge to use as a keepsake.

c Bonding with the stillborn by holding and viewing after delivery is well documented by research to provide a source of comfort and closure. Although it will be important for family members to comfort the couple, it is more important for the family unit to be alone to adapt to the delivery. Providing a quiet environment is important but it not the priority action to be taken at this time. Taking a photograph is important as a keepsake but it is typically taken before the stillborn leaves the hospital.

A nurse is caring is administering a gavage feeding to an infant. What should the nurse document each time? a. The infant's suck and swallow coordination b. The infant's heart rate and respirations c. The infant's response to the feeding d. The infant's abdominal circumference after the feeding

c Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Some older infants may be learning to suck, but the important factor to document is the infant's response to the feeding (including attempts to suck). Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained prior to feeding, but the infant's response is more important.

A nurse is placing a newborn under a radiant heat warmer for temperature stabilization. Which action should the nurse include during this procedure? a. Cover the probe with a nonreflective material. b. Recheck temperature by periodically taking a rectal temperature. c. Perform all examinations and activities under the warmer. d. Place the thermistor probe on the left side of the chest.

c During all procedures, heat loss must be avoided or minimized for the newborn. All examinations and activities are performed with the infant under the heat panel. The thermistor probe should be placed on the upper abdomen away from the ribs and should be covered with reflective material. Rectal temperature measurements should be avoided because rectal thermometers can perforate the intestine, and the rectal temperature may remain normal until cold stress is advanced.

A nurse is reviewing the concept of breastfeeding. Which statement should the nurse identify as being inaccurate as it relates to the effect of breastfeeding on the family or society at large? a. Breastfeeding benefits the environment. b. Breastfeeding requires fewer supplies and less cumbersome equipment. c. Breastfeeding costs employers in terms of time lost from work. d. Breastfeeding saves families money.

c Less time is lost from work by breastfeeding mothers, in part because infants are healthier than bottle-fed infants. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment, and it saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Also, breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal.

A nurse is working with bereaved parents. What is the most appropriate statement that the nurse can make? a. "You're young and can have other children." b. "I understand how you must feel." c. "I'm sorry." d. "You have an angel in heaven."

c One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. At the very least, the nurse should acknowledge the loss with a simple but sincere comment, such as, "I'm sorry." The initial impulse may be to reduce one's sense of helplessness and to say or do something that you think will reduce their pain. Although such a response may seem supportive at the time, it can stifle the further expression of emotion. The nurse should resist the temptation to give advice or to use clichés when offering support to the bereaved. The statement in C is not a therapeutic response for the nurse to make.

A nurse is reviewing the concept of complicated bereavement. Which statement would the nurse identify as being accurate? a. Occurs when, in multiple births, one child dies and the other or others live. b. Is felt by the family of adolescent mothers who lose their babies. c. Is an extremely intense grief reaction that persists for a long time. d. Is a state in which the parents are ambivalent, as with an abortion.

c Parents showing signs of complicated grief should be referred for counseling. Multiple births in which not all the babies survive creates a complicated parenting situation, abortion can generate complicated emotional responses, and families of lost adolescent pregnancies may have to deal with complicated issues, but these situations are not complicated bereavement.

The nurse is reviewing the clinical diagnosis of necrotizing enterocolitis (NEC). What would the nurse indicate as being a generalized sign associated with NEC? a. Hypertonia, tachycardia, and metabolic alkalosis. b. Scaphoid abdomen, no residual with feedings, and increased urinary output. c. Abdominal distention, temperature instability, and grossly bloody stools. d. Hypertension, absence of apnea, and ruddy skin color.

c Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall.

A nurse is reviewing concepts of small-for-gestational age (SGA) infants and intrauterine growth restriction (IUGR). Which statement would the nurse identify as being accurate? a. Symmetric IUGR occurs in the later stages of pregnancy. b. In the first trimester, diseases or abnormalities result in asymmetric IUGR. c. Infants with asymmetric IUGR have the potential for normal growth and development. d. In asymmetric IUGR, weight is slightly more than SGA, whereas length and head circumference are somewhat less than SGA.

c The infant with asymmetric IUGR has the potential for normal growth and development.IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester, as a result of disease or abnormalities; SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile, but the head circumference is greater than the 10th percentile (within normal limits).

A nurse is observing a premature infant's breathing pattern who is exhibiting a compensatory rapid respirations. How would the nurse intepret this finding? a. Trying to maintain a neutral thermal environment. b. Suffering from sleep or wakeful apnea. c. Breathing in a respiratory pattern common to premature infants. d. Experiencing severe swings in blood pressure.

c The pattern of 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of rapid respiration is called periodic breathing, which is common to premature infants. It may require nursing intervention such as oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. An infant who presents with fluctuation in systemic blood pressure may have experienced a central nervous system injury. An infant attempting to maintain body temperature is likely to present with hypoglycemia, shivering, and mottled color.

After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die?" What is the nurse's best response? a. Silence. b. "That's not likely. Paint is associated with elevated pediatric lead levels." c. "I can understand your need to find an answer to what caused this. What else are you thinking about?" d. "That's an old wives' tale; lots of women are around paint during pregnancy, and this doesn't happen to them."

c The statement in c is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. Trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feelings does not help the process of grief. Additionally the response in B probably would increase the mother's feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories, and listening with care, which silence would not do.

A nurse is taking care of an infant born with myelomeningocele. What is the highest priority nursing intervention that the nurse should perform? a. Assess for cyanosis. b. Prepare the parents for closure of the sac when the child is approximately 2 years of age. c. Prepare the parents for the child's paralysis from the waist down. d. Protect the sac from injury.

d A major preoperative nursing intervention for a neonate with a myelomeningocele is the protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system (CNS) infection. The long-term prognosis in an affected infant can be determined to a large extent at birth, with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. A myelomeningocele should be surgically closed within 24 hours. Although the nurse should assess for multiple potential problems in this infant, the major nursing intervention is to protect the sac from injury.

A nurse is monitoring an infant who is diagnosed with erythroblastosis fetalis. What clinical finding would the nurse most likely to be exhibited? a. Ascites b. Enlargement of the heart c. Edema d. Immature red blood cells

d Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. Edema occurs with hydrops fetalis, a more severe form of erythroblastosis fetalis. The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces, as well as demonstrate signs of ascites.

A nurse is reviewing the concept of injuries occuring to the infant's plexus during labor and birth. Which statement would the nurse identify as being accurate? a. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves. b. Parents of children with brachial palsy are taught to pick up the child from under the axillae. c. Erb palsy is damage to the lower plexus. d. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.

d If the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated in facial nerve paralysis, but both mother and infant will need help from the nurse at the start.

A nurse is monitoring a healthy newborn's blood glucose level 90 minutes after birth. Which result should the nurse anticipate in terms of mg/dL? a. 80-100 b. 60-70 c. less than 40 d. 55-60

d In most healthy term newborns, blood glucose levels stabilize at 55 to 60 mg/dL between 30 and 90 minutes after birth. 80 to 100 mg/dL is the normal plasma glucose level in the adult. A blood glucose level less than 40 mg/dL in the newborn is considered abnormal and warrants intervention. An infant with this level can display classic symptoms of jitteriness, lethargy, apnea, feeding problems, or seizures. By the third day of life the blood glucose levels should be approximately 60 to 70 mg/dL.

A group of nursing students are reviewing the process of bathing for a newborn. Which statement should the nursing students identify as being incorrect? a. Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. b. Only plain warm water should be used to preserve the skin's acid mantle. c. Powders are not recommended because the infant can inhale powder. d. Newborns should be bathed every day, for the bonding as well as the cleaning.

d Newborns do not need a bath every day, as it can disrupt the integrity of a newborn's skin. The diaper area and creases under the arms and neck need more attention. Tub baths may be given as soon as an infant's temperature has stabilized. Unscented mild soap is appropriate to use to wash the infant. Powder is not recommended because of the risk of inhalation. Should a parent elect to use baby powder, it should never be sprinkled directly onto the baby's skin. The parent can apply a small amount of powder to his or her own hand and then apply it to the infant.

A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, how should the nurse respond? a. Children outgrow this condition when they learn to walk. b. Traction is tried first. c. Surgical intervention is needed. d. Frequent, serial casting is tried first.

d Serial casting, the preferred treatment, is begun shortly after birth and before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are frequently repeated (every week) to accommodate the rapid growth of early infancy. Surgical intervention is performed only if serial casting is not successful. Children do not improve without intervention.

A group of nurses are discussing congenital anomalies of the cardiovascular and respiratory systems. Which statement would the nurses identify as being accurate? a. Screening for congenital anomalies of the respiratory system need only be performed for infants experiencing respiratory distress. b. Choanal atresia can be corrected with the use of a suction catheter to remove the blockage. c. Congenital diaphragmatic hernias are diagnosed and treated after birth. d. Cardiac disease may demonstrate signs and symptoms of respiratory illness.

d The cardiac and respiratory systems function together; therefore, initial findings will be related to respiratory illness. Screening for congenital respiratory system anomalies is necessary, even for infants who appear normal at birth. All newborns should have critical congenital heart disease (CCHD) screening performed before discharge. Choanal atresia requires emergency surgery. Congenital diaphragmatic hernias are prenatally discovered on ultrasound.

While evaluating the reflexes of a male newborn, the nurse notes that with a loud noise, the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse documents this finding as a positive: a. Glabellar (Myerson) reflex response b. Babinski reflex response c. Tonic neck reflex response d. Moro reflex response

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

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black. She asks the nurse whether something is wrong. Which of the following would be the best response offered by the nurse? a. Telling the mother not to worry because all breastfed babies have this type of stool. b. Asking the mother what she ate for her last meal. c. Suggesting to the mother that she ask her pediatrician to explain normal newborn stooling patterns to her. d. Explaining to the mother that this stool is called meconium and is expected for the first few bowel movements of all newborns.

d The majority of healthy term infants pass meconium during the first 12 to 24 hours after birth. Meconium is composed of amniotic fluid, intestinal secretions, shed mucosal cells, and possibly blood, resulting in the dark green to black color. At this early age this type of stool is typical of both bottle- and breastfed newborns. The mother's nutritional intake is not responsible for the appearance of a meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.

A woman is diagnosed with having a stillborn. At first she appears stunned by the news, cries a little, and then asks the nurse to call her mother. What phase of bereavement does the nurse identify that the woman is experiencing? a. Grief. b. Reorganization. c. Intense grief. d. Acute distress.

d he immediate reaction to news of a perinatal loss or infant death encompasses a period of acute distress. Disbelief and denial can occur. However, parents also feel very sad and depressed. Intense outbursts of emotion and crying are normal, but lack of affect, euphoria, and calmness may occur and may reflect numbness, denial, or personal ways of coping with stress. Grief applies to the grief related to a potential loss of an infant. The parent grieves in preparation of the infant's possible death, although the parent clings to the hope that the child will survive. Intense grief occurs in the first few months after the death of the infant. This phase encompasses many different emotions, including loneliness, emptiness, yearning, guilt, anger, and fear. Reorganization occurs after a long and intense search for meaning. Parents are better able to function at work and home, experience a return of self-esteem and confidence, can cope with new challenges, and have placed the loss in perspective.