MATERNAL CH 18-25

Question 1

A woman gave birth to an infant boy 10 hours ago. Where would the nurse expect to locate this woman’s fundus?

Answer 1

One centimeter above the umbilicus

Question 2

Which woman is most likely to experience strong afterpains?

Answer 2

A woman who is a gravida 4, para 4-0-0-4

Question 3

A woman gave birth to a healthy infant boy 5 days ago. What type of lochia would the nurse expect to find when assessing this woman?

Answer 3

Lochia serosa….

Question 4

Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman?

Answer 4

Prolactin

Question 5

Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is:

Answer 5

Loss of increased blood volume associated with pregnancy.

Question 6

A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the womans bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:

Answer 6

Excessive uterine bleeding.

Question 7

The nurse caring for the postpartum woman understands that breast engorgement is caused by:

Answer 7

Congestion of veins and lymphatics.

Question 8

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal, and the estimated blood loss (EBL) was approximately 1500 mL. When assessing the womans vital signs, the nurse would be concerned to see:

Answer 8

Temperature 37.9 C, heart rate 120, respirations 20, blood pressure (BP) 90/50.

Question 9

Which statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth?

Answer 9

My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles.

Question 10

The interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state is called the:

Answer 10

Puerperium, or fourth trimester of pregnancy.

Question 11

The self-destruction of excess hypertrophied tissue in the uterus is called:

Answer 11

Autolysis

Question 12

With regard to the postpartum uterus, nurses should be aware that:

Answer 12

After 2 weeks postpartum it should not be palpable abdominally.

Question 13

With regard to afterbirth pains, nurses should be aware that these pains are:

Answer 13

More noticeable in births in which the uterus was overdistended.

Question 14

Postbirth uterine/vaginal discharge, called lochia:

Answer 14

Should smell like normal menstrual flow unless an infection is present.

Question 15

Which description of postpartum restoration or healing times is accurate?

Answer 15

Vaginal rugae reappear by 3 weeks postpartum.

Question 16

With regard to postpartum ovarian function, nurses should be aware that:

Answer 16

The first menstrual flow after childbirth usually is heavier than normal

Question 17

As relates to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that:

Answer 17

Fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium.

Question 18

Knowing that the condition of the new mothers breasts will be affected by whether she is breastfeeding, nurses should be able to tell their clients all the following statements except:

Answer 18

Breast tenderness is likely to persist for about a week after the start of lactation.

Question 19

With regard to the postpartum changes and developments in a womans cardiovascular system, nurses should be aware that:

Answer 19

Respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth.

Question 20

Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium?

Answer 20

Headaches

Question 21

Several changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed?

Answer 21

Nail brittleness

Question 22

Childbirth may result in injuries to the vagina and uterus. Pelvic floor exercises also known as Kegel exercises will help to strengthen the perineal muscles and encourage healing. The nurse knows that the client understands the correct process for completing these conditioning exercises when she reports:

Answer 22

I pretend that I am trying to stop the flow of urine midstream.

Question 23

Which maternal event is abnormal in the early postpartum period?

Answer 23

Lochial color changes from rubra to alba

Question 24

Which finding 12 hours after birth requires further assessment?

Answer 24

The fundus is palpable two fingerbreadths above the umbilicus.

Question 25

If the patients white blood cell (WBC) count is 25,000/mm on her second postpartum day, the nurse should:

Answer 25

Recognize that this is an acceptable range at this point postpartum.

Question 26

A postpartum patient asks, Will these stretch marks go away? The nurses best response is:

Answer 26

They will fade to silvery lines but won`t disappear completely.

Question 27

Which documentation on a womans chart on postpartum day 14 indicates a normal involution process?

Answer 27

Fundus below the symphysis and not palpable

Question 28

Changes in blood volume after childbirth depend on several factors such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. A postpartum nurse anticipates blood loss of (Select all that apply):

Answer 28

c.

300 to 500 mL

d.

500 to 1000 mL

Question 29

Puerperal sepsis

Answer 29

Elevated temperature at 36 hours postpartum

Question 30

Unusually high epidural or spinal block

Answer 30

Hypoventilation

Question 31

Dehydrating effects of labor

Answer 31

Elevated temperature within the first 24 hours

Question 32

Hypovolemia resulting from hemorrhage

Answer 32

Rapid pulse

Question 33

Excessive use of oxytocin

Answer 33

Hypertension

Question 34

A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, Im bleeding a lot. The most likely cause of postpartum hemorrhage in this woman is:

Answer 34

Uterine atony

Question 35

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurses first action is to:

Answer 35

Massage the womans fundus

Question 36

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?

Answer 36

The woman has an episiotomy.

Question 37

The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data?

Answer 37

Rubella vaccine should be given.

Question 38

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by:

Answer 38

Applying ice to the breasts for comfort

Question 39

A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurses most appropriate response is to ask the woman:

Answer 39

Ill warm the soup in the microwave for you.

Question 40

A primiparous woman is to be discharged from the hospital tomorrow with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged?

Answer 40

The woman leaves the infant on her bed while she takes a shower.

Question 41

In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice:

Answer 41

Is inconsistent with the Baby Friendly Hospital Initiative.

Question 42

A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurses best response is:

Answer 42

You have calf pain when the nurse flexes your foot.

Question 43

In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she:

Answer 43

Has recovered from epidural or spinal anesthesia.

Question 44

Under the Newborns and Mothers Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth.

Answer 44

48, 96

Question 45

In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with:

Answer 45

The nurse

Question 46

Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to:

Answer 46

Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.

Question 47

Excessive blood loss after childbirth can have several causes; the most common is:

Answer 47

Failure of the uterine muscle to contract firmly.

Question 48

A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to:

Answer 48

Improve the accuracy of blood loss estimation, which usually is a subjective assessment.

Question 49

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is:

Answer 49

Inserting a sterile catheter.

Question 50

If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid?

Answer 50

Having the patient sit in a chair.

Question 51

As relates to rubella and Rh issues, nurses should be aware that:

Answer 51

Women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination.

Question 52

Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins:

Answer 52

At the time of admission to the nurses unit.

Question 53

A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman:

Answer 53

Has not given the baby a name.

Question 54

Which breastfeeding patient is most likely to have severe afterbirth pains and request a narcotic analgesic?

Answer 54

Gravida 5, para 5

Question 55

Postpartal overdistention of the bladder and urinary retention can lead to which complications?

Answer 55

Postpartum hemorrhage and urinary tract infection

Question 56

Rho immune globulin will be ordered postpartum if which situation occurs?

Answer 56

Mother Rh?2-, baby Rh+

Question 57

Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus?

Answer 57

Assist the patient in emptying her bladder.

Question 58

When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is:

Answer 58

Early and frequent ambulation.

Question 59

The nurse caring for the postpartum woman understands that breast engorgement is caused by:

Answer 59

Congestion of veins and lymphatics.

Question 60

Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security?

Answer 60

The mother should check the photo ID of any person who comes to her room.
Parents should use caution when posting photos of their infant on the Internet.
The mom should request that a second staff member verify the identity of any questionable person.

Question 61

Muslim countries

Answer 61

Will not eat pork or pork products

Question 62

Korean or other South East Asian countries.

Answer 62

Prefer not to give babies colostrum

Question 63

Chinese

Answer 63

Have an IUD inserted after the first child

Question 64

Haitian

Answer 64

Take the placenta home to bury

Question 65

Mexican

Answer 65

Eat only warm foods and hot drinks

Question 66

After giving birth to a healthy infant boy, a primiparous woman, 16 years old, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is Risk for impaired parenting related to deficient knowledge of newborn care. In planning for the woman’s discharge, what should the nurse be certain to include in the plan of care?

Answer 66

Provide time for the patient to bathe her infant after she views an infant bath demonstration.

Question 67

The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, would the nurse identify as a possible maladaptive behavior regarding parent-infant attachment?

Answer 67

Seldom makes eye contact with her son

Question 68

The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to:

Answer 68

Show the mother how the infant initiates interaction and pays attention to her.

Question 69

The nurse hears a primiparous woman talking to her son and telling him that his chin is just like his dads chin. This womans statement reflects:

Answer 69

Claiming

Question 70

New parents express concern that, because of the mothers emergency cesarean birth under general anesthesia, they did not have the opportunity to hold and bond with their daughter immediately after her birth. The nurses response should convey to the parents that:

Answer 70

Attachment, or bonding, is a process that occurs over time and does not require early contact.

Question 71

During a phone follow-up conversation with a woman who is 4 days postpartum, the woman tells the nurse, I dont know whats wrong. I love my son, but I feel so let down. I seem to cry for no reason! The nurse would recognize that the woman is experiencing:

Answer 71

Postpartum (PP) blues.

Question 72

The nurse can help a father in his transition to parenthood by:

Answer 72

Pointing out that the infant turned at the sound of his voice.

Question 73

The nurse notes that a Vietnamese woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In evaluating the womans behavior with her infant, the nurse realizes that:

Answer 73

What appears to be a lack of interest in the newborn is in fact the Vietnamese way of demonstrating intense love by attempting to ward off evil spirits.

Question 74

Many first-time parents do not plan on their parents help immediately after the newborn arrives. What statement by the nurse is the most appropriate when counseling new parents about the involvement of grandparents?

Answer 74

Grandparents can help you with parenting skills and also help preserve family traditions.

Question 75

When the infants behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, this is called:

Answer 75

Mutuality

Question 76

In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. Which one is a facilitating behavior?

Answer 76

The parents hover around the infant, directing attention to and pointing at the infant.

Question 77

With regard to parents early and extended contact with their infant and the relationships built, nurses should be aware that:

Answer 77

Extended contact is especially important for adolescents and low-income women because they are at risk for parenting inadequacies.

Question 78

In the United States the en face position is preferred immediately after birth. Nurses can facilitate this process by all of these actions except:

Answer 78

Washing both the infants face and the mothers face.

Question 79

Other early sensual contacts between infant and mother involve sound and smell. Nurses should be aware that, despite what folk wisdom may say:

Answer 79

Infants can learn to distinguish their mothers voice from others soon after birth.

Question 80

After they are born, a crying infant may be soothed by being held in a position in which the newborn can hear the mothers heartbeat. This phenomenon is known as:

Answer 80

Biorhythmicity

Question 81

Of the many factors that influence parental responses, nurses should be conscious of negative stereotypes that apply to specific patient populations. Which response could be an inappropriate stereotype of adolescent mothers?

Answer 81

Adolescent mothers have a higher documented incidence of child abuse.

Question 82

When working with parents who have some form of sensory impairment, nurses should understand that ________ is an inaccurate statement.

Answer 82

Visually impaired mothers cannot overcome the infants need for eye-to-eye contact.

Question 83

With regard to the adaptation of other family members, mainly siblings and grandparents, to the newborn, nurses should be aware that:

Answer 83

Participation in preparation classes helps both siblings and grandparents.

Question 84

Nursing activities that promote parent-infant attachment are many and varied. One activity that should not be overlooked is management of the environment. While providing routine mother-baby care, the nurse should ensure that:

Answer 84

An environment that fosters as much privacy as possible should be created.

Question 85

The early postpartum period is a time of emotional and physical vulnerability. Many mothers can easily become psychologically overwhelmed by the reality of their new parental responsibilities. Fatigue compounds these issues. Although the baby blues are a common occurrence in the postpartum period, about one-half million women in America experience a more severe syndrome known as postpartum depression (PPD). Which statement regarding PPD is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis?

Answer 85

PPD can easily go undetected.

Question 86

The mother-baby nurse is able to recognize reciprocal attachment behavior. This refers to:

Answer 86

The positive feedback an infant exhibits toward parents during the attachment process.

Question 87

The postpartum woman who continually repeats the story of her labor, delivery, and recovery experience is:

Answer 87

Making the birth experience real.

Question 88

On observing a woman on her first postpartum day sitting in bed while her newborn lies awake in the bassinet, the nurse should:

Answer 88

Hand the baby to the woman.

Question 89

A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old brother is punching his mother on the back. The nurse should

Answer 89

Realize that this is a normal family adjusting to family change.

Question 90

The best way for the nurse to promote and support the maternal-infant bonding process is to:

Answer 90

Assist the family with rooming-in.

Question 91

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby?

Answer 91

Letting go

Question 92

A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry. Your initial action should be to

Answer 92

Allow her time to express her feelings.

Question 93

A man calls the nurses station and states that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, She was never like this before the baby was born. The nurses initial response could be to:

Answer 93

Reassure him that this behavior is normal.

Question 94

To promote bonding and attachment immediately after delivery, the most important nursing intervention is to:

Answer 94

Assist the mother in assuming an en face position with her newborn.

Question 95

A new father states, I know nothing about babies, but he seems to be interested in learning. This is an ideal opportunity for the nurse to:

Answer 95

Include him in teaching sessions.

Question 96

Which concerns about parenthood are often expressed by visually impaired mothers (Select all that apply)?

Answer 96

Infant safety

b.

Transportation

d.

Missing out visually

e.

Needing extra time for parenting activities to accommodate the visual limitations

Question 97

A parent who has a hearing impairment is presented with a number of challenges in parenting. Which nursing approaches are appropriate for working with hearing-impaired new parents (Select all that apply)?

Answer 97

Use devices that transform sound into light.
Ascertain whether the patient can read lips before teaching.
Written messages aid in communication.

Question 98

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is:

Answer 98

Uterine atony.

Question 99

A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to:

Answer 99

Perform fundal massage.

Question 100

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage (PPH) is most likely caused by:

Answer 100

Subinvolution of the placental site.

Question 101

Which woman is at greatest risk for early postpartum hemorrhage (PPH)?

Answer 101

A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced

Question 102

The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to:

Answer 102

Palpate the uterus and massage it if it is boggy.

Question 103

When caring for a postpartum woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is:

Answer 103

Urinary output of at least 30 mL/hr.

Question 104

One of the first symptoms of puerperal infection to assess for in the postpartum woman is:

Answer 104

Temperature of 38 C (100.4 F) or higher on 2 successive days starting 24 hours after birth.

Question 105

The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by:

Answer 105

Using proper breastfeeding techniques.

Question 106

Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance:

Answer 106

Traditionally PPH has been classified as early or late with respect to birth.

Question 107

A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect __________ and should confirm the diagnosis by ___________.

Answer 107

Thrombophlebitis; using real-time and color Doppler ultrasound

Question 108

What PPH conditions are considered medical emergencies that require immediate treatment?

Answer 108

Inversion of the uterus and hypovolemic shock

Question 109

What infection is contracted mostly by first-time mothers who are breastfeeding?

Answer 109

Mastitis

Question 110

Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for postpartum hemorrhage from birth until 4 weeks after delivery as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the client with von Willebrand disease who experiences a postpartum hemorrhage is:

Answer 110

Desmopressin

Question 111

The nurse should be aware that a pessary would be most effective in the treatment of what disorder?

Answer 111

Uterine prolapse

Question 112

A mother in late middle age who is certain she is not pregnant tells the nurse during an office visit that she has urinary problems and sensations of bearing down and of something in her vagina. The nurse would realize that the client most likely is suffering from:

Answer 112

Cystoceles and/or rectoceles.

Question 113

The prevalence of urinary incontinence (UI) increases as women age, with more than one third of women in the United States suffering from some form of this disorder. The symptoms of mild to moderate UI can be successfully decreased by a number of strategies. Which of these should the nurse instruct the client to use first?

Answer 113

Bladder training and pelvic muscle exercises

Question 114

When a woman is diagnosed with postpartum depression (PPD) with psychotic features, one of the main concerns is that she may:

Answer 114

Harm her infant.

Question 115

According to Becks studies, what risk factor for postpartum depression is likely to have the greatest effect on the womans condition?

Answer 115

Prenatal depression

Question 116

To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) without psychotic features

Answer 116

Is distinguished by irritability, severe anxiety, and panic attacks.

Question 117

To provide adequate postpartum care, the nurse should be aware that postpartum depression (PPD) with psychotic features:

Answer 117

May include bipolar disorder (formerly called manic depression).

Question 118

With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or postpartum depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent postpartum depression. The most accurate statement as related to these activities is to:

Answer 118

Realize that this is a common occurrence that affects many women.

Question 119

A newborn in the neonatal intensive care unit (NICU) is dying as a result of a massive infection. The parents speak to the neonatologist, who informs them of their sons prognosis. When the father sees his son, he says, He looks just fine to me. I cant understand what all this is about. The most appropriate response by the nurse would be:

Answer 119

This must be a difficult time for you. Tell me how youre doing.

Question 120

After giving birth to a stillborn infant, the woman turns to the nurse and says, I just finished painting the babys room. Do you think that caused my baby to die? The nurses best response to this woman is:

Answer 120

I can understand your need to find an answer to what caused this. What else are you thinking about?

Question 121

Which options for saying goodbye would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl?

Answer 121

When your baby is born, would you like to see and hold her?

Question 122

A woman experienced a miscarriage at 10 weeks of gestation and had a dilation and curettage (D&C). She states that she is just fine and wants to go home as soon as possible. While you are assessing her responses to her loss, she tells you that she had purchased some baby things and had picked out a name. On the basis of your assessment of her responses, what nursing intervention would you use first?

Answer 122

Ask her what name she had picked out for her baby.

Question 123

A woman is diagnosed with having a stillborn. At first, she appears stunned by the news, cries a little, and then asks you to call her mother. The phase of bereavement the woman is experiencing is called:

Answer 123

Acute distress

Question 124

During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. The nurses role should be to:

Answer 124

Make sure the parents themselves approve the final decisions.

Question 125

The nurse caring for a family during a loss may notice that survival guilt sometimes is felt at the death of an infant by the childs:

Answer 125

Grandparents

Question 126

Complicated bereavement:

Answer 126

Is an extremely intense grief reaction that persists for a long time.

Question 127

Early postpartum hemorrhage is defined as a blood loss greater than:

Answer 127

500 mL in the first 24 hours after vaginal delivery.

Question 128

A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she feels all wet underneath. You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action?

Answer 128

Assess the fundus for firmness.

Question 129

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests:

Answer 129

Lacerations of the genital tract.

Question 130

Which instructions should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications?

Answer 130

Notify the physician of any increase in the amount of lochia or a return to bright red bleeding.

Question 131

If nonsurgical treatment for late postpartum hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition?

Answer 131

D&C

Question 132

A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that:

Answer 132

The organisms that cause mastitis are not passed to the milk.

Question 133

Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth?

Answer 133

Postpartum blues

Question 134

Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is:

Answer 134

Post-traumatic stress disorder (PTSD).

Question 135

Medications used to manage postpartum hemorrhage (PPH) include (Select all that apply):

Answer 135

Pitocin
Methergine
Hemabate

Question 136

Possible alternative and complementary therapies for postpartum depression (PPD) for breastfeeding mothers include

Answer 136

Acupressure
Aromatherapy
Yoga

Question 137

Pulse oximetry

Answer 137

Measurement

Question 138

Heart sounds

Answer 138

Auscultation

Question 139

Arterial pulses

Answer 139

Palpation

Question 140

Skin color, temperature, turgor

Answer 140

Inspection

Question 141

Presence or absence of anxiety

Answer 141

Observation

Question 142

A woman gave birth to a healthy 7-pound, 13-ounce infant girl. The nurse suggests that the woman place the infant to her breast within 15 minutes after birth. The nurse knows that breastfeeding is effective during the first 30 minutes after birth because this is the:

Answer 142

First period of reactivity.

Question 143

Part of the health assessment of a newborn is observing the infants breathing pattern. A full-term newborns breathing pattern is predominantly

Answer 143

Abdominal with synchronous chest movements.

Question 144

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is:

Answer 144

120 to 160 beats/min.

Question 145

A newborn is placed under a radiant heat warmer, and the nurse evaluates the infants body temperature every hour. Maintaining the newborns body temperature is important for preventing:

Answer 145

Cold stress.

Question 146

An African-American woman noticed some bruises on her newborn girls buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called:

Answer 146

Mongolian spots.

Question 147

While examining a newborn, the nurse notes uneven skin folds on the buttocks and a click when performing the Ortolani maneuver. The nurse recognizes these findings as a sign that the newborn probably has:

Answer 147

Hip dysplasia.

Question 148

A new mother states that her infant must be cold because the babys hands and feet are blue. The nurse explains that this is a common and temporary condition called:

Answer 148

Acrocyanosis

Question 149

The nurse assessing a newborn knows that the most critical physiologic change required of the newborn is:

Answer 149

Initiation and maintenance of respirations.

Question 150

The parents of a newborn ask the nurse how much the newborn can see. The parents specifically want to know what type of visual stimuli they should provide for their newborn. The nurse responds to the parents by telling them:

Answer 150

Infants can track their parents eyes and distinguish patterns; they prefer complex patterns.

Question 151

While evaluating the reflexes of a 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 would document this finding as a positive:

Answer 151

Moro reflex

Question 152

While assessing the integument of a 24-hour-old newborn, the nurse notes a pink, papular rash with vesicles superimposed on the thorax, back, and abdomen. The nurse should:

Answer 152

Document the finding as erythema toxicum.

Question 153

A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on high. The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurses best response is:

Answer 153

Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.

Question 154

A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, What is this black, sticky stuff in her diaper? The nurses best response is:

Answer 154

Thats meconium, which is your babys first stool. Its normal.

Question 155

The transition period between intrauterine and extrauterine existence for the newborn:

Answer 155

Lasts from birth to day 28 of life.

Question 156

Which statement describing the first phase of the transition period is inaccurate?

Answer 156

It may involve the infants suddenly sleeping briefly.

Question 157

With regard to the respiratory development of the newborn, nurses should be aware that:

Answer 157

The first gasping breath is an exaggerated respiratory reaction within 1 minute of birth.

Question 158

With regard to the newborns developing cardiovascular system, nurses should be aware that:

Answer 158

The point of maximal impulse (PMI) often is visible on the chest wall.

Question 159

By knowing about variations in infants blood count, nurses can explain to their clients that:

Answer 159

The early high white blood cell (WBC) count is normal at birth and should decrease rapidly.

Question 160

What infant response to cool environmental conditions is either not effective or not available to them?

Answer 160

What infant response to cool environmental conditions is either not effective or not available to them?

Question 161

As related to the normal functioning of the renal system in newborns, nurses should be aware that:

Answer 161

The pediatrician should be notified if the newborn has not voided in 24 hours.

Question 162

With regard to the gastrointestinal (GI) system of the newborn, nurses should be aware that

Answer 162

Regurgitation during the first day or two can be reduced by burping the infant and slightly elevating the babys head.

Question 163

Which statement describing physiologic jaundice is incorrect?

Answer 163

Breastfed babies have a lower incidence of jaundice.

Question 164

The cheeselike, whitish substance that fuses with the epidermis and serves as a protective coating is called:

Answer 164

Vernix caseosa.

Question 165

What marks on a babys skin may indicate an underlying problem that requires notification of a physician?

Answer 165

Petechiae scattered over the infants body

Question 166

An examiner who discovers unequal movement or uneven gluteal skin folds during the Ortolani maneuver would then:

Answer 166

Alert the physician that the infant has a dislocated hip.

Question 167

One reason the brain is vulnerable to nutritional deficiencies and trauma in early infancy is the:

Answer 167

Cerebellum growth spurt.

Question 168

The nurse caring for the newborn should be aware that the sensory system least mature at the time of birth is:

Answer 168

Vision

Question 169

During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is not one of these essential factors?

Answer 169

Psychologic

Question 170

A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition:

Answer 170

May occur with spontaneous vaginal birth.

Question 171

A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago by cesarean section is found to have moist lung sounds. What is the best interpretation of these data?

Answer 171

The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.

Question 172

Nurses can prevent evaporative heat loss in the newborn by:

Answer 172

Drying the baby after birth and wrapping the baby in a dry blanket.

Question 173

A first-time dad is concerned that his 3-day-old daughters skin looks yellow. In the nurses explanation of physiologic jaundice, what fact should be included?

Answer 173

The bilirubin levels of physiologic jaundice peak between the second and fourth days of life.

Question 174

Cardiovascular changes that cause the foramen ovale to close at birth are a direct result of:

Answer 174

Increased pressure in the left atrium.

Question 175

The nurse should immediately alert the physician when:

Answer 175

The infant is dusky and turns cyanotic when crying.

Question 176

While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is:

Answer 176

120 to 160 beats/min.

Question 177

In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is:

Answer 177

Not initially synthesized because of a sterile bowel at birth.

Question 178

A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is:

Answer 178

Passed in the first 12 hours of life.

Question 179

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is known as:

Answer 179

Conjugation of bilirubin.

Question 180

Which newborn reflex is elicited by stroking the lateral sole of the infants foot from the heel to the ball of the foot?

Answer 180

Babinski

Question 181

Infants in whom cephalhematomas develop are at increased risk for:

Answer 181

Jaundice

Question 182

Plantar creases should be evaluated within a few hours of birth because:

Answer 182

As the skin dries, the creases will become more prominent.

Question 183

What are modes of heat loss in the newborn (Select all that apply)?

Answer 183

b.

Convection

c.

Radiation

d.

Conduction

Question 184

Signs of stress related to homeostatic adjustment

Answer 184

Autonomic stability

Question 185

Ability to respond to discrete stimuli while asleep

Answer 185

Habituation

Question 186

Measure of general arousability

Answer 186

Range of state

Question 187

How the infant responds when aroused

Answer 187

Regulation of state

Question 188

Ability to attend to visual and auditory stimuli while alert

Answer 188

Orientation

Question 189

An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed:

Answer 189

At least twice, 1 minute and 5 minutes after birth.

Question 190

A new father wants to know what medication was put into his infants eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to:

Answer 190

Prevent gonorrheal and chlamydial infection of the infants eyes potentially acquired from the birth canal.

Question 191

The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks?

Answer 191

Flexed posture

Question 192

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. Information given to the infants parents should be based on the knowledge that petechiae:

Answer 192

Are benign if they disappear within 48 hours of birth.

Question 193

A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:

Answer 193

Place eye shields over the newborns closed eyes.

Question 194

Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after:

Answer 194

The infant voids.

Question 195

A mother expresses fear about changing her infants diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?

Answer 195

Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.

Question 196

When preparing to administer a hepatitis B vaccine to a newborn, the nurse should:

Answer 196

Obtain a syringe with a 25-gauge, 5/8-inch needle.

Question 197

The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that this finding:

Answer 197

May indicate that the infant has a tracheoesophageal fistula or esophageal atresia.

Question 198

As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is:

Answer 198

To protect the nurse from contamination by the newborn.

Question 199

The nurses initial action when caring for an infant with a slightly decreased temperature is to:

Answer 199

Place a cap on the infants head and have the mother perform kangaroo care.

Question 200

An Apgar score of 10 at 1 minute after birth would indicate a(n):

Answer 200

Infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.

Question 201

With regard to umbilical cord care, nurses should be aware that:

Answer 201

The stump can easily become infected.

Question 202

In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would

Answer 202

Fall between the 10th and 90th percentiles for the infants age.

Question 203

During the complete physical examination 24 hours after birth:

Answer 203

The nurse can gauge the neonates maturity level by assessing the infants general appearance.

Question 204

As related to laboratory tests and diagnostic tests in the hospital after birth, nurses should be aware that:

Answer 204

If genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks.

Question 205

Nurses can assist parents who are trying to decide whether their son should be circumcised by explaining:

Answer 205

The pros and cons of the procedure during the prenatal period.

Question 206

As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Which statement is incorrect?

Answer 206

Place the infant on his or her abdomen to sleep.

Question 207

The normal term infant has little difficulty clearing the airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to:

Answer 207

Suction the mouth first.

Question 208

When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to:

Answer 208

Recognize and treat newborn disorders early.

Question 209

To prevent the abduction of newborns from the hospital, the nurse should:

Answer 209

Apply an electronic and identification bracelet to mother and infant.

Question 210

The nurse administers vitamin K to the newborn for which reason?

Answer 210

Bacteria that synthesize vitamin K are not present in the newborns intestinal tract.

Question 211

Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct?

Answer 211

Ideally, the visit is scheduled within 72 hours after discharge.

Question 212

Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain management techniques include (Select all that apply):

Answer 212

a.

Swaddling.

b.

Nonnutritive sucking.

c.

Skin-to-skin contact with the mother.

d.

Sucrose.

Question 213

Hearing loss is one of the genetic disorders included in the universal screening program. Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics. Reasons for having this testing performed include (Select all that apply):

Answer 213

Prevention or reduction of developmental delay.Early identification and treatment.

d.

Helping the child communicate better.

e.

Recommendation by the Joint Committee on Infant Hearing.

Question 214

At 1 minute after birth, the nurse assesses the infant and notes a heart rate of 80 beats/minute, some flexion of the extremities, a weak cry, grimacing, and a pink body with blue extremities. The nurse would calculate an Apgar score of:

Answer 214

5

Question 215

A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until her infant is crying frantically. On the basis of this information, this woman should feed her infant about every 2.5 to 3 hours when she:

Answer 215

Makes sucking motions.

Question 216

A new father is ready to take his wife and newborn son home. He proudly tells the nurse who is discharging them that within the next week he plans to start feeding the infant cereal between breastfeeding sessions. The nurse can explain to him that beginning solid foods before 4 to 6 months may:

Answer 216

Lead to early cessation of breastfeeding.

Question 217

A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle-feeding. Which statement is most accurate? Bottle-feeding using commercially prepared infant formulas:

Answer 217

Increases the risk that the infant will develop allergies.

Question 218

A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who:

Answer 218

Has at least six to eight wet diapers per day.

Question 219

A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. The nurse can facilitate the infants correct latch-on by helping the woman hold the infant:

Answer 219

With his head and body in alignment.

Question 220

A breastfeeding woman develops engorged breasts at 3 days postpartum. What action would help this woman achieve her goal of reducing the engorgement? The woman:

Answer 220

Breastfeeds her infant every 2 hours.

Question 221

At a 2-month well-baby examination, it was discovered that a breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse agree that, to gain weight faster, the infant needs to:

Answer 221

Add at least one extra breastfeeding session every 24 hours.

Question 222

A new mother wants to be sure that she is meeting her daughters needs while feeding her commercially prepared infant formula. The nurse should evaluate the mothers knowledge about appropriate infant care. The mother meets her childs needs when she:

Answer 222

Burps her infant during and after the feeding as needed.

Question 223

The nurse is discussing storage of breast milk with a mother whose infant is preterm and in the special care unit. What statement would indicate that the mother needs additional teaching?

Answer 223

I can store my breast milk in the refrigerator for 3 months.

Question 224

According to the recommendations of the American Academy of Pediatrics on infant nutrition:

Answer 224

Infants should be given only human milk for the first 6 months of life.

Question 225

According to demographic research, the woman least likely to breastfeed and therefore most likely to need education regarding the benefits and proper techniques of breastfeeding would be:

Answer 225

A woman who is younger than 25 years of age, African-American, and employed full time outside the home.

Question 226

Which statement concerning the benefits or limitations of breastfeeding is inaccurate?

Answer 226

Breastfeeding increases the risk of childhood obesity.

Question 227

The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would be inaccurate and provide conflicting information to the patient?

Answer 227

Breastfeeding is an effective method of birth control.

Question 228

While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the patient accordingly. Which statement as part of this discussion would be incorrect?

Answer 228

Breastfeeding costs employers in terms of time lost from work.

Question 229

The best reason for recommending formula over breastfeeding is that:

Answer 229

The mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk.

Question 230

With regard to the nutrient needs of breastfed and formula-fed infants, nurses should be understand that:

Answer 230

Breastfeeding infants should receive oral vitamin D drops daily at least during the first 2 months.

Question 231

Nurses providing nutritional instruction should be cognizant of the uniqueness of human milk. Which statement is correct?

Answer 231

Frequent feedings during predictable growth spurts stimulate increased milk production.

Question 232

In assisting the breastfeeding mother position the baby, nurses should keep in mind that:

Answer 232

Whatever the position used, the infant is belly to belly with the mother.

Question 233

Nurses should be able to teach breastfeeding mothers the signs that the infant has latched on correctly. Which statement indicates a poor latch?

Answer 233

She hears a clicking or smacking sound.

Question 234

The process whereby parents awaken the infant to feed every 3 hours during the day and at least every 4 hours at night is:

Answer 234

Necessary during the first 24 to 48 hours after birth.

Question 235

The nurse providing couplet care should understand that nipple confusion results when:

Answer 235

Breastfeeding babies receive supplementary bottle feedings.

Question 236

With regard to basic care of the breastfeeding mother, nurses should be able to advise her that she:

Answer 236

Should avoid trying to lose large amounts of weight.

Question 237

The breastfeeding mother should be taught a safe method to remove the breast from the babys mouth. Which suggestion by the nurse is most appropriate?

Answer 237

Break the suction by inserting your finger into the corner of the infants mouth.

Question 238

A newly delivered mother who intends to breastfeed tells her nurse, I am so relieved that this pregnancy is over so I can start smoking again. The nurse encourages the client to refrain from smoking. However, this new mother insists that she will resume smoking. The nurse will need to adapt her health teaching to ensure that the client is aware that:

Answer 238

The mother should always smoke in another room.

Question 239

Which type of formula is not diluted before being administered to an infant?

Answer 239

Ready-to-use

Question 240

How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day?

Answer 240

95 to 110

Question 241

The hormone necessary for milk production is:

Answer 241

Prolactin

Question 242

To initiate the milk ejection reflex (MER), the mother should be advised to:

Answer 242

Place the infant to the breast.

Question 243

As the nurse assists a new mother with breastfeeding, the client asks, If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better? The nurses best response is that it contains:

Answer 243

Important immunoglobulins.

Question 244

When responding to the question Will I produce enough milk for my baby as she grows and needs more milk at each feeding? the nurse should explain that:

Answer 244

The mothers milk supply will increase as the infant demands more at each feeding.

Question 245

To prevent nipple trauma, the nurse should instruct the new mother to:

Answer 245

Position the infant so the nipple is far back in the mouth.

Question 246

Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them about pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid?

Answer 246

A premature infant more easily digests breast milk than formula.

Question 247

A new mother asks whether she should feed her newborn colostrum, because it is not real milk. The nurses most appropriate answer is:

Answer 247

Colostrum is high in antibodies, protein, vitamins, and minerals.

Question 248

All parents are entitled to a birthing environment in which breastfeeding is promoted and supported. The Baby Friendly Hospital Initiative endorsed by WHO and UNICEF was founded to encourage institutions to offer optimal levels of care for lactating mothers. Which instruction is not included in the Ten Steps to Successful Breastfeeding for Hospitals?

Answer 248

Give artificial teats or pacifiers as necessary.

Question 249

Examples of appropriate techniques to wake a sleepy infant for breastfeeding include (

Answer 249

a.

Unwrapping the infant.

b.

Changing the diaper.

c.

Talking to the infant

Question 250

A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion (Select all that apply)?

Answer 250

a.

Breast tenderness

b.

Warmth in the breast

c.

An area of redness on the breast often resembling the shape of a pie wedge
e.

Fever and flulike symptoms

Question 251

Late in pregnancy, the womans breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Some nipple conditions make it necessary to provide intervention before birth. These include(Select all that apply):

Answer 251

b.

Flat nipples

c.

Inverted nipples

d.

Nipples that contract when compressed

Question 252

A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurses most appropriate action is to:

Answer 252

Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.

Question 253

Infants of mothers with diabetes (IDMs) are at higher risk for developing:

Answer 253

Respiratory distress syndrome.

Question 254

An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of:

Answer 254

Hypoglycemia

Question 255

When assessing the preterm infant the nurse understands that compared with the term infant, the preterm infant has:

Answer 255

Greater surface area in proportion to weight.

Question 256

On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask whether they can hold their infant during his next gavage feeding. Given that this newborn is physiologically stable, what response would the nurse give?

Answer 256

You may hold your baby during the feeding.

Question 257

A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents?

Answer 257

Surfactant improves the ability of your babys lungs to exchange oxygen and carbon dioxide.

Question 258

When providing an infant with a gavage feeding, which of the following should be documented each time?

Answer 258

The infants response to the feeding

Question 259

An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise?

Answer 259

Slow, small, warm bolus feedings over 30 minutes

Question 260

An infant at 26 weeks of gestation arrives intubated from the delivery room. 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 saturations of 80%. The prescribed saturations are 92%. The nurses most appropriate action would be to:

Answer 260

Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.

Question 261

A newborn was admitted to the neonatal intensive care unit after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborns parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurses most appropriate action would be to:

Answer 261

Go to the parents, introduce himself or herself, and gently encourage the parents to come meet their infant; explain the equipment first, and then focus on the newborn.

Question 262

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include:

Answer 262

Abdominal distention, temperature instability, and grossly bloody stools.

Question 263

An infant is being discharged from the neonatal intensive care unit after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infants mother asks the nurse whether her baby will meet developmental milestones on time, as did her son who was born at term. The nurses most appropriate response is:

Answer 263

Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing.

Question 264

A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetricians office revealed a nonreactive tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. The nurse caring for the infant after birth should anticipate:

Answer 264

Meconium aspiration, hypoglycemia, and dry, cracked skin.

Question 265

In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level?

Answer 265

Retinopathy of prematurity (ROP)

Question 266

In the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect:

Answer 266

Hypovolemia and/or shock.

Question 267

Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are:

Answer 267

Breathing in a respiratory pattern common to premature infants.

Question 268

The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infants gestational age. This intervention:

Answer 268

Helps infants to interact directly with their parents and enhances their temperature regulation.

Question 269

For clinical purposes, preterm and post-term infants are defined as:

Answer 269

Preterm before 37 weeks, and post-term beyond 42 weeks, no matter the size for gestational age at birth.

Question 270

With regard to small for gestational age (SGA) infants and intrauterine growth restrictions (IUGR), nurses should be aware that:

Answer 270

Infants with asymmetric IUGR have the potential for normal growth and development.

Question 271

As related to the eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that:

Answer 271

Parents of high risk infants need special support and detailed contact information.

Question 272

Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC:

Answer 272

Breastfeeding

Question 273

As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits:

Answer 273

Mottled skin with acrocyanosis.

Question 274

Because of the premature infants decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant?

Answer 274

Risk for infection

Question 275

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborns distress is most likely to be:

Answer 275

Sepsis

Question 276

The most important nursing action in preventing neonatal infection is:

Answer 276

Good handwashing.

Question 277

A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infants physical findings, this woman should be questioned about her use of which substance during pregnancy?

Answer 277

Alcohol

Question 278

A plan of care for an infant experiencing symptoms of drug withdrawal should include:

Answer 278

Swaddling the infant snugly and holding the baby tightly.

Question 279

Human immunodeficiency virus (HIV) may be perinatally transmitted:

Answer 279

Through the ingestion of breast milk from an infected mother.

Question 280

The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States?

Answer 280

Alcohol

Question 281

During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurses best response would be:

Answer 281

Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child.

Question 282

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infants eyes when the mother asks, What is that medicine for? The nurse responds:

Answer 282

Erythromycin is given prophylactically to prevent a gonorrheal infection.

Question 283

With regard to injuries to the infants plexus during labor and birth, nurses should be aware that:

Answer 283

If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.

Question 284

As related to central nervous system injuries that could occur to the infant during labor and birth, nurses should be aware that:

Answer 284

In many infants signs of hemorrhage in a full-term infant are absent and are diagnosed only through laboratory tests.

Question 285

To care adequately for infants at risk for neonatal bacterial infection, nurses should be aware that:

Answer 285

Nosocomial infection can be prevented by effective handwashing; early-onset infections cannot.

Question 286

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of:

Answer 286

Congenital syphilis.

Question 287

What bacterial infection is definitely decreasing because of effective drug treatment?

Answer 287

Group B streptococcal infection

Question 288

In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that:

Answer 288

Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.

Question 289

A careful review of the literature on the various recreational and illicit drugs reveals that:

Answer 289

More longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs.

Question 290

To provide optimal care of infants born to mothers who are substance abusers, nurses should be aware that:

Answer 290

Mothers who abuse one substance likely will use or abuse another, thus compounding the infants difficulties.

Question 291

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is:

Answer 291

Neonatal abstinence syndrome scoring.

Question 292

While completing a newborn assessment, the nurse should be aware that the most common birth injury is:

Answer 292

Fracture of the clavicle.

Question 293

The most common cause of pathologic hyperbilirubinemia is:

Answer 293

Hemolytic disorders in the newborn.

Question 294

Which infant would be more likely to have Rh incompatibility?

Answer 294

Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor

Question 295

With regard to hemolytic diseases of the newborn, nurses should be aware that:

Answer 295

The indirect Coombs test is performed on the mother before birth; the direct Coombs test is performed on the cord blood after birth.

Question 296

An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which highly technical method of treatment may be necessary for an infant who does not respond to conventional treatment?

Answer 296

Extracorporeal membrane oxygenation

Question 297

The goal of treatment of the infant with phenylketonuria (PKU) is to:

Answer 297

Prevent central nervous system (CNS) damage, which leads to mental retardation.

Question 298

HIV may be perinatally transmitted:

Answer 298

Through the ingestion of breast milk from an infected mother.

Question 299

Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (Select all that apply):

Answer 299

a.

Amphetamine.

b.

Heroin.

c.

Nicotine.

d.

PCP

Question 300

Risk factors associated with necrotizing enterocolitis (NEC) include (Select all that apply):

Answer 300

a.

Polycythemia.

b.

Anemia.

c.

Congenital heart disease

Question 301

Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for (Select all that apply):

Answer 301

a.

Problems with thermoregulation
c.

Hyperbilirubinemia

d.

Sepsis

Question 302

Car seat safety is an essential part of discharge planning, and infants younger than 37 weeks of gestation should have a period of observation in an appropriate car seat to monitor for possible apnea, bradycardia, and decreased SaO2. The nurse who is about to perform a car seat evaluation on a late-preterm infant will perform the sequence of the test in which order?

Answer 302

Use the parents car seat.
Perform the evaluation 1 to 7 days before discharge.
Secure the infant in the car seat per guidelines using blanket rolls on the side.

Set the pulse oximeter low alarm at 88%.
Set the heart rate alarm at 80 bpm and the apnea alarm at 20 seconds.
Leave the infant undisturbed for 90 to 120 minutes.
Document the infants tolerance to the test.