Maternity

Question 1

Non-Stress Test

Answer 1

A standard nonstress test occurs over 20 minutes. If the required two accelerations of 15 beats/minute over 15 seconds are not met in 20-minutes, the analysis is extended to 40 minutes. There must be at least two accelerations in a 20-minute time frame for the nonstress test to be reactive. The accelerations must be at least 15 beats/minute and last 15 seconds during the nonstress test for the test to be reactive.

Question 2

Three Monitoring parameters essential to infusing oxytocin

Answer 2

• FHR patterns
• Uterine Activity
• Blood pressure

Question 3

Side Effects of Oxytocin

Answer 3

• non reassuring FHR patterns such as tachycardia, bradycardia, decreased variability, and pathologic decelerations
• excessive uterine activity
• rapid infusion may cause maternal hypotension.

Question 4

Oxytocin administration considerations

Answer 4

• must be administered via IV pump
• avoid rapid infusion as it may cause hypotension
• adverse maternal reactions include excessive uterine activity, impaired uterine blood flow, uterine rupture, and placental abruption
• adverse fetal reactions include fetal bradycardia, fetal tachycardia, reduced variability, and late or prolonged decelerations
• discontinue infusion if any non-reassuring FHR occurs

Question 5

Pregnancy related spinal change that can alter mobility

Answer 5

The spinal change that is common in pregnancy is lordosis. This is the result of the increasing weight of the enlarging uterus and the effect of gravity. As a fetus grows, a variety of changes appear in a pregnant woman’s body. The thoracic and lumbar spine curvature change, pain in the low back, and pelvic region can increase, and the balance and gait pattern also changes. Some studies report that the center of gravity of pregnant women moves towards the abdomen, resulting in an increase in lumbar lordosis, posterior tilt of the sacrum, and movement of the head to the back to compensate for the increased weight as the fetus grows.

Question 6

Carseat Safety

Answer 6

When counseling a client about car seat safety, the nurse should provide the following information -

Parents should not place an infant in the front seat of a car with a passenger-side airbag.
Infants and toddlers should ride in a rear-facing child safety seat in the car’s back seat until age two years or until they reach the highest weight or height recommended by the car seat manufacturer.
Rolled blankets and towels may be needed between the crotch and legs to prevent slouching and can be placed along the sides to minimize lateral movements.
Placing the infant in a safety seat at a 45-degree angle will prevent slumping and airway obstruction.
Padding is never placed underneath or behind the infant because it creates slack in the harness, leading to the possibility of the child’s ejection from the seat in the event of a crash.

Question 7

Signs of congenital heart failure in neonates

Answer 7

Poor feeding is often one of the first signs of decreased cardiac output in an infant. It becomes harder for the infant to breathe while feeding; they often become sweaty and pale during feedings. This is a classic sign of decreased cardiac output (Choice A). Irritability, restlessness, or lethargy are vital signs of decreased cardiac output in the infant
Other signs of decreased cardiac output may include:

✓ oliguria

✓ pale, cool extremities with decreased pulses

✓ hypotension

✓ restlessness
and tachcyardia

Question 8

At the time of birth, the nurse should accomplish which tasks?

Answer 8

According to the American Heart Association and the American Academy of Pediatrics Neonatal Resuscitation Program algorithm, the team should first assess the newborn’s muscle tone and breathing. If those are abnormal, the team should provide a patent airway, including positioning and suctioning as needed. At the same time, the team should ensure that the infant is warm. The third task is to assess the newborn’s heart rate to ensure that it is at least 100 beats per minute. The fourth task in this sequence is to provide positive pressure ventilation if the heart rate is less than 100 bpm.

Question 9

Criteria for severe pre-eclampsia

Answer 9

The following are the clinical criteria for severe preeclampsia

If one or more of the following criteria are present:

1. Blood pressure of ≥160 mm Hg systolic or ≥110 mm Hg diastolic or higher on two occasions at least 6 hr apart while the patient is on bed rest
2. Oliguria of <500 mL in 24 hr
3. Cerebral or visual disturbances
4. Pulmonary edema or cyanosis
5. Epigastric or right upper quadrant pain
6. Impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes

(to twice normal concentration), severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses, or both

7. Thrombocytopenia
8. Renal insufficiency

Question 10

IM injection considerations for neonates

Answer 10

When administering IM medications to a neonate or young child, the vastus lateralis is the preferred site. For the volume to be administered in an IM, it is recommended to be 0.5 mL or less for infants; up to 2 mL for children.
✓ A key advantage of using the vastus lateralis is that an intramuscular (IM) injection may be given if the client is supine, side-lying, or sitting.

✓ Aspiration for routine injections into deltoid or vastus lateralis is not indicated because there are no large blood vessels in these locations.

✓ To locate the vastus lateralis, the nurse should palpate to find greater trochanter and knee joints; divide vertical distance between these two landmarks into thirds; inject into middle third.

Question 11

Presumptive Signs of PRegnancy

Answer 11

Amenorrhea
Nausea and vomiting
Fatigue
Urinary frequency
Quickening (slight fluttering movement usually between 16-20 weeks gestation)

Question 12

probable signs of pregnancy

Answer 12

Goodell’s sign (softening of the cervix)
Chadwick’s sign (bluish appearance of the cervix)
Hegar’s sign (softening of the isthmus of the cervix)
Ballottement (sudden tap on the cervix during the vaginal examination may cause the fetus to rise in the amniotic fluid and then rebound to its original position)
Braxton hicks contractions
Positive pregnancy test
Palpation of fetal outline

Question 13

Positive signs of pregnancy

Answer 13

Fetal movements detected by an examiner
Auscultation of fetal heart sounds
Visualization of embryo or fetus

Question 14

Reactive Non-Stress test

Answer 14

When undergoing a nonstress test (NST), results are considered reactive (reassuring) if there are a minimum of two accelerations of 15 beats/minute above the baseline, each lasting a minimum of 15 seconds over the 20-minute testing period.
A nonstress test records fetal heart rate and uterine contractions using external electronic monitors and correlates the heart rate with fetal movements (reported by the mother).
A nonstress test is typically performed for 20 minutes (occasionally, the exam may be extended to 40 minutes if needed).
Results are considered reactive (reassuring) if there are two accelerations of 15 beats/minute over the 20-minute duration of the exam.
An absence of accelerations is considered nonreactive (nonreassuring).
The presence of late decelerations suggests hypoxemia, potential for fetal acidosis, and/or the need for intervention.

Question 15

Positive Contraction Test

Answer 15

A positive contraction stress test means the baby had decelerations in response to contractions and therefore, may not tolerate labor. Therefore, follow-up is needed (Choice C). A nonreactive nonstress test means that the baby did not have two or more 15 by 15 accelerations during the 20 minute test period and is not responding appropriately to movement. Follow-up would be needed for this test result, most likely with a contraction stress test (Choice D). If the mother has Rh-negative blood and the father has Rh-positive blood, further testing and treatment may be needed to prevent complications related to Rh incompatibility.

Question 16

What are maternal risk factors for client’s wanting to get pregnant?

Answer 16

Substance use during pregnancy puts the fetus at risk for abnormal growth, abruptio placentae, and fetal bradycardia. This is a severe risk factor and should be discussed with women trying to conceive (Choice B). Abuse and violence put both the mother and fetus at risk. There are higher instances of abruptio placentae, preterm birth, and infections from unwanted and forced sex (Choice C). Concurrent medical conditions such as diabetes mellitus and hypertension cause the pregnancy to be considered high risk. Different risks are dependent on the situation, such as macrosomia and hypoglycemia in infants of a diabetic mother. These should be discussed thoroughly for women wishing to become pregnant who live with a severe medical condition (Choice D). Sexually transmitted infections, such as syphilis, gonorrhea, and chlamydia, can increase risk of spontaneous abortion, premature rupture of membranes and subsequent labor, as well as transmission during a vaginal birth

Question 17

Copper IUD

Answer 17

The copper intrauterine device is non-hormonal; therefore, it does not raise the risk of breast cancer. Unlike depot medroxyprogesterone, the IUD does not cause bone demineralization, so weight-bearing exercises are not a relevant teaching point for this type of contraception (where they would be for depot medroxyprogesterone). An increase in cardiovascular disease is not associated with the copper IUD as it is non-hormonal. The IUD is to be replaced every ten years (US FDA approved duration).
The copper IUD is an effective contraceptive method that does not involve the use of hormones. This is an attractive feature because it does not raise the risk of cancers, thromboembolism, or cardiovascular disease. The IUD has a high degree of client satisfaction and is one of the most effective methods of contraception. The client should be educated that menstrual cycles with the copper IUD may be heavier and cause more cramping. This device may also be utilized for emergency contraception.

Question 18

Risk factors for gestational diabetes

Answer 18

Risk factors for gestational diabetes include –

Overweight (BMI 25-25.9) or obesity (BMI 30 or greater)
Maternal age older than 25
Advanced maternal age
Gestational diabetes in a previous pregnancy
History of polycystic ovary syndrome
History of prediabetes
First-degree relative with diabetes
A glucose tolerance test may be administered between 24 and 28 weeks of gestation if necessary.

Question 19

Tetralogy of Fallot

Answer 19

Tetralogy of Fallot is a congenital heart defect composed of four errors, a ventricular septal defect (VSD) being one of them. The VSD is a hole between the right and left ventricles, allowing the oxygenated and deoxygenated blood to mix in, essentially one ventricle. An overriding aorta being one of them is another feature. This means the aorta is positioned over the VSD instead of over the left ventricle, where it should be. Pulmonary stenosis is another feature of ToF. The pulmonary arteries are narrowed and hardened, making it difficult for the right ventricle to pump blood to the lungs. Right ventricular hypertrophy is one of them. This portion of the error is actually due to another part: pulmonary stenosis. Since these vessels are narrowed and hardened, it is difficult for the right ventricle to pump blood through them and out to the lungs. This puts extra work on the heart, and after some time, the muscle of the right ventricle gets more substantial or hypertrophied due to the extra work.
✓ Calming the infant or child is an early intervention for hypercyanotic episodes.

✓ Additionally, the nurse should increase systemic vascular resistance by placing the infant’s knees to their chest or having the child squat.

✓ Other key interventions include the administration of prescribed oxygen, morphine, and isotonic saline.

Question 20

infant NG tube measurement

Answer 20

For infants ( less than one year of age), the nurse should measure the distance from the bridge of the nose to the earlobe to a point halfway between the xiphoid process and the umbilicus. This measurement ensures that the tube is long enough to enter the stomach. However, for children older than one year, the NG tube measurement should be from the bridge of the nose to the earlobe to the xiphoid process.

Question 21

Which lab must be ruled out to diagnose bipolar disorder I

Answer 21

A TSH is the standard of care before diagnosing a mood disorder such as bipolar disorder or major depressive disorder. While this test does not confirm the presence of a mood disorder, it excludes alterations of the thyroid, which could alternatively explain the client’s symptoms.
TSH levels would help exclude thyroid disorders that may explain bipolar symptoms. Hypothyroidism may cause an individual to experience depressive mood symptoms, whereas hyperthyroidism may induce agitation, restlessness, irritability, and emotional lability.

Question 22

infant pyloric stenosis

Answer 22

Hypertrophic pyloric stenosis (HPS) occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric canal, producing an outlet obstruction and compensatory dilation, hypertrophy, and hyperperistalsis of the stomach.
This condition usually develops in the first few weeks of life, causing nonbilious vomiting, which occurs after a feeding; projectile vomiting may develop, and the infant is fussy and hungry after vomiting.
Projectile vomiting (i.e., vomiting accompanied by vigorous peristaltic waves) is typically associated with pyloric stenosis.

Question 23

pregnancy complications

Answer 23

Possible complications during pregnancy include anemia (Choice A, mood changes (Choice B), and nausea/vomiting (Choice D). Miscarriage (Choice E) is more common in first-time pregnancies, with around 10-20% of pregnancies ending in miscarriage.Anemia is typically caused by dilution of red blood cells as blood volume increases. Depression usually occurs after birth and is often called postpartum depression or “baby blues.” However, as hormones change during pregnancy, the mother-to-be can experience mood changes. Nausea and vomiting usually occur during the first trimester as a result of increasing levels of human chorionic gonadotropin (HCG). This “morning sickness” is thought to be a sign of a healthy pregnancy during the first three months, but when the vomiting is persistent and prolonged, it can result in hyperemesis gravidarum. This condition may require intervention to prevent weight loss and dehydration.

Question 24

immature hemangioma

Answer 24

immature hemangioma (capillary hemangioma, superficial hemangioma). Because of their bright-red appearance, they are often referred to as “strawberry nevi.” They blanch with pressure, which can help differentiate these lesions from port-wine stains. Immature hemangiomas are common, harmless tumors of blood vessels that occur within the first year of life. They do not require any treatment and typically resolve on their own by 5-7 years of age. They commonly appear on the face, scalp, chest, or back. Occasionally, some immature hemangiomas can interfere with vision or cause other symptoms based on their location. Such hemangiomas may be treated with medications or laser surgery.

Question 25

physiological changes in pregnancy

Answer 25

✓ Cardiac output is increased in pregnancy, leading to the need for increased heart rate to meet the cardiac output demands.

✓ Plasma volume increases in pregnancy, leading to hemodilution which can present as lower hemoglobin and hematocrit values

Question 26

second stage labor support

Answer 26

✓ The second stage of labor is known as the pushing stage

✓ It begins with complete (10 cm) dilation and full (100%) effacement of the cervix and ends with the birth of the baby

✓ Contractions are strong and about 2 to 3 minutes apart, lasting 40 to 60 seconds

Dystocia is a term used to describe difficult or prolonged labor, typically due to an obstruction in the birth canal or other issues that interfere with the progress of labor. The following are some common causes of dystocia:

Malpresentation of the fetus: When the fetus is not positioned correctly, such as being in a breech position, labor may be prolonged or difficult.
Fetal macrosomia: When the fetus is larger than average, it may not fit easily through the birth canal, leading to dystocia.
Pelvic abnormalities: Certain pelvic abnormalities can make it difficult for the fetus to pass through the birth canal.
Inefficient uterine contractions: Weak or infrequent contractions may prolong labor and lead to dystocia.
Maternal exhaustion or fatigue: Prolonged labor can lead to maternal exhaustion or fatigue, making it difficult to continue pushing.
Use of anesthesia: Certain types of anesthesia can slow labor and increase the risk of dystocia.

Question 27

Postpartum hemorrhage

Answer 27

Postpartum hemorrhage (PPH) is serious and a significant contributor to maternal death in morbidity worldwide

Risk factors and causes of PPH include
Multiple gestation
Uterine atony
Macrosomia birth (increased risk of lacerations)
Hydramnios (large amniotic fluid volume making uterine contraction difficult)
Retained placenta (it will now allow the uterus to fully contract)
Manual removal of the placenta
Clotting disorders
Lacerations
Any delivery that was assisted with a tool or instrument (increased risk of lacerations)
Manifestations of a client experiencing PPH include excessive lochia, uterine tenderness, and unstable vital signs (tachycardia, hypotension)

Treatment includes prompt recognition and activation of a PPH protocol (each facility is required to have a protocol that streamlines treatment). If uterine atony is the cause, a fundal massage is necessary. Blood product replacement, intravenous oxytocin, and/or intramuscular (IM) methylergonovine.

Question 28

trichomoniasis

Answer 28

Trichomoniasis patients would yield a malodorous, thin, yellow discharge. Trichomoniasis is caused by a protozoon, Trichomonas vaginalis.

Question 29

Treatment for Mastitis

Answer 29

Mastitis is commonly caused by Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci. Thus, antibiotics such as cephalexin are effective in the treatment of mastitis.
✓ Mastitis is often caused by Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci.

✓ The bacteria are most often carried on the skin of the mother or in the mouth or the nose of the newborn.

✓ The organism enters through an injured area on the nipple, such as a crack or blister.

✓ The primary medical treatment is antibiotics and continued emptying of the breast.

✓ Comfort measures during mastitis include applying moist heat or ice packs, breast support, bed rest, fluids, and analgesics.

Question 30

Which drugs are contraindicated in pregnancy?
- Warfarin
- Finasteride
- Celecoxib
- Clonidine
- transdermal Nicotine
- Clofazimine

Answer 30

Warfarin (coumadin) has a pregnancy category X. It is associated with central nervous system defects, spontaneous abortion, stillbirth, prematurity, illness, and ocular defects at any time during pregnancy and fetal warfarin syndrome when given during the first trimester (Choice A). Finasteride also has a pregnancy category X, which has a high risk of causing permanent damage to the fetus (Choice B).

Question 31

a congenital abnormality where their abdominal contents come through the umbilicus while remaining in the peritoneal sac

Answer 31

This infant has an omphalocele. An omphalocele is a congenital abnormality where the abdominal contents come through the umbilicus while remaining in the peritoneal sac.

Question 32

Pre-Eclampsia

Answer 32

Severe pre-eclampsia manifests as epigastric to right-upper quadrant pain suggestive of a liver injury. This, combined with a frontal headache, is highly concerning for severe pre-eclampsia. The client needs to be immediately evaluated as these symptoms may worsen to an eclamptic seizure.

✓ Preeclampsia is hypertension (systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg) occurring after 20 weeks of pregnancy in women with previously normal blood pressure, usually accompanied by proteinuria.

✓ The client with preeclampsia should be instructed to check her blood pressure and report symptoms that suggest worsening preeclampsia, such as visual disturbance, severe headache, or epigastric pain.

✓ Symptoms that suggest a fetal compromise, such as reduced fetal movement, also should be taught.

Question 33

Normal Assessment findings following birth

Answer 33

Assessment findings within normal limits

Head: the head circumference should be between 33-35 cm - the head circumference should be approximately 2 to 3 cm more than the chest circumference. The fontanels should be soft and flat.
Cardiovascular: S1 and S2 heart tones should be auscultated without any murmur. The rhythm should be regular. Femoral pulses should be palpable.
Lungs: respirations are chiefly abdominal. The breath sounds should be clear without any adventitious sounds. Respirations that are chiefly abdominal are expected. The cough reflex is absent at birth and will be present in 1-2 days.
Abdomen: The abdomen should be cylindric in shape. The umbilical cord should have two arteries and one vein. The bowel sounds should be normoactive bowel sounds in all quadrants. Passage of meconium should occur within the first 24 hours after birth.

Question 34

Which symptoms indicate need for PPV one minute after birth?

Answer 34

Apnea, gasping, or heart rate less than 100 bpm indicates that the team should begin positive pressure ventilation (PPV) within one minute after birth. The unit can also consider a trial of PPV if it cannot maintain oxygen saturation despite using oxygen or continuous positive airway pressure (CPAP). If a newborn has aspirated meconium (Choice E), which can cause respiratory distress and airway obstruction, PPV may be required to maintain adequate oxygenation.
✓ According to the American Academy of Pediatrics and the American Heart Association’s guidelines for neonatal resuscitation, PPV is indicated if the infant has inadequate or ineffective breathing efforts, apnea, gasping, bradycardia, or a heart rate below 100 beats per minute despite adequate stimulation and supplemental oxygen.
✓ Additionally, PPV should be initiated if the infant’s oxygen saturation levels are below the target range despite oxygen therapy or if there are signs of respiratory distress such as intercostal or subcostal retractions, nasal flaring, or grunting.
✓ The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) jointly publish guidelines for neonatal resuscitation.

Question 35

HPV is an indicator of what type of cancer?

Answer 35

cervical cancer

Question 36

Testicular torsion

Answer 36

Testicular torsion requires immediate surgical intervention to prevent strangulation of the testicle.

Question 37

Epididyimitis

Answer 37

Epididymitis is a medical condition characterized by inflammation of the epididymis, a curved structure at the back of the testicle. The onset of pain is typically over a day or two. The pain may improve with raising the testicle.

Question 38

inguinal hernia

Answer 38

An inguinal hernia occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles. The resulting bulge can be painful, especially when you cough, bend over or lift a heavy object.

Question 39

Hydrocele

Answer 39

A hydrocele is a sac filled with fluid that forms around a testicle. They’re usually painless and are most common in babies, but they can affect males of any age.

Question 40

Small for gestational age

Answer 40

he term “Small for Gestational Age (SGA)” is used when the infants are smaller than normal for the number of weeks of pregnancy (gestational age). When an infant’s weight is below the 10th percentile for the gestational age, it is considered small for gestational age. By definition, about 10 percent of all newborns are labeled as SGA. Not all “Low Birth Weight” babies are SGA. Infants may be of low birth weight but may still fall above the 10th percentile for gestational age. It is important to distinguish SGA from other related terms, “Low Birth Weight (LBW)”, “Very Low Birth Weight (VLBW), and “Extremely Low Birth Weight (ELBW).” These definitions are based on the infant’s weight at the time of birth. These are not percentile scores and are defined on the absolute weight limit. An LBW infant is defined as an infant with a weight of less than 2500 grams (5 lb. and 8 ounces), regardless of gestational age at the time of birth. A VLBW infant is defined as one with a weight less than 1500 grams at the time of birth. An ELBW infant is less than 1000 grams at the time of birth.

Question 41

Lofenac

Answer 41

Lofenalac is a formula that is very low in the amino acid phenylalanine. In phenylketonuria (PKU), there is impaired metabolism of this essential amino acid. When patients eat foods that contain this amino acid, they cannot break it down, so levels of this amino acid can then become toxic to the patient. Therefore, the formula Lofenalac is the appropriate choice for patients with PKU.

Question 42

Which interventions should the nurse anticipate for an infant with omphalocele awaiting surgical repair?

Answer 42

Postnatal nursing interventions for omphalocele are aimed at minimizing the complications to the neonate. Although the intestines remain in a peritoneal sac in an omphalocele, there is no skin covering the defect. Therefore, there is an insensible loss of heat and fluids. Complications such as dehydration, electrolyte imbalance, hypothermia, and infection ( necrotizing enterocolitis) may ensue. Because of the defect, infants with omphalocele have reduced chest capacity and respiratory reserve. The pre-operative nursing management of neonates with omphalocele involves airway stabilization, covering the defect with sterile gauze soaked in saline, inserting an orogastric tube for bowel decompression, and establishing peripheral intravenous access. Subsequent interventions include the administration of intravenous fluids and broad-spectrum antibiotics.
The defect should be covered with sterile gauze soaked in saline ( Choice A). This keeps the intestines moist and reduces insensible fluid loss. Additionally, such a protective covering will prevent infection. Infection prevention in omphalocele patients is a priority because exposed abdominal contents are prone to severe infection when there is no protective skin covering.
Due to insensible heat loss from the exposed viscera, hypothermia is a critical complication of an omphalocele. Affected infants struggle to maintain their body temperature. The affected infants should not be tightly swaddled because this would put pressure on the exposed intestines compromising the blood flow. Strategies such as using a radiant warmer can help with thermoregulation in these infants without compromising the intestines

Question 43

Gastroschisis

Answer 43

Gastroschisis is an abdominal wall defect that presents laterally and to the right of the umbilicus. There is no peritoneal sac covering the exposed intestines in a gastroschisis defect.

Question 44

The nurse is working on the pediatric clinic and checks the list of clients who are lined up to see the physician for today. Which client would warrant the nurse’s attention?

A. A 5-year-old who sustained a fall and is complaining of leg pain.
B. A 2-year-old who is drooling and does not want to swallow.
C. An 8-year-old child with a headache for 2 days.
D. A 10-year-old child who is always thirsty and has lost weight.

Answer 44

A child who is drooling and does not want to swallow is indicative of epiglottitis, which can be a life-threatening situation. The nurse should assess this child first and inform the physician in case an emergency tracheostomy is required.

Question 45

The rooting Reflex

Answer 45

The Rooting reflex should disappear by 3-4 months of age. It occurs when the infants turn their face toward stimulation (such as stroking their cheek) and make sucking (rooting) motions with the mouth. This reflex helps to ensure successful feeding.

Question 46

The Moro Reflex

Answer 46

The Moro reflex should disappear by 5-6 months of age. This reflex is a response to a sudden loss of support. When support is removed, the infant spreads out the arms and cries.

Question 47

The palmar Reflex

Answer 47

The Palmar reflex should disappear by 2-3 months of age. When an object is placed in an infant’s hand, and the palm is stroked, the fingers will close reflexively.

Question 48

Tonic Neck Reflex

Answer 48

The tonic neck reflex disappears around 4 months of age. This reflex is elicited by turning the infant’s head to one side and is considered positive if the infant extends the extremities on the side that the head is turned toward, and flexes the extremities on the opposite side.

Question 49

The plantar Reflex

Answer 49

The Plantar reflex (Babinski sign) should not disappear until 8-9 months of age. When the sole of the foot is stroked upwards, the great toe moves upward (dorsiflexes/extends) while the other toes fan out.

Question 50

Sucking Reflex

Answer 50

The sucking reflex should not disappear until around 12 months of age. To elicit this reflex, a nipple or gloved finger is placed in the infant’s mouth and rubbed against the palate. This reflex is considered positive if the infant begins sucking, but may be diminished if the infant has recently been fed.

Question 51

An absent or diminished plantar reflex at 7 months

Answer 51

may indicate a neurological problem or a muscle injury.

Question 52

An absent or diminished sucking reflex at 7 months

Answer 52

may indicate prematurity, a neurological problem, or maternal drug use.

Question 53

Late Decelerations

Answer 53

late decelerations are primarily caused by uteroplacental insufficiency, and the client should be repositioned into a left lateral position. If the left lateral position is ineffective, then the nurse may consider using the right lateral position. The nurse should also consider prescribed intravenous (IV) fluids to restore maternal blood volume.
Late decelerations are concerning because they it may cause fetal hypoxia. Late decelerations are commonly caused by maternal hypotension, therefore, changing maternal position is key to resolving this non-reassuring pattern.

Question 54

Early decelerations

Answer 54

Early decelerations are a reassuring pattern caused by fetal head compression. Early decelerations are symmetric in shape and have a gradual decrease and return of FHR baseline that mirrors a uterine contraction. Variable decelerations are non-reassuring and triggered by umbilical cord compression.

Question 55

Quad Screening Test

Answer 55

✓ The quad screen test, also known as the quadruple marker test, is a prenatal blood test that is usually performed between 15 and 22 weeks of pregnancy.

✓ It measures the levels of four substances in the mother’s blood to assess the risk of certain genetic conditions in the developing baby.

Alpha-fetoprotein (AFP)
Human chorionic gonadotropin (hCG)
Estriol
Inhibin A
✓ An abnormal quad screen test result may indicate an increased risk of certain genetic conditions, including Down syndrome, Trisomy 18, and neural tube defects such as spina bifida.

✓ The quad screen test is not a diagnostic test but rather a screening test. If the results of the test are abnormal, further testing may be recommended to confirm or rule out the presence of a genetic condition.

Question 56

Which of the following would the nurse expect to be administered to treat a newborn with Respiratory Distress Syndrome (RDS) ?
A. Theophylline
B. Colfosceril
C. Dexamethasone
D. Albuterol

Answer 56

Colfosceril palmitate is a medication used as a pulmonary surfactant to treat and prevent respiratory distress syndrome (RDS). A fetus’s lungs start making surfactants during the third trimester of pregnancy, or around 26 weeks gestation through labor and delivery. Surfactant coats the insides of the alveoli reducing the surface tension of fluid in the lungs, which helps make the alveoli more stable. This keeps the lungs from collapsing when the newborn exhales. Respiratory distress syndrome (RDS) is a type of neonatal respiratory disease that is most often caused by a lack of surfactant in the lungs. Prevention of RDS is generally desired in babies born at a gestational age less than 32 weeks. In an infant with RDS, colfosceril palmitate may be given via endotracheal tube in two to four doses during the first 24-48 hours after birth. Research shows that these surfactant medications improve respiratory status and decrease the incidence of pneumothorax.

Question 57

Nursing Interventions for Late Decelerations in labour

Answer 57

✓ Late decelerations are primarily caused by uteroplacental insufficiency, and the client should be repositioned into a left lateral position.

✓ If the left lateral position is ineffective, the nurse may consider using the right lateral position.

✓ The nurse should also consider prescribed intravenous (IV) fluids to restore maternal blood volume.

Question 58

amniocentesis

Answer 58

An amniocentesis may be conducted on patients who have a high-risk pregnancy.

This procedure can be performed as early as fourteen weeks and is often used to detect fetal neural tube defects and chromosomal abnormalities.
Amniocentesis can also be used later in pregnancy to determine fetal lung maturity.
The client will need to consent before the procedure, and if the client is Rh-negative, she will need to receive prescribed RhoGAM to prevent Rh-isoimmunization.
Complications such as infection or bleeding may occur. The client should be instructed to report post-procedure fever, leaking of amniotic fluid, or bleeding.

Question 59

Post-Cleft Lip surgery Nursing Care

Answer 59

✓ Following a cleft lip repair, some surgeons allow the infant to return to breastfeeding or bottle-feeding, whereas others require syringe-feeding once the child is awake and alert.

✓ The nurse should provide pain management which may include acetaminophen.

✓ The nurse should ensure that no rigid objects are inserted into the mouth that may disrupt the suture line.

✓ Finally, the infant should not be positioned prone and positioned to prevent airway obstruction.

✓ The ideal position is the infant positioned on their back, slightly upright.

Question 60

Which assessment does the provider not perform on a patient with placenta previa

Answer 60

If the prenatal client has a current case of placenta previa, the cervix should not be assessed for dilation. Placenta previa arises when the placenta develops in a problematic spot, close to or over the cervical os. To prevent bleeding or premature labor, women with placenta previa shouldn’t have their cervix checked manually. Instead, an ultrasound may be performed.

Question 61

Fetal Circulation

Answer 61

✓Fetal circulation is a unique system that allows the developing fetus to receive oxygen and nutrients from the mother while also removing waste products.

✓The fetal circulation system is different from the circulation system of a newborn or adult.

✓The circulation system undergoes significant changes during the transition from fetal to newborn circulation shortly after birth.
In fetal circulation, the alveoli are filled with fluid. This causes high pressures in the fetal lungs, which shunts blood away from the pulmonary circulation. The ductus venosus is a bypass in fetal circulation that shunts blood away from the weak fetal liver and to the brain. This allows the brain to get fresh oxygen first.The pressures on the right side of the heart are higher in fetal circulation than on the left side of the heart.
The foramen ovale and ductus arteriosus normally close shortly after birth, allowing the baby’s lungs to take over oxygenation of the blood.Blood shunts from right to left in the fetal circulation; this is due to increased pulmonary pressures caused by the fluid-filled alveoli. The high pulmonary pressures increase pressure on the right side of the heart, creating a gradient across the foramen ovale shunting blood from right to left.

Question 62

Strategies to Prevent Infant Abduction

Answer 62

Explanation
Choice D is correct. Photographing all visitors and requiring visitors to sign in is fundamental to preventing infant abduction. This creates a record of the visitor, and the photograph is helpful if an abduction should occur.

Choices A, B, and C are incorrect. Cribs should be located away from doors to prevent rapid abduction. Infants should always be transported in the hallway with bassinets and not carried. Carrying an infant in the hallway should raise suspicion as this is not a standard mode of transport. Staff identification badges should be unique, contain a recent photo of the employee, and have the ability to be deactivated if it is lost.

Additional Info
Strategies to prevent infant abduction include -

Annual staff training on prevention strategies
Robust logging of visitors including photographs
Staff identification badges that are unique and able to be deactivated if the badge is lost.
A lockdown plan that is reviewed annually.
Security cameras positioned in multiple areas.
High presence of security.

Question 63

The nurse is caring for a client in labor and discovers the client has a completely prolapsed umbilical cord. The nurse should take which action?

Answer 63

A prolapsed umbilical cord is a serious finding that may lead to fetal hypoxia. The nurse must act quickly if this is suspected. Nursing and medical care will overlap, but one of the earliest interventions is to reposition the client either knee to chest, Trendelenburg, or hips elevated with pillows with a side-lying position maintained. The goal of repositioning is to position the woman’s hips higher than her head to shift the fetal presenting part toward her diaphragm.
✓ A prolapsed umbilical cord is a medical emergency

✓ The prolapse may be hidden or complete

✓ This condition should be suspected if the fetal heart monitor should show sustained bradycardia, variable decelerations or prolonged deceleration

✓ The nurse should reposition the client with the intent to position the woman’s hips higher than her head to shift the fetal presenting part

✓ Acceptable positions include knee-chest, Trendelenburg, or hips elevated with pillows, with side-lying position maintained

✓ The nurse should shout for help, pause oxytocin infusion, and provide oxygen via face mask at 8-10 liters/minute

✓ Provide and maintain vaginal elevation of the presenting part using a gloved hand

✓ An emergency cesarean section is likely

Question 64

A pregnant woman with preexisting hypertension is being seen in the clinic. Her blood pressure continues to rise despite attempting first-line therapy with anti-hypertensives. Which of the following medications will be used for the prenatal patient resistant to other blood pressure-lowering medications?

A. A calcium channel blocker
B. Methyldopa
C. Labetalol
D. Hydralazine

Answer 64

Hydralazine is the second-line therapy for high blood pressure in prenatal patients who are not seeing any results from other medications.

Question 65

You are caring for a pregnant woman with a baseline BMI of 22. You educate this client on the desirable weight gain during pregnancy with one baby for her is:

Answer 65

The amount of optimal weight gain during pregnancy is determined based on the woman’s body mass index (BMI) before pregnancy. BMI is a measure of body fat calculated from weight and height. Please use the following table to determine the recommended weight gain during pregnancy. A baseline BMI of 22 indicates that this woman’s baseline is in the healthy range (Normal BMI = 18.5 to 24.9). The recommended weight gain for this client is 25 to 35 pounds. Weight gain during pregnancy is crucial to the health and well-being of the baby and the mother.
Gaining too little weight can lead to premature birth and low infant birth weight.
Gaining too much weight can also result in premature birth and obesity of the child in later life.
Excessive weight gain can result in strenuous labor, the increased possibility of needing a caesarian section, and increased bleeding.

Question 66

An infant is admitted to the pediatric floor to rule out cystic fibrosis. The nurse assesses the infant’s stool, concluding the stool is consistent with a diagnosis of cystic fibrosis. How would you describe this infant’s stool?

Answer 66

This disease process frequently affects the pancreas, intestines, and hepatobiliary systems, resulting in the malabsorption of fats, fat-soluble vitamins, and protein in 85 to 95% of cystic fibrosis patients. As a result, gastrointestinal manifestations include the frequent passage of bulky, foul-smelling, oily stools.
Cystic fibrosis is an inherited disease affecting primarily the gastrointestinal and respiratory systems.
While universal newborn screening for cystic fibrosis is now standard in the United States, it is important to note that this screening tool cannot diagnose cystic fibrosis alone. When a newborn screening returns a positive result, it is followed by a sweat test to confirm the diagnosis.
Despite advances in genetic testing, the sweat chloride test remains the standard for confirming a cystic fibrosis diagnosis in most cases because of the test’s sensitivity, specificity, simplicity, and availability.
Although most cases of cystic fibrosis are first identified by newborn screening, up to 10% of those with cystic fibrosis are not diagnosed until adolescence or early adulthood.

Question 67

You are a nurse in the L&D department of the local hospital. You are caring for a newborn born at term with APGAR scores of 8 and 10. Before discharge, the infant should receive…

Answer 67

The Hepatitis B vaccine is given in three doses; the first dose is administered at the time of birth, the second dose at two months, and the third dose at six months of age. The Centers for Disease Control and Prevention (CDC) makes recommendations for vaccines and reviews special situations in vaccinations.

Question 68

You are reinforcing counseling for two parents preparing for their first child’s birth. The mother has sickle cell anemia. The father undergoes genetic testing and discovers he is not a carrier. You tell them that their baby has what chance of having sickle cell anemia?

Question 69

Rh immune globulin

Answer 69

Rh immune globulin (RhoGAM) prevents the production of anti-Rho(D) antibodies in Rh-negative women who have been exposed to Rh-positive blood by suppressing the immune reaction of the Rh-negative woman to the antigen in Rh-positive blood; preventing antibody response and thereby preventing hemolytic disease of the newborn in future Rh-positive pregnancies.

Type and antibody screening of the mother’s blood and cord blood type of the newborn should be performed to determine the need for the medication.
The mother must be Rh-negative and negative for Rh antibodies.
The newborn must be Rh-positive. If the fetal blood type after the termination of pregnancy is uncertain, the medication should be administered.
The newborn might have a weakly positive antibody test if the woman received Rho(D) immune globulin during pregnancy.
The drug is administered to the mother, not the infant.
The deltoid muscle is recommended for intramuscular administration. The medication may be given intravenously if prescribed.

Question 70

The mother of a child with lactose intolerance asks for more nutrition information. Which mineral and vitamin deficiencies are the lactose intolerant children at the most significant risk for developing?

Answer 70

Vitamin D and calcium are most frequently found in lactose-containing products like milk and cheese. Only very few foods contain high amounts of vitamin D ( milk, cheese, fatty fish like salmon and tuna, egg yolks, fortified cereals, and orange juice). Milk is fortified with vitamin D and is one of the primary sources of vitamin D for most people. Milk is also one of the major sources of daily calcium. A child with lactose intolerance is at the most significant risk of developing vitamin D and calcium deficiencies because lactose-containing products are often avoided in these children. Vitamin D and calcium deficiencies can lead to sub-optimal bone growth in children. The nurse should be aware of this so that necessary alternatives such as nutrient supplementation or dietary modifications may be pursued to avoid deficiencies in these children.

Question 71

A client who is 31 weeks gestation arrives to the clinic reporting headache, as well as swelling in her hands and face. The nurse should take which action? 

Answer 71

This client has symptoms of preeclampsia. She has a headache and swelling in her hands/face. These are symptoms of preeclampsia that may get overlooked. Preeclampsia can develop after 20 gestational weeks. Clinical features of preeclampsia include: blood pressure above 140/90 mmHg, proteinuria, and swelling (usually in the hands and face). The nurse should obtain vital signs to determine the client’s overall stability and help establish this potential diagnosis. The nurse should report: BP > 140/90, > 1+ proteinuria, weight gain of more than 2 lb./wk., and facial swelling. These are concerning findings for preeclampsia.

Question 72

While working in the emergency department, the nurse assesses a 3-day old infant brought in by the mother. The mother states, “My baby is always so sweaty and hot, and just doesn’t want to eat! I think something is wrong.” The nurse is unable to palpate a femoral pulse but notes +3 brachial pulses. Based on this assessment, which congenital heart defect does the nurse suspect?

Answer 72

The nurse suspects that this infant has coarctation of the aorta. In this defect, there is a stricture in the aorta preventing blood flow out of the left ventricle. It usually occurs beyond the blood vessels that branch off to your upper body and before the blood vessels that lead to your lower body. So blood flow to the upper body is abundant, but hardly any of it can make it to the lower part of the body. Therefore, there are decreased lower extremity pulses and increased upper extremity pulses.

Question 73

Normal Vital signs for a newborn

Answer 73

Normal vital signs for a newborn include –

Respiratory Rate:

30 to 60 breaths per minute

Apical Pulse:

120 – 160 beats per minute (may decrease to 100 if sleeping; may increase to 180 if crying)

Temperature:

36.5° to 37.5°C (97.7° to 99.5°F) axillary

Other reassuring findings include a vigorous cry, appropriate muscle tone (the ability for the infant to move extremities randomly), a patent airway, umbilical cord that has two arteries and one vein, and symmetrical facial features.

Question 74

stages of Freud’s psychosexual development

Answer 74

The oral stage is first. According to Freud’s psychosexual stages, children from 0 to 1 years old are in the oral stage. In this stage, children are interested in putting things in their mouths, sucking, and tasting. They will put unfamiliar objects in their mouth and derive pleasure from oral activities.
The second is the anal stage. Children from 2-3 years old are in the anal stage. This is the stage when toilet training occurs. If children can complete this activity, they pass out of the anal stage, but if they struggle, they may become ‘stuck’ in their psychosexual development.
The third is the phallic stage. Freud believes that 3-6-year-old children are in the phallic stage of psychosexual development. In this stage, boys become very attached to their mothers, whereas girls become very attached to their fathers.
Fourth is the latency stage. According to Freud’s psychosexual stages, children from 6 years old until puberty starts are in the latency stage. In the latency stage, children spend most of their time with peers of the same sex. This is when they begin school and tend to interact mainly with those of the same sex.
Lastly is the genital stage. This stage occurs from puberty and beyond. In the genital stage, individuals are attracted to opposite-sex peers.

Question 75

The nurse is assessing a newborn that was delivered 8 hours ago. The nurse notices hyperactivity, a persistent shrill cry, and jitteriness. The nurse suspects which condition?

Answer 75

Neonates born to drug-dependent mothers exhibit jitteriness, hyperactivity, and a shrill cry. These signs usually appear within 24 hours of being delivered.

Question 76

The nurse is caring for a client in labor who just received epidural analgesia. The nurse should monitor the client for which adverse effects?

Answer 76

Epidural analgesia may cause bladder distention. Bladder distention may cause pain that remains after initiation of the block and may interfere with fetal descent in labor.
The epidural space is entered at the L3-L4 interspace (below the end of the spinal cord), and a catheter is passed through the needle into the epidural space. The catheter allows continuous infusion or intermittent injection of medication to maintain pain relief during labor and vaginal or cesarean birth. The infusion of epidural medication also may be regulated by a patient-controlled epidural analgesia (PCEA) pump

Question 77

Mastitis

Answer 77

Mastitis is often caused by Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci. The bacteria are most often carried on the skin of the mother or in the mouth or the nose of the newborn. The organism enters through an injured area on the nipple, such as a crack or blister. The primary medical treatment is antibiotics and continued emptying of the breast. Comfort measures during mastitis include applying moist heat or ice packs, breast support, bed rest, fluids, and analgesics.

Question 78

Which factors contribute to labour dystocia

Answer 78

The following factors may contribute to labor dystocia, which may reduce the progression of labor:

Maternal fatigue
Uterine overdistention such as with multiple gestation
Maternal inactivity
Uncontrolled maternal pain
Fluid and electrolyte imbalance
Hypoglycemia
Excessive analgesia or anesthesia

Question 79

While caring for a newly pregnant mother, the nurse notes that she has a rubella infection. Which of the following conditions would the nurse be concerned about in this case?

Select all that apply.

Intrauterine growth restriction (IUGR)

Hemolytic disease of the newborn

Hydrocephaly

Large for gestational age infant (LGA)

Stillbirth

Answer 79

Women infected with rubella are at an increased risk of having a miscarriage or a stillbirth. Their infants are more likely to suffer from intrauterine growth restriction and hydrocephaly.