NURS 326 All Set Practice and Verified Correct Answers Final Exam 2025

Nurs326 NURS 326 All Set Practice and Verified Correct Answers Final Exam 2025 A nurse is reviewing contraceptive failure rate. Which statement should the nurse identify as being accurate? a. It varies from couple to couple, depending on the method and the users. b. It refers to the minimum level that must be achieved to receive a government license. c. It refers to the percentage of users expected to have an accidental pregnancy over a 5-year span. d. It increases over time as couples become more careless. a. It varies from couple to couple, depending on the method and the users. A nurse is reviewing aspects of fertilty awareness-based (FAB) methods. What should the nurse identify as being in common for these methods? a. They all rely on measurement of body temperature. b. They all involve abstinence at some point. c. They all require the cooperation of the woman's partner. d. They all require a woman to be able to touch her genitals to assess cervical mucus. c. They all require the cooperation of the woman's partner. What information should nurses be aware of with regard to emergency contraception pills? a. Emergency contraception has no medical contraindications. b. The pills should be readily available during the initial learning phase when a woman is using a new method of contraception. c. The pills protect the woman against pregnancy even if she engages in unprotected intercourse in the days after treatment. d. The pills must be taken no later than 48 hours after unprotected intercourse or birth control mishap. b. The pills should be readily available during the initial learning phase when a woman is using a new method of contraception. The nurse is providing instructions to a woman taking an oral contraceptive pill (OCP) as her birth control method. Which finding should the nurse identify as requiring the client to immediately contact her physician? a. Swelling and pain in one of her legs Nurs326 Nurs326 b. Weight gain c. Breast tenderness and swelling d. Mood swings a. Swelling and pain in one of her legs The nurse has performed inspection of a 55-year-old woman's breast. Which observation if noted by the nurse would require the client to be referred for additional testing? a. Bilateral symmetry of venous network, which is faintly visible b. Eversion (elevation) of both nipples c. Small dimple located in the upper outer quadrant of the right breast d. Left breast slightly smaller than right breast c. Small dimple located in the upper outer quadrant of the right breast The nurse is peforming a breast assessment on a client with a history of fibrocysts and fibroadenmoa. Which of the following findings should the nurse anticipate? a. Firm b. No nipple discharge c. Single lump d. Moveable d. Moveable A 38-year-old woman is screened for breast cancer risk and is found to be at high risk for it. She has no immediate health presentations. Which priorityaction should the nurse identify to be taken as part of the treatment therapy? a. Schedule an MRI and mammogram after consultation with her health care provider. b. Schedule an ultrasound and, based on the results, schedule an MRI. c. Instruct the clienton how to perform a self-breast exam on a monthly basis. d. Refer to the surgeon for discussion of mastectomy. a. Schedule an MRI and mammogram after consultation with her health care provider. A nurse is providing dietary counseling to a client who has fibrocystic breast disease. Which food selection should the nurse instruct the client to avoid? a. Coffee drinks b. Water taken with each meal. c. Use of artificial sweeteners. d. Fruit a. Coffee drinks A married couple is discussing male and female sterilization with the nurse. Which statement is most appropriate for the nurse to make? Nurs326 Nurs326 a. "Male and female sterilization methods are 100% effective." b. "Tubal ligation can be easily reversed if you change your mind in the future." c. "A vasectomy may have a slight effect on sexual performance." d. "Major complications after sterilization are rare." d. "Major complications after sterilization are rare." A 男性一开始可能还有精子存在 A nurse is caring for a postpartum client who is experiecing profuse postpartum bleeding. What is the priority intervention to be performed by the nurse? a. Call the woman's primary health care provider. b. Administer the standing order for an oxytocic. c. Palpate the uterus and massage it if it is boggy. d. Assess maternal blood pressure and pulse for signs of hypovolemic shock. c. Palpate the uterus and massage it if it is boggy. A nurse is caring for a first-time mother who is breastfeeding. Which postpartum infection would the nurse identify as being most often contracted by this client type? a. Urinary tract infections (UTIs) b. Wound infections c. Endometritis d. Mastitis d. Mastitis An appropriate nursing action for a woman with a postspinal headache is: 1.Keep her in bed in semi-fowlers position 2.Encourage the intake of fluids that she enjoys 3.Have her ambulate at least every 4 hours 4.Restrict intake of high-carbohydrate foods 2.Encourage the intake of fluids that she enjoys During rounds, a nurse suspects that a client who has recently delivered via vaginal route is having excessive postpartum bleeding. Which intervention would be the priority action taken by the nurse at this time? a. Increase the rate of intravenous fluids. b. Monitor pad count and perform catheterization. c. Call the physician. d. Massage the uterine fundus. Nurs326 Nurs326 d. Massage the uterine fundus. nurse is caring for a postpartum client who has a significant bleed. In which clincial situations would the nurse identify the use of Methergine or prostaglandin be contraindicated even if the client was experiencing a postpartum significant bleed? (Select all that apply.) a. Client's blood pressure postpartum is 180/90. b. Client has delivered twin pregnancies. c. Client has a history of asthma. d. Client has a mitral valve prolapse. e. Client is a grand multip. a, c, and d What's the nurse's first action immediately following rupture of membranes of a woman in labor? 1.Document the color and consistency of the fluid 2.Assess the fetal heart rate 3.Look for presence of the umbilical cord at the vaginal orifice 4.Keep her in bed until the MDs contacted 2.Assess the fetal heart rate In which of the following clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform an amnioinfusion? 1.Placental abruption 2.Meconium stained fluid 3.Polyhydramnios 4.Late decelerations 2.Meconium stained fluid A method to prepare the cervix for induction of labor the following day is: 1.Prostaglandin preparations 2.Fetal fibronectin 3.Oral oxytocin tablets 4.Amniotomy 1.Prostaglandin preparations A client has just had an External Version. The nurse monitors this client carefully for which of the following? 1.Decreased urinary output 2.Elevated blood pressure Nurs326 Nurs326 3.Severe occipital headache 4.Variable fetal heart decelerations 4.Variable fetal heart decelerations During the recovery period after low forceps birth with a median episiotomy, the nurse should: 1.Assess for purulent drainage from the episiotomy 2.Apply cold packs to the perineal area promptly 3.Expect a larger quantity of lochia rubra 4.Limit oral intake to ice chips until transfer to a room 2.Apply cold packs to the perineal area promptly Choose the correct preoperative teaching before planned C-section 1.Oral intake will be limited to clear fluids for 12 hours before surgery 2.IV fluids are usually continued for two days after birth 3.The woman will be asked to take deep breaths and cough regularly after birth 4.The nurse will help her ambulate to the restroom to urinate within four hours after birth. 3.The woman will be asked to take deep breaths and cough regularly after birth A nurse is monitoring a client who was receiving an amnioinfusion. Which of the following assessment is critical for the nurse to make in order to prevent a serious complication related to the procedure? 1.Color of the amniotic fluid 2.Maternal blood pressure 3.Cervical effacement 4.Uterine resting tone 4.Uterine resting tone On the first postpartum day, the nurse teaches the client about breast-feeding. Two hours later she seems to remember very little of teaching. The nurse understands this memory lapse is due to 1.The taking hold phase 2.Postpartum hemorrhage 3.The taking in phase 4.Epidural anesthesia 3.The taking in phase The nurse determines the fundus of a postpartum client to be boggy. Initially the nurse should: Nurs326 Nurs326 1.Document the findings 2.Assess maternal vital signs 3.Call the primary care provider 4.Massage the fundus and reassess 4.Massage the fundus and reassess The postpartum nurse is caring for a client who gave birth to twins earlier today. The nurse will assess for symptoms of: 1.Increased blood pressure 2.Hypoglycemia 3.Postpartum hemorrhage 4.Postpartum infection 3.Postpartum hemorrhage A woman is determined to be group B streptococci (GBS) positive at the onset of her labor. The nurse should prepare this woman for: A.Cesarean birth. B.Isolation of her newborn after birth. C.Intravenous antibiotic prophylaxis (IAP) using penicillin G during labor. D.Application of acyclovir to her labial lesions. C.Intravenous antibiotic prophylaxis (IAP) using penicillin G during labor. Cervical neoplasia has been linked to which of the following sexually transmitted infections? A.Herpes simplex virus (HSV). B.Human papillomavirus (HPV). C.Human immunodeficiency virus (HIV). D.Chlamydia. B.Human papillomavirus (HPV). Which of the following factors would be contraindicated with use of oral contraception with estrogen and progesterone? (Circle all that apply) A.Uncontrolled hypertension B.History of asthma C.Active liver disease D.History of endometriosis E.Undiagnosed vaginal bleeding. A, C, and E Nurs326 Nurs326 A woman comes to the clinic to report she had unprotected intercourse the previous night. She is nervous she may get pregnant and asks the nurse for Plan B. Which of the following instructions given to the woman by the nurse is correct? A."You will need to take a dose now and repeat the dose in 12 hours." B."This medication will cause heavy bleeding" C."This medication will likely cause nausea and vomiting, you may take an over the counter antiemetic." D."If you cannot tolerate taking oral contraception this medication is not a good option for you." C."This medication will likely cause nausea and vomiting, you may take an over the counter antiemetic." Which of the following infections may lead to pelvic inflammatory disease (PID) and increase a woman's risk for infertility? A.Vulvovaginal candidiasis. B.Group B streptococci. C.Chlamydia. D.Human papillomavirus virus (HPV) C.Chlamydia. A patient, 32 weeks pregnant complaining of a severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1.Assess deep tendon reflexes 2.Obtain CBC 3.Assess baseline weight gain 4.Obtain urine for protein 1.Assess deep tendon reflexes A 24 week gravid client is being seen in the prenatal clinic. She states, "I've had a terrible headache for the past two days". Which of the following is the most appropriate action for the nurse to perform next? 1.Inquire whether or not the client has allergies 2.Take the woman's blood pressure 3.Assess the fundal height 4.Ask the woman about stressors at work 2.Take the woman's blood pressure Nurs326 Nurs326 A pregnant client experiencing severe abruption placentae would most likely exhibit: 1.Maternal bradycardia 2.Painless vaginal bleeding 3.Rigid, board-like abdomen 4.Vague abdominal discomfort 3.Rigid, board-like abdomen A client has just done a fetal kick count assessment. She noted six movements during the last hour. If taught correctly, what should her next action be? 1.Nothing because further action is not warranted 2.Call the provider to set up a NST 3.Redo the test during the next 30 min. 4.Drink a glass of orange juice and redo the test 1.Nothing because further action is not warranted An insulin-dependent diabetic woman will require higher doses of insulin as which of the following pregnancy hormones increases in her body? 1.Estrogen 2.Progesterone 3.Human chorionic gonadotropin 4.Human placental lactogen/ human chorionicsommatropin 4.Human placental lactogen/ human chorionicsommatropin A pregnant diabetic has been diagnosed with polyhydramnios. Which of the following would explain this finding? 1.Excessive fetal urination 2.Recurring hypoglycemic episodes 3.Fetal sacral agenesis 4.Placental vascular damage 1.Excessive fetal urination A woman's glucose challenge test ( GCT ) results are 155 mg/dL at one hour post glucola ingestion. Which of the following actions, as ordered by the physician, is appropriate? 1.Send the woman for a 3 hr glucose tolerance test (GTT) 2.Notify the woman of the normal results 3.Provide the woman with oral hypoglycemic agents 4.Teach the woman how to inject herself with insulin 1.Send the woman for a 3 hr glucose tolerance test (GTT) Nurs326 Nurs326 A 15-year-old client is being seen for her first prenatal visit. Because of this client's special nutritional needs, the nurse evaluates the client's intake of: 1.Protein and magnesium 2.Calcium and iron 3.Carbohydrates and zinc 4.Folic acid and thiamine 2.Calcium and iron During a prenatal examination, the nurse notes scarring on and around the woman's genitalia. Which of the following questions is most important for the nurse to ask in relation to these observations? 1.Have you ever had a severe infection of your sex organs? 2.Have you worn any piercings in your genital area? 3.Have you had a tattoo removed from your genital area? 4.Have you ever been forced to have sex without your permission? 4.Have you ever been forced to have sex without your permission? The nurse is caring for 32-week G8P7007 with placenta previa. Which of the following interventions with the nurse expect to perform? Select all that apply. 1.Daily contraction stress tests 2.Blood type and crossmatch 3.Bedrest with passive range of motion exercises 4.Weekly biophysical profiles 2, 3, and 4 A gestational diabetic, who requires insulin therapy to control her blood glucose levels, telephones the triage nurse complaining of dizziness and headache. Which of the following actions should the nurse take at this time? 1.Have the client proceed to the office to see her physician 2.Advise the client to drink a glass of milk 3.Instruct the client to inject yourself with regular insulin 4.Tell the client immediately to telephone her medical doctor 2.Advise the client to drink a glass of milk Which of the following pregnant client's is most high risk for PPROM (preterm premature rupture of membranes)? 1.30 week gestation with prolapsed mitral valve 2.32 week gestation with urinary tract infection Nurs326 Nurs326 3.34 weeks gestation with gestational diabetes ( GDM ) 4.36 weeks gestation with deep vein thrombosis ( DVT ) 2.32 week gestation with urinary tract infection A nurse administers magnesium sulfate via infusion pump to a pre-eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1.Client has no patellar reflex response 2.Urinary output 30 mL/hr 3.Respiratory rate 16 4.Client has no tonic-clonic convulsion signs 4.Client has no tonic-clonic convulsion signs A doctor orders a narcotic analgesic for a laboring client. Which of the following situations would lead a nurse to hold the medication? 1.Contraction pattern is every 3 min. x 60 sec 2.Fetal monitoring tracing shows late decelerations 3.Client sleeps between contractions 4.Blood pressure is 150/90 2.Fetal monitoring tracing shows late decelerations The nurse is monitoring a woman, G2P1001, 41 weeks gestation, in labor. At 12 PM assessment revealed: cervix 4cm; 80% effaced; -3 station; FHT moderate variability. A 5 PM assessment revealed cervix 6 cm; 90%, -3 station; FHT 124, moderate variability. At 10 PM assessment: cervix 8 cm, 100% effaced, -3 station, FHT 128 with moderate variability. Based on the assessments, which of the following should the nurse conclude? 1.Labor is progressing well 2.The woman may be carrying a macrosomic infant 3.The baby is in fetal distress 4.The woman will be in second stage of labor in three hours 2.The woman may be carrying a macrosomic infant Which of the following signs and symptoms with the nurse expect to see in woman with placenta abruption? 1.Increasing fundal height measurements 2.Pain-free vaginal bleeding 3.Fetal heart rate accelerations 4.Hypertension with +3 proteinuria Nurs326 Nurs326 1.Increasing fundal height measurements A labor nurse is caring for client, 38 weeks gestation, who is been diagnosed symptomatic placenta previa. Which of the following physician orders should the nurse question? 1.Begin oxytocin drip rate at 1 mU/min 2.Assess FHT Q 10 min. 3.Weigh all perineal pads 4.Obtain CBC with diff 1.Begin oxytocin drip rate at 1 mU/min The nurse in the OB office is caring for four 25-week gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor? 1.38-year-old registered nurse in an abusive relationship 2.32-year-old secretary whose first child was post-term 3.26-year-old attorney whose baby has a 2-vessel cord 4.20-year-old college student with a history of irregular menstrual periods 1.38-year-old registered nurse in an abusive relationship A woman at 42 weeks gestation, is admitted to the labor and delivery suite for induction. A biophysical profile report on the client's chart states a score of 6/10. The nurse should monitor this client carefully for which of the following? 1.Maternal hypertension 2.Maternal hyperglycemia 3.Increased fetal heart rate variability 4.Late fetal heart rate decelerations 4.Late fetal heart rate decelerations 6保持观察 6以下生 A client is been receiving magnesium sulfate for severe preeclampsia for 12 hours. Reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? 1.Apical heart rate 104 2.Urinary output 240 mL/12 hours 3.Blood pressure 160/120 4.Temperature 100° 2.Urinary output 240 mL/12 hours Nurs326 Nurs326 The nurse should suspect puerperal infection when the client exhibits which of the following? 1.Temperature of 100.2°F 2.White blood cell count of 14,500/mm 3.Diaphoresis during the night 4.Malodorous lochial discharge 4.Malodorous lochial discharge Which symptoms with the nurse expect to observe and postpartum client with a vaginal hematoma? 1.Pain/pressure 2.Redness 3.Bleeding 4.Warmth 1.Pain/pressure A woman has just had macrosomic baby after a 12 hour labor. For which of the following complications should the woman be carefully monitored? 1.Uterine atony 2.Puerperal infection 3.Mastitis 4.Postpartum depression 1.Uterine atony A nurse is working on a postpartum unit. Which of the following patient's should the nurse assess first? 1.One-day postpartum SVD c/o burning on urination 2.One day forceps delivery with blood loss of 500 ML at delivery 3.Three day postpartum after vacuum extraction with Hgb 7.2g/dL 4.Three day C-section c/o firm and painful breasts 3.Three day postpartum after vacuum extraction with Hgb 7.2g/dL The nurse is providing discharge counseling to woman who is breast-feeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? 1.Gently massage the area toward the nipple especially during feeding 2.Apply ice to the area between feedings Nurs326 Nurs326 3.Bottlefeed for the next 24 hours 4.Apply lanolin ointment to the areas after each feeding 1.Gently massage the area toward the nipple especially during feeding A home care nurse is visiting a breast-feeding client who is two weeks post delivery of the 7 pound baby girl with a midline episiotomy. Which of the following findings should take priority? 1.Minimal lochia serosa 2.Client cries throughout the visit 3.Nipples are cracked 4.Client yells at the baby for crying 4.Client yells at the baby for crying A nursing diagnosis for five-day-old newborn under phototherapy is: Risk for fluid volume deficit. For which of the following client outcomes should the nurse plan to monitor the baby? 1.Six wet diapers in 24 hours 2.Breast-feeds six times in 24 hours 3.12% weight loss since birth 4.Apical heart rate 176 bpm 1.Six wet diapers in 24 hours A woman has just had a low forceps delivery. For which of the following should the nurse assess the woman during Stage IV of delivery (priority assessment)? 1.Infection 2.Hematuria 3.Rectal abrasions 4.Early PPH 4.Early PPH A baby whose mother was addicted to heroin during the pregnancy is in the nursery. Which of the following nursing actions would be appropriate? 1.Tightly swaddle the baby 2.Place the baby prone in the crib 3.Provide needed stimulation to the baby 4.Feed the baby have half strength formula 1.Tightly swaddle the baby A nurse makes the following observations when admitting a full-term, breast-feeding baby into the neonatal nursery : 9 lb 2 oz, 21 in , Temp 96.6, HR 156, R 62, jittery, body pink with acrocyanosis. What is the priority nursing action? Nurs326 Nurs326 1.Swaddle the baby to provide warmth 2.Assess the glucose level the baby 3.Take the baby to the mother for feeding 4.Administer the neonatal medications 2.Assess the glucose level the baby Four babies are in the newborn nursery. The nurse pages the neonatologist to see the baby , who exhibits which of the following? 1.Erythema toxicum 2.Pseudostrabismus 3.Intercostal retractions 4.Vernix caseosa 3.Intercostal retractions Which of the following neonates is at highest risk for cold stress syndrome? 1.Infant of a diabetic mother 2.Infant with Rh incompatibility 3.Postdates neonate 4.Down syndrome neonate 1.Infant of a diabetic mother A newborn nursery nurse notes that baby's body is jaundiced at 36 hours of life. Which of the following nursing interventions would be most therapeutic? 1.Maintain a warm ambient environment 2.Have the mother feed the baby frequently 3.Have the mother hold the baby skin to skin 4.Place the naked baby by a closed sunny window 2.Have the mother feed the baby frequently A newborn admitted to the nursery has a positive direct Coombs test. Which of the following is an appropriate action by the nurse? 1.Monitor the baby for jitters 2.Assess the blood glucose level 3.Assess the rectal temperature 4.Monitor the baby for jaundice 4.Monitor the baby for jaundice A baby was just born to a mother who had positive Group B Strep. For which of the following should the nursery nurse closely observe this baby? Nurs326 Nurs326 1.Hypothermia 2.Mottling 3.Omphalocele 4.Meconium staining 1.Hypothermia The primary expected outcome for nursing care associated with the administration of magnesium sulfate would be met if which assessment finding is present? The patient : a. Exhibits a decrease in both systolic and diastolic blood pressure b. Experiences no seizures c. States that she feels more relaxed and calm d. Urinates more frequently resulting in a decrease in pathologic edema b. Experiences no seizures A patient with severe preeclampsia is receiving nifedipine (Procardia). They ask the nurse what this medication is for. The nurse should tell the patient that nifedipine is used to: a. Prevent seizures b. Relieve the headache she is beginning to have. c. Decrease her blood pressure. d. Reduce the edema in her hands and legs c. Decrease her blood pressure. A pregnant patient's preeclampsia has advanced to the severe stage. They are admitted to the hospital and her primary health care provider has ordered an infusion of magnesium sulfate be started. In implementing this order, the nurse should: Select all that apply a. Prepare a solution of 20g of magnesium sulfate in 100 mL of 5% glucose in water b. Monitor maternal vital signs FHR patterns and uterine contractions c. Expect the maintenance dose to be approxmiately 2g/hr d. Administer a loading dose of 4 to 6 g over 15 to 30 minutes e. Prepare to administer Apresoline if signs of toxcity appear f. Report a respiratory rate of 12 breaths or less to the Primary health care provider immediately b, c, d, and f Following vaginal birth 2 hours ago a patient with preeclampsia is experiencing a heavy flow as a result of a boggy uterus. It is determined that this patient will require medication to reduce the amount of blood loss. Which medication would the nurse anticipate administering? Nurs326 Nurs326 a. Methylergonovine (Methergine) b. Calcium gluconate c. Oxytocin (Pitocin) d. Labetalol (Normodyne) c. Oxytocin (Pitocin) A patient at 35 weeks of gestation with preeclampsia, has a seizure. Immediately after the seizure , the nurse's priority action is to: a. Evaluate FHR and pattern for signs of decreasing variability, late decelerations, or bradycardia b. Assess status of the maternal airway, respiratory effort, and pulse c. Determine if membranes have ruptured and if the amniotic fluids contain meconium d. Prepare to increase the amount of magnesium sulfate being infused from 1g/hr to 2g/hr b. Assess status of the maternal airway, respiratory effort, and pulse A nurse is preparing to administer Rhogam to a post partum patient. Before implementing this care measure the nurse should: a. Ensure that medication is given at least 24 hours after the birth. b. Verify that the indirect and direct Coombs' test results are negative. c. Make sure that the newborn is Rh negative. d. Cancel the Cancel administration of the Rhogam if it was given to the woman during her pregnacy. b. Verify that the indirect and direct Coombs' test results are negative. When assessing postpartum patient during the first 24 hours after birth the nurse must be alert for signs which could indicate the development of postpartum physiologic complications. Which signs are of concern to the nurse? Select all that apply. a. Temperature - 100 F b. Fundus - midline, boggy c. Lochia- three quarters of pad saturated in 3 hours. d. Positive Homan's sign in right leg e. Anoerxia f. Voids appromiately 150 ml to 200 ml of urine for each of the first 3 voidings after birth. b, e d C. saturation of the pad in 15 minutes or less would be a concern A postpartum patient expresses a need to review their labor and birth experience with the nurse who cared for them while in labor. This behavior is most characteristic of which phase of maternal postpartum adjustment. Nurs326 Nurs326 a. Taking - hold b. Taking- in c. Letting - go d. Post partum blues b. Taking- in A nurse has assessed a postpartum patient who gave birth vaginally 12 hours ago. Which findings would require further assessment? a. Bright to dark red uterine discharge b. Midline episiotomy- approximated, moderate edema, slight erythema, absence of ecchymosis c. Protusion of abdomen with separation of abdominal wall muscles. d. Fundus firm at 1 cm above the umbilicus and to the right of midline. d. Fundus firm at 1 cm above the umbilicus and to the right of midline. Which postpartum patient 24 hours following birth is least likely to experience afterpains? a. Primipara who is breastfeeding her twins that were born at 38 weeks of gestation? b. Multipara who is breastfeeding her 10 pound full- term baby girl. c. Multipara who is bottle feeding her 8 pound baby boy. d. Primipara who is bottle feeding her 7 pound baby girl d. Primipara who is bottle feeding her 7 pound baby girl The nurse responsible for the care of postpartum patient recognizes that the first sign of puerperal infection most likely is: a. Temperature elevation to 38 degree C or higher after 24 hours following birth. b. Increased white blood cell count c. Foul- smelling profuse lochia d. Bradycardia a. Temperature elevation to 38 degree C or higher after 24 hours following birth. A postpartum patient in the fourth stage of labor received Hemabate 0.25 mg intramuscularly . The expected outcome of care for the administration of this medication is: a. Relief from the pain of uterine cramping b. Prevention of intrauterine infection c. Reduction in the blood's ability to clot d. Limitation of excessive blood loss that is occurring after birth d. Limitation of excessive blood loss that is occurring after birth Nurs326 Nurs326 A breastfeeding postpartum patient cesarean birth occurred 2 days ago. Investigation of the pain, tenderness, and swelling in her left leg led to a medical diagnosis of deep vein thrombosis (DVT). Care management for this woman during the acute stage of the DVT involves: Select all that apply a. Explaining that she will need to stop breastfeeding until anticoagulation therapy is completed. b. Administer Coumadin c. Placing the patient on bedrest with left leg elevated. d. Fitting the woman with elastic stockings so that she can exercise her legs. e. Tell her to avoid changing position for the first 24 hours f. Administering heparin IV for the first 3 to 5 days. b, c, and f Infections of the female mid-reproductive tract such as chlamydia are dangerous primarily because they: a. Are asymptomatic or silent b. Cause infertility c. Lead to pelvic inflammatory disease (PID) d. Are difficulty to treat effectively. a. Are asymptomatic or silent A finding associated with human papillomavirus (HPV) infection includes: a. White curd-like adherent discharge b. Soft papillary swellings occurring singly or in clusters c. Vesicles progressing to pustules and then to ulcers d. Yellow to green frothy, malodorous discharge b. Soft papillary swellings occurring singly or in clusters A pregnant patient is determined to be group B streptococci (GBS) positive at the onset of her labor. The nurse should prepare this woman for: a. Cesarean birth b. Isolation of her newborn after birth c. IV administration of penicillin during labor d. Application of acyclovir to their labial lesions c. IV administration of penicillin during labor For some individuals the most distressing side effect of progestin-only contraception is: a. Irregular vaginal bleeding. b. Headache Nurs326 Nurs326 c. Nervousness d. Nausea a. Irregular vaginal bleeding. A 36 year old individual has chosen depot medroxyprogesterone acetate (DNPA, Depo Provera) as the method of contraception most suitable for her lifestyle. Which statement made by this patient indicates a lack of understanding and a need for further instruction by the nurse? a. "I will need to receive another injection every 4 weeks." b. "I am going to watch my diet and exercise, because weight gain is common." c. "If I plan to continue with the Depo-Provera, I should have my bone density assessed." d. "This method will result in a smaller amount of thicker cervical mucus." a. "I will need to receive another injection every 4 weeks." Joyce has chosen the diaphragm as her method of contraception. Which action indicates that Joyce is using the diaphragm effectively? a. Joyce came to be refitted after healing was complete following the term vaginal birth of her son. b. Joyce applies a spermicide only to the rim of the diaphragm just before insertion. c. Joyce removes the diaphragm within 1 hour of intercourse. d. Joyce empties her bladder after intercourse. a. Joyce came to be refitted after healing was complete following the term vaginal birth of her son. An individual with an intrauterine device (IUD) should confirm its placement by checking the IUD's string: a. After each menstrual period. b. After intercourse. c. At the time of ovulation. d. During menstrual bleeding. a. After each menstrual period. A nurse is caring for a client who is bottlefeeding but has engorged breasts. What action should the nurse implement? a. Allow warm water to soothe the breasts during a shower. b. Express milk from breasts occasionally to relieve discomfort. c. Wear a snug, supportive bra. d. Place absorbent pads with plastic liners into her bra to absorb leakage. Nurs326 Nurs326 c. Wear a snug, supportive bra. Rationale: A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Ice packs, fresh cabbage leaves, and mild analgesics may also relieve discomfort. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners would keep the nipples and areola moist, leading to excoriation and cracking. A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. What does the nurse identify as being the most serious complication based on this finding? a. Urinary tract infection. b. A ruptured bladder. c. Excessive uterine bleeding. d. Bladder wall atony. c. Excessive uterine bleeding. A nurse is working with a postpartum client about resumption of menstrual activity following childbirth. Which of the following statements indicate that the client has a correct understanding? a. "My first menstrual cycle will be heavier than normal and then will be light for several months after." b. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." c. "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." d. "I will not have a menstrual cycle for 6 months after childbirth." c. "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." The nurse is teaching a new parent how to bottlefeed their newborn. Instructions the new parent should receive regarding this feeding method include. a. Check the nipple before feeding to ensure that it allows passage of formula in a slow stream. b. Feed the newborn water in between feedings at least 2 ounces a day. c. Expect a 2 week old newborn to eat every 3 to 4 hours during the day. d. Microwave formula for about 2 minutes before feeding the newborn. c. Expect a 2 week old newborn to eat every 3 to 4 hours during the day. Nurs326 Nurs326 A new breastfeeding/chestfeeding patient asks the nurse how to prevent nipple soreness. The nurse tells this patient that the key to preventing sore nipples is: a. Limiting the lenght of breastfeeding to 10 minutes a side until the mature milk comes in. b. Apply lanlion to each nipple and areola after each feeding. c. Correct latch and removal from breast d. Using breast shields to protect the nipples and areola between feedings. c. Correct latch and removal from breast When assessing a newborn after birth, the nurse notes flat, irregular, pinkish marks on the bridge of the nose, nape of the neck and over the eyelids. The areas blanch when pressed with a finger. The nurse documents this finding as: a. Milia b. Nevus vasculosus (strawberry mark) c. Telangietatic nevi (Stork bite) d. Nevus flammeus (port wine stain) c. Telangietatic nevi (Stork bite) Newborn, at 5 hours old, wakes from a sound sleep and becomes very active and begins to cry. Which sign if exhibited by this newborn indicates expected adaptation to extrauterine life? a. Increased mucus production b. Fine crackles on auscultation c. A respiratory rate of 24 and irregular d. A heart rate of 155 beats/minute d. A heart rate of 155 beats/minute A newborn is very susceptible to heat loss. Which of the following symptoms exhibited by the newborn may indicate a newborn is experiencing cold stress. a. Respiratory rate of 66 b. Blood sugar of 52 c. Pink mucos membranes d. Metabolic Alkalosis a. Respiratory rate of 66 A healthy baby girl is delivered term via a non complicated spontaneous vaginal delivery. The newborn is immediately dried off. Which action by the nurse best protects the newborn from cold stress. a. Bathing the newborn in warm water under the radiant warmer. Nurs326 Nurs326 b. Places the newborn on her mother's chest for skin to skin contact. c. Wraps the newborn up in a blanket d. Places the baby under the radiant warmer b. Places the newborn on her mother's chest for skin to skin contact. A nurse is assessing babies in the nursery. When the nurse starts to assess a 2 day old term breastfeeding newborn boy , he finds yellowing on the face. Which type of jaundice does this assessment describe? a. Pathological b. Physiologic c. Kernicterus d. Bilirubin encephalopathy b. Physiologic A 26 year old woman has just been diagnosed with fibrocystic changes in her breasts. Which nursing diagnosis is appropriate for this woman? a. Acute pain related to cyclic enlargement of the breast cysts. b. Risk for infection related to altered integrity of the areola associated with accumulation of a thick sticky discharge from both nipples. c. Anxiety related to anticipated surgery to remove the cysts in her breasts. d. Fear related to high risk for breast cancer. a. Acute pain related to cyclic enlargement of the breast cysts. A nurse is working with a postpartm client who is experiencing after birth pains. Which statement should the nurse identify as being accurate with regard to afterbirth pains? a. Alleviated somewhat when the mother breastfeeds. b. They are caused by mild, continual contractions for the duration of the postpartum period. c. More common in first-time mothers. d. More noticeable in births in which the uterus was overdistended. d. More noticeable in births in which the uterus was overdistended. a. 当母亲进行母乳喂养时，疼痛会得到一定程度的缓解 b. 它们是由轻微的持续的宫缩引起的，持续时间为产后一段时间 c. 在初为人母的母亲中更常见 d. 在子宫过度扩张的分娩中更明显 A nurse is reviewing the concept of lochia. Which statement should the nurse identify as correct? Nurs326 Nurs326 a. Will usually decrease with ambulation and breastfeeding. b. Should smell like normal menstrual flow unless an infection is present. c. Is similar to a light menstrual period for the first 6 to 12 hours. d. Is usually greater after cesarean births. b. Should smell like normal menstrual flow unless an infection is present. A group of nursing students are discussing the condition and reconditioning of the urinary system after childbirth. Which statement should the nursing students identify as correct? a. Fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. b. Kidney function returns to normal a few days after birth. c. With adequate emptying of the bladder, bladder tone is usually restored 2 to 3 weeks after childbirth. d. Diastasis recti abdominis is a common condition that alters the voiding reflex. a. Fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman 1 day postpartum. What should the nurse identify as an expected finding? a. Little if any change. b. Leakage of milk at let-down. c. Swollen, warm and tender on palpation. d. A few blisters and a bruise on each areola. a. Little if any change. Rationale: Breasts are essentially unchanged for the first 24 hours after birth. Colostrum is present and may leak from the nipples. Leakage of milk occurs after the milk comes in 72 to 96 hours after birth. Engorgement occurs at day 3 or 4 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used. A nurse is reviewing metabolic functions occuring during the postpartum period. Which of the following changes would the nurse identify as being consistent with that timeframe? (Select all that apply.) a. Mildly increased T3 and T4 levels for the first several weeks postpartum b. Increased BMR in the immediate postpartum period c. Secretion of insulinase Nurs326 Nurs326 d. Decrease in estrogen and cortisol levels e. Moderate hyperglycemia b, c, and d Rationale: BMR remains elevated for the first 2 weeks after birth and then returns to prepregnancy levels. Insulinase enzyme reverses the diabetogenic effects of pregnancy, leading to decreased glucose levels in the postpartum period. Decreases in hormones such as estrogen and cortisol are seen during the postpartum period.Blood sugar levels typically decrease in the postpartum period as a result of the reversal of diabetogenic effects of pregnancy. Thyroid hormones gradually decrease to prepregnant levels in the 4 weeks following delivery. A nurse is preparing to educate a group of postpartum clients. Which description of postpartum restoration or healing times should the nurse identify as being accurate? a. Most episiotomies heal within a week. b. Hemorrhoids usually decrease in size within 2 weeks of childbirth. c. Rugae reappear within 3 to 4 weeks. d. The cervix shortens, becomes firm, and returns to form within a month postpartum. c. Rugae reappear within 3 to 4 weeks. Rationale: Rugae are never again as prominent as in a nulliparous woman. Localized dryness may occur until ovarian function resumes. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take up to 6 weeks to decrease in size. Which of the following findings would raise concern for the nurse who is monitoring a postpartum client who had a spontaneous vaginal delivery (SVD) of a 10-lb baby boy? a. Fundus midline and firm with spurts of bright red blood upon fundal massage b. Lochia rubra with minimal clots expressed on fundal massage c. Fundus midline and firm with non-palpable bladder d. Client report of mild to moderate cramping and request for pain medication a. Fundus midline and firm with spurts of bright red blood upon fundal massage A nurse is providing instruction to a postpartum client regarding perineal care technique. When evaluating the postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: a. Uses soap and warm water to wash the vulva and perineum. b. Uses the peribottle to rinse upward into her vagina. c. Washes from symphysis pubis back to the episiotomy. d. Changes her perineal pad every 2 to 3 hours. Nurs326 Nurs326 b. Uses the peribottle to rinse upward into her vagina. 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. What is the first action to be taken by the nurse? a. Call the woman's primary health care provider. b. Begin an IV infusion of Ringer's lactate solution. c. Assess the woman's vital signs. d. Massage the woman's fundus. d. Massage the woman's fundus. A nurse observes a postpartum client to have excessive blood loss. Which cause should the nurse identify as being the most common cause for this finding? a. Unrepaired lacerations of the vagina or cervix. b. Vaginal or vulvar hematomas. c. Failure of the uterine muscle to contract firmly. d. Retained placental fragments. c. Failure of the uterine muscle to contract firmly. A nurse is assesing a client who is 12 hours postpartum. Which finding would be a source of concern if observed by the nurse? a. Bradycardia—pulse rate of 55 beats/min b. Postural hypotension c. Pain in left calf with dorsiflexion of left foot d. Temperature of 38° C c. Pain in left calf with dorsiflexion of left foot Rationale: These findings indicate presence of Homans sign, are suggestive of thrombophlebitis, and should be investigated. The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. What is the nurse's intial action? a. Massage her fundus b. Place her on a bedpan to empty her bladder c. Administer methylergonovine (Methergine), 0.2 mg IM, which has been ordered prn d. Call the physician a. Massage her fundus Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, Nurs326 Nurs326 at the umbilicus, and midline. Her lochia is moderate rubra with no clots. What clinical finding should the nurse expect? a. Hematoma formation b. Uterine atony c. Constipation d. Bladder distention a. Hematoma formation The nurse is observing a postpartum client who has been bleeding excessively during the first hour, saturating multiple pads. Which interventions would the nurse anticipate that the physician would order? (Select all that apply.) a. Administer oxygen via nonrebreather mask @ 10 L/minute b. Insert a secondary intravenous line access c. Document findings in the health care record d. Type & screen for 2 units of blood e. Decrease flow rate for intravenous fluid administration a and b The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? a. Tells visitors how well her son is feeding b. Talks and coos to her son c. Cuddles her son close to her d. Seldom makes eye contact with her son d. Seldom makes eye contact with her son The nurse is reviewing concepts related to healthy-parent infants bonding. The nurse recognizes that the process in which the infant's behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics is called: a. Claiming. b. Acquaintance. c. Mutuality. d. Bonding. c. Mutuality. Rationale: Bonding is the process through which over time parents form an emotional attachment to their infant. Mutuality refers to a shared set of behaviors that is a part of the bonding process. Like mutuality, acquaintance is part of attachment. It describes Nurs326 Nurs326 how parents get to know their baby during the immediate postpartum period through eye contact, touching, and talking. Claiming is the process by which parents identify their new baby in terms of likeness to other family members, the differences, and the baby's uniqueness. 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 of the following should the nurse identify as a facilitating behavior? a. The parents have difficulty naming the infant. b. The parents make no effort to interpret the actions or needs of the infant. c. The parents do not move from fingertip touch to palmar contact and holding. d. The parents hover around the infant, directing attention to and pointing at the infant. d. The parents hover around the infant, directing attention to and pointing at the infant. A group of nurses are discussing care options for lesbian partners in childbearing experiences. Which opportunity should the nurses identified as not being able to be provided to male partners? a. Cutting the cord b. Breastfeeding the infant c. Rooming-in during hospitalization d. Labor support b. Breastfeeding the infant A nurse is making a home visit to a postpartum woman 1 week after childbirth. Which client observation should the nurse expect? a. Have reestablished her role as a spouse or partner. b. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. c. Express a strong need to review the events and her behavior during the process of labor and birth. d. Exhibit a reduced attention span, limiting readiness to learn. b. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. nurse is talking to parents about the adjustment of a new baby to the family unit. Which parent action should the nurse identify as facilitating the adjustement of other children to the new baby? a. Emphasizing activities that keep the new baby and other children together. b. Having the mother carry the new baby into the home so she can show the other children the baby. Nurs326 Nurs326 c. Having children at home choose or make a gift to give the new baby on his or her arrival home. d. Reducing stress on the other children by limiting their involvement and care of the new baby. c. Having children at home choose or make a gift to give the new baby on his or her arrival home. Which statement regarding Postpartum Depression (PPD) is essential for the nurse to be aware of when attempting to formulate a nursing diagnosis? a. PPD symptoms are consistently severe. b. PPD can easily go undetected. c. Only mental health professionals should teach new parents about this condition. d. This syndrome affects only new mothers. b. PPD can easily go undetected. A nurse is reviewing phases of maternal postpartum adjustment. Which behaviors should the nurse identify as being exhibited during the letting-go phase of maternal role adaptation? (Select all that apply.) a. Being talkative and excited about becoming a mother b. Sexual intimacy relationship continuing c. Emergence of family unit d. Defining one's individual roles e. Dependent behaviors b, c, and d Rationale: Dependent behaviors are exhibited in the "taking in" phase and being talkative and excited about becoming a mother occurs in the "taking hold" phase. On examination of the infant, the nurse notes a sharply demarcated swelling over the parietal bones. The occipital and frontal bones are not affected. The neck does not appear edematous and is soft to the touch. The infant is awake and breast-feeding well. What is the most probable cause of the swelling? a. Cephalhematoma b. Subgaleal hemorrhage c. Caput succedaneum d. Hydrocephalus a. Cephalhematoma Rationale: The boundaries of the cephalhematoma are sharply demarcated and do not extend beyond the limits of the bones, usually the parietals. sharply demarcated边界分明!!! Nurs326 Nurs326 While evaluating the reflexes of a male newborn, the nurse notes that with a loud noise, the newborn symmetrically abducts and extends his arms, his fingers fan out and form a "C" with the thumb and forefinger, and he has a slight tremor. The nurse documents this finding as a positive: a. Glabellar (Myerson) reflex response b. Babinski reflex response c. Tonic neck reflex response d. Moro reflex response d. Moro reflex response A nurse is monitoring a healthy newborn's blood glucose level 90 minutes after birth. Which result should the nurse anticipate in terms of mg/dL? a. 80 to 100 b. 60 to 70 c. Less than 40 d. 55 to 60 d. 55 to 60 The nurse is assessing a newbown and discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver. What should be the priority action taken by the nurse? a. Informs the parents and physician that molding has not taken place. b. Tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. c. Alerts the physician that the infant has a dislocated hip. d. Suggests that if the condition does not change, surgery to correct vision problems might be needed. c. Alerts the physician that the infant has a dislocated hip. The nurse is assessing the respiratory system of a newborn. Which statement should the nurse be aware of with regard to the respiratory development of the newborn? a. Crying increases the distribution of air in the lungs. b. Seesaw respirations are no cause for concern in the first hour after birth. c. Newborns must expel the fluid at uterine life from the respiratory system within a few minutes of birth. d. Newborns are instinctive mouth breathers. a. Crying increases the distribution of air in the lungs. While caring for the newborn, the nurse must be alert for any signs of cold stress. Which finding should the nurse anticpate? Nurs326 Nurs326 a. Increased respiratory rate b. Decreased activity level c. Hyperglycemia d. Shivering a. Increased respiratory rate Rationale: In an infant who is cold, the respiratory rate rises in response to the increased need for oxygen. Signs of cold stress include increased activity level and crying (increased basal metabolic rate [BMR] and heat production). A cold infant is at risk for hypoglycemia as the glucose stores are depleted. The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black. She asks the nurse whether something is wrong. Which of the following would be the best response offered by the nurse? a. Telling the mother not to worry because all breastfed babies have this type of stool. b. Asking the mother what she ate for her last meal. c. Suggesting to the mother that she ask her pediatrician to explain normal newborn stooling patterns to her. d. Explaining to the mother that this stool is called meconium and is expected for the first few bowel movements of all newborns. d. Explaining to the mother that this stool is called meconium and is expected for the first few bowel movements of all newborns. A nurse is examining a newborn male, who is estimated to be 39 weeks of gestation. Which physical finding should the nurse anticipate to be present? a. Abundant lanugo over his entire body. b. Ability to move his elbow past his sternum. c. Testes descended into the scrotum. d. Extended posture when at rest. c. Testes descended into the scrotum. A nurse examining a newborn infant notes that the infant is jaundiced. Which observation would lead the nurse to continue to monitor but not to intervene and contact the physician? a. Infant is being bottle fed and within the first 24 hours of life. b. Jaundice appeared on the third day of life. Nurs326 Nurs326 c. Jaundice appeared within the first 24 hours of life. d. Preterm infant who is 12 hours old. b. Jaundice appeared on the third day of life. Rationale: Physiologic jaundice can be seen in a large percentage of newborns, 60% of term and 80% of preterm, but typically resolves without immediate intervention. The critical factor here is the time of appearance, being within the first 24 hours of life. Jaundice appearing at this time is considered pathological and requires further investigation. A nurse is reviewing possible etiologies for hyperbilirubinemia in the newborn. Which findings would the nurse expect to lead to increased bilirubin levels in the newborn? (Select all that apply.) a. Cord clamped immediately following delivery of newborn b. Initiation of newborn feedings delayed following birth c. Twin-to-twin transfusion syndrome d. Hyperglycemia e. Meconium passed after 24 hours b, c, and e Rationale: Delay in passage of meconium or in newborn feedings could lead to increased bilirubin levels because of increased enterohepatic circulation. Twin-to-twin transfusion syndrome could lead to increased bilirubin levels as a result of an increased amount of hemoglobin. An increase in bilirubin levels would be seen if cord clamping were delayed. Hypoglycemia could lead to increased bilirubin levels. A first-time mother expresses concern over her child's Apgar score of 7 and 10. Which statement should the nurse make to the parents? a. An Apgar score of 7 at 1 minute is a poor result. The test should be repeated to confirm the results. b. Apgar scores of 7 and 10 indicate that the infant's physical and neurologic systems are premature. c. The Apgar score indicates the condition of the infant at 1 and 5 minutes based on heart and respiratory rate, muscle tone, reflex, irritability, and color. The scores of 7 and 10 indicate adjustment to extrauterine life. d. The Apgar score measures the infant's response to stimulus. A score of 7 and 10 indicates that the newborn's first cry was strong and that the initial parental response was good. Nurs326 Nurs326 c. The Apgar score indicates the condition of the infant at 1 and 5 minutes based on heart and respiratory rate, muscle tone, reflex, irritability, and color. The scores of 7 and 10 indicate adjustment to extrauterine life. A newborn passed her first stool 12 hours after delivery. Her stool was dark green and sticky. The parents are concerned and ask if she is constipated. Which statement is an appropriate response to the parents' concerns? a. This is a normal newborn's first stool, called meconium. b. The newborn's first stool should be yellowish brown and nonsticky. c. The newborn may have a bowel obstruction. d. The newborn will be observed for signs of infection. a. This is a normal newborn's first stool, called meconium. A first-time mother has chosen to breastfeed her infant. In preparation for discharge, she asks the nurse how she will know if her baby is getting enough milk. Which is the most appropriate response by the nurse? a. Provide a pamphlet about the La Leche League for breastfeeding problems or concerns. b. Suggest supplementation with formula if there is concern with the infant's intake. c. Instruct the parents to call if the infant cries frequently or vomits after a feeding. d. She will know by the presence of 6 to 10 wet diapers and 2 to 3 stools per day since she is breast-fed. d. She will know by the presence of 6 to 10 wet diapers and 2 to 3 stools per day since she is breast-fed. A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. What information should the nurse provide to the parents regarding the presence of petechiae? a. Should always be further investigated. b. Are benign if they disappear within 48 hours of birth. c. Usually occur with forceps delivery. d. Result from increased blood volume. b. Are benign if they disappear within 48 hours of birth. A mother expresses fear about changing her infant's diaper after he is circumcised. What should the nurse teach the mother about providing caring for the infant upon discharge? a. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. Nurs326 Nurs326 b. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. c. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. d. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection. a. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. Following birth, the nurse assigns an Apgar score of 10 at 1 minute to a newborn. How would the nurse explain this score? a. An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth. b. An infant having no difficulty adjusting to extrauterine life and needing no further testing. c. A prediction of a future free of neurologic problems. d. An infant in severe distress that needs resuscitation. a. An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth. A nurse is providing umbilical cord care to a newly delivered infant. What information should the nurse be aware of? a. The cord clamp is removed at cord separation. b. The stump can easily become infected. c. The average cord separation time is 5 to 7 days. d. A nurse noting bleeding from the vessels of the cord should immediately call for assistance. b. The stump can easily become infected. A group of nursing students are reviewing the process of bathing for a newborn. Which statement should the nursing students identify as being incorrect? a. Tub baths may be given before the infant's umbilical cord falls off and the umbilicus is healed. b. Only plain warm water should be used to preserve the skin's acid mantle. c. Powders are not recommended because the infant can inhale powder. d. Newborns should be bathed every day, for the bonding as well as the cleaning. d. Newborns should be bathed every day, for the bonding as well as the cleaning. Rationale: Newborns do not need a bath every day, as it can disrupt the integrity of a newborn's skin. Tub baths may be given as soon as an infant's temperature has stabilized. Unscented mild soap is appropriate to use to wash the infant. Powder is not Nurs326 Nurs326 recommended because of the risk of inhalation. Should a parent elect to use baby powder, it should never be sprinkled directly onto the baby's skin. The nurse is providing discharge instructions related to the baby's respiratory system. Which statement should the nurse not include as part of discharge teaching? a. Don't let the infant sleep on his or her back. b. Avoid loose bedding, waterbeds, and beanbag chairs. c. Prevent exposure to people with upper respiratory tract infections. d. Keep the infant away from secondhand smoke. a. Don't let the infant sleep on his or her back. b正确 A nurse is preparing to weight a newborn. Which action should the nurse include as part of the procedure? a. Weigh the newborn at the same time each day for accuracy. b. Place a sterile scale paper on the scale for infection control. c. Keep a hand on the newborn's abdomen for safety. d. Leave its diaper on for comfort. a. Weigh the newborn at the same time each day for accuracy. A nurse administers Vitamin K to the newborn post delivery. The nurse understands that the reason for this medication to be given is? a. Reduce bilirubin levels. b. Enhance the ability of blood to clot. c. Stimulate the formation of surfactant. d. Increase the production of red blood cells. b. Enhance the ability of blood to clot. A nurse must administer erythromycin ophthalmic ointment to a newborn after birth. Which action shoud the nurse include when administering the medication? a. Cleanse eyes from inner to outer canthus before administration if necessary. b. Flush eyes 10 minutes after instillation to reduce irritation. c. Apply directly over the cornea. d. Instill within 15 minutes of birth for maxim