Exam 3: General

Question 1

Caput succedaneum

Answer 1

edema of the presenting part of the newborn’s head due to pressure during labor. The edema extends across the suture lines of the skull.

Question 2

cephalhematoma

Answer 2

swelling, indicating bleeding under the subcutaneous tissues of the newborn’s scalp. The collection of blood is beneath the periosteum of the cranial bone and therefore does not cross the suture line.

Question 3

Molding

Answer 3

temporary misshaping of the fetal head due to overlapping cranial bones at the suture lines to accommodate the passage of the fetal head through the birth canal.

Question 4

Pilonidal dimple

Answer 4

can be observed when assessing the vertebral column and can be associated with spina bifida

Question 5

rooting reflex

Answer 5

elicited when the client strokes the newborn’s lips, cheek, or corner of the mouth with her nipple. The newborn will turn his head while making sucking motions with his mouth and latch onto the nipple

Question 6

Babinski reflex

Answer 6

elicited by stroking upward along the lateral edge of the sole of the newborn’s foot.

Question 7

Moro reflex

Answer 7

elicited by striking the surface next to the newborn to startle him.

Question 8

Symptoms of mastitis

Answer 8

Localized breast tenderness along with fever and malaise

Question 9

S/S Endometritis

Answer 9

Chills, fever, tachycardia, anorexia, fatigue, and pelvic pain, foul-smelling, profuse lochia

Question 10

Methylergonovine

Answer 10

oxytocic medication that is administered to promote uterine contractions. This medication is indicated for treatment of postpartum hemorrhage caused by uterine atony or subinvolution; the desired effect is an increase in uterine tone.

A rise in blood pressure is an adverse effect of the medication.

Question 11

A full bladder can do what in the immediate postpartum period?

Answer 11

Raise the level of uterine fundus and possibly deviate it to the side

Question 12

At 1 hr postpartum, lochia rubra should be

Answer 12

Intermittent and associated with uterine contractions; volume of lochia resembles that of a heavy menstrual period; Small clots are common

Question 13

Expected findings of a postmature newborn

Answer 13

• Physical findings that indicate postmaturity in a newborn (gestational age of greater than 42 weeks) include cracked, peeling skin.
• Reflexes that are present in a postmature newborn are the same as those that are present in a mature newborn. These reflexes include a positive Moro reflex.
• Long and hard fingernails

Question 14

Manifestations of hydrocephalus in newborns include

Answer 14

Dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement

Hydrocephalus increases pressure within the central nervous system, not within the cardiovascular system. Signs of increased pressure in the CNS include irritability, lethargy, and vomiting.

Newborns who have hydrocephalus will have widened suture lines and full or bulging fontanels due to pressure from the increased amount of cerebrospinal fluid.

Question 15

Immediately after birth, the nurse ensures a patent airway. Following this, what is the priority nursing action?

Answer 15

The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother’s abdomen, and a cap applied to the newborn’s head to prevent cold stress. The newborn responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory distress. Based on Maslow’s hierarchy of needs, this is the most important nursing action after securing the airway.

Question 16

Mongolian spots

Answer 16

bluish-black areas of pigmentation more commonly noted on the back and buttocks.

Question 17

Most reliable indicator of fluid loss for infants and young children

Answer 17

Body weight

Question 18

Prevention of jaundice can be facilitated best by

Answer 18

Early and frequent feeding, which stimulates intestinal activity and passage of meconium. Jaundice occurs due to elevated serum bilirubin, which is excreted primarily in the newborn’s stool. Physiologic jaundice manifests after 24 hr and is considered benign. However, bilirubin may accumulate to hazardous levels and lead to a pathologic condition.

Question 19

A bulb syringe is used to…

Answer 19

Remove excess or tenacious mucus from the newborn’s nose and mouth and to maintain a patent airway.

Question 20

Phototherapy is a treatment for …

Answer 20

hyperbilirubinemia

Question 21

What is the priority assessment for a newborn immediately following a cesarean delivery?

Answer 21

The priority is to assess the newborn for respiratory distress

Shortly before labor, there is a decreased production of fetal lung fluid and a catecholamine surge that promotes fluid clearance from the lungs. Newborns born by cesarean, in which labor did not occur, can experience lung fluid retention, which leads to respiratory distress.

Question 22

Acrocyanosis is…

Answer 22

A bluish discoloration of the hands and feet and is an expected finding in the first 24 hours following delivery

Question 23

An infant who is dehydrated will exhibit

Answer 23

Irritability, tachycardia, increased temperature

Question 24

Tetany (intermittent muscular spasms) is a manifestation of

Answer 24

hypoglycemia [also commonly caused by hypocalcemia]

Question 25

Vitamin K (phytonadione)

Answer 25

Route - IM
Site - Vastus lateralis muscle (in the thigh)
Use - Prevents and treats hemorrhagic disease of the newborn, as newborns are born with vitamin K deficiency.
Time - Within 1 hour of birth

Question 26

Usual time frame for the onset of breast milk production

Answer 26

3 to 5 days - By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.

Question 27

Why would a provider order an indirect Coombs test for a 6 hrs postpartum client who is Rh - with an Rh + baby?

Answer 27

To detect Rh-positive antibodies in the mother’s blood. An indirect Coombs test determines the presence of Rh antibodies. If the client has Rh-negative blood, she does not produce Rh factor. Exposure to Rh positive blood, such as from an Rh factor positive fetus, could trigger the client to begin producing antibodies against Rh factor. These antibodies can cross the placenta and harm an Rh-positive fetus.

Question 28

What does a direct Coombs test measure?

Answer 28

The presence of maternal antibodies in the newborn’s blood.

Question 29

Which anatomical landmark should be used when measuring the circumference of the newborn’s chest?

Answer 29

The nipple line

The nurse should measure the newborn’s chest circumference at the nipple line.

Question 30

What is a reliable indicator that a breastfed infant is receiving enough breastmilk?

Answer 30

Newborns should wet 6 to 8 diapers per day. This is an indication that the newborn is getting enough fluids.

Question 31

Why is monitoring of blood glucose levels a priority intervention in a newborn who is small for gestational age (SGA)?

Answer 31

Decreased stores of glycogen and a lower rate of gluconeogenesis place newborns who are SGA at higher risk for hypoglycemia. This makes monitoring of blood glucose levels is a priority intervention.

Question 32

The expected reference range for a newborn’s resting respiratory rate is…

Answer 32

30 to 60/min.

Question 33

Interventions to promote development in a preterm newborn

Answer 33

Continued development - By clustering activities and organizing care, the nurse prevents excessive interruptions and allows the newborn extended periods of rest and energy conservation that promote development.
Muscle flexion - Preterm newborns lack motor development that allows for muscle flexion. A prone position or the use of a sling promotes flexion.

Calming - The use of both hands is the most effective calming technique, especially when repositioning the newborn’s extremities close to his body.
Sleep - To promote sleep-wake cycles, newborns should be protected from light at night by dimming nursery illumination, placing a cover over the incubator, or positioning a mask over the eyes.

Question 34

Umbilical cord stump care

Answer 34

Bathing - Sponge baths only - Immersing the umbilical cord stump in water can delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off. The client should be instructed to wash the skin around the base of the cord, not the cord stump, with mild soap and water.

Diaper - The parent should fold the edge of the diaper downward to avoid exposing the cord stump to urine and feces in the diaper.

Question 35

Comfort measures for breast engorgement

Answer 35

Breast engorgement is characterized by painful overfilling of the breasts. The client should be instructed to feed every 2 hr to soften one breast and pump the other.

Cold compresses can be used to reduce the swelling of the breast tissue surrounding the milk glands and milk ducts. Cold compresses should be applied after feeding or pumping.

Raw cabbage leaves placed over the breast between feedings can help reduce swelling. The client should wash the cabbage leaves and place them in the refrigerator to cool. The leaves are crushed and placed over the breasts for 15 to 20 min and can be repeated for two to three sessions.

Question 36

Crib safety

Answer 36

Loose bedding such as sheets and blankets need to be removed to prevent suffocation

Infants should be placed in the fully supine position

Infants should sleep on a firm crib mattress

The cribs should be a safe distance from any heat source

Question 37

Is blood pressure a reliable measure of impending shock from hemorrhage?

Answer 37

Blood pressure is not a reliable indicator of impending shock from hemorrhage because compensatory mechanisms prevent a significant drop in blood pressure until the client has lost 30 to 40% of her blood volume.

Question 38

What intervention is priority in the initial management of excessive uterine bleeding?

Answer 38

Firm massage of the uterine fundus. This action stimulates contraction of the uterine muscles, which constrict the maternal uterine blood vessels.

If manual massage of the uterine fundus does not increase contractility and slow bleeding, it would then be appropriate to empty the bladder and administer a continuous IV infusion of oxytocin.

Question 39

When assessing the postpartum client, if the nurse finds the uterus to be boggy and displaced, what is the priority intervention?

Answer 39

To assist the client to the restroom to void.

A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage.

Question 40

VBAC considerations

Answer 40

The most common type of incision during a cesarean birth is transverse, which is made across the lower, thinner part of the uterus. It is the primary criteria that permits a vaginal birth after a cesarean (VBAC). Other types of incisions increase the risk of uterine rupture. Additional criteria for VBAC include an adequate maternal pelvis, no uterine scars or history of rupture, the availability of a provider to monitor labor, and personnel to perform a cesarean birth if needed.

Question 41

Flushed face, high fever with chills, and myalgia are all findings associated with:

Answer 41

Influenza

Question 42

Sneezing, coughing, nasal congestion, intermittent fever, and in severe cases, apneic spells, most common in infants between 2 and 12 months of age, are all findings associated with:

Answer 42

Bronchiolitis

Question 43

Stridor (not wheezing) and a barky cough, often seen in children who are between 6 months to 3 years of age, are all findings associated with:

Answer 43

Croup

Question 44

The most common cause of postpartum infections is…

Answer 44

Endometritis

Question 45

A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of

Answer 45

Uterine atony

Question 46

The expected reference range for an apical pulse in a newborn who is awake is

Answer 46

120 to 160/min

Question 47

Myelomeningocele

Answer 47

Congenital disorder that causes the spine and spinal canal to not close prior to birth, which results in the spinal cord, meninges, and nerve roots protruding out of the child’s back in a fluid-filled sac.

Question 48

Priority in care of the infant born with myelomeningocele

Answer 48

Maintain the integrity of the sac

Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord and to maintain the integrity of the sac.

Question 49

An adverse effect of methylergonovine is

Answer 49

hypertension

Question 50

Methylergonovine is administered

Answer 50

Intramuscularly

Question 51

Methylergonovine is an

Answer 51

oxytocic medication. It causes uterine contractions, which control postpartum bleeding.

Question 52

Methylergonovine is given to control

Answer 52

postpartum hemorrhage

Question 53

What is the purpose of putting a toddler with laryngotracheobronchitis in a cool mist tent?

Answer 53

Laryngotracheobronchitis, or croup, is a condition caused by an infection of the upper airway (larynx, trachea, and bronchus) and is characterized by a barking cough. Edema and obstruction in the upper airways cause the characteristic cough and stridor (noisy breathing). The direct purpose of a cool mist tent is to humidify the inspired air, which decreases respiratory effort.

Question 54

What is the purpose of placing a newborn under a radiant heat warmer?

Answer 54

To prevent cold stress.

When an infant is stressed by cold exposure, oxygen consumption increases and pulmonary and peripheral vasoconstriction occurs. Metabolic demands for glucose increase. If the cold stress continues, hypoglycemia and metabolic acidosis can result.

Question 55

Iron supplements should be administered…

Answer 55

• Between meals
• With citrus fruit or juice to aid absorption
• At least 1 hr prior to bedtime

Question 56

Maternal/newborn blood group incompatibility is the most common form of

Answer 56

pathologic jaundice and the jaundice appears within the first 24 hr of life

Question 57

The absence of vitamin K results in

Answer 57

increased bleeding and hemorrhagic disease of the newborn

Question 58

Physiologic jaundice in the term newborn appears after

Answer 58

24

Question 59

The newborn exposed to maternal cocaine abuse is often

Answer 59

small for gestational age, exhibits tremors, irritability, hyperactivity to stimuli, and poor feeding