Maternal-Child Nursing 6th Edition Chapter 1-55 Test Bank - (SCORED A+) Q&A EXPLAINED LATEST 2023

1. A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data? a. The nurse should notify the pediatrician stat for this emergency situation. b. The neonate must have aspirated surfactant. c. If this baby was born vaginally, it could indicate a pneumothorax. d. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth. ANS: D The condition will resolve itself within a few hours. For this common condition of newborns, surfactant acts to keep the expanded alveoli partially open between respirations. In vaginal births, absorption of remaining lung fluid is accelerated by the process of labor and delivery. Remaining lung fluid will move into interstitial spaces and be absorbed by the circulatory and lymphatic systems. There is no need to notify the pediatrician. Surfactant is produced by the lungs, so aspiration is not a concern. Pneumothorax is also not a concern. PTS:1 DIF: Cognitive Level: Understanding OBJ:Nursing Process: Assessment MSC:Client Needs: Health Promotion and Maintenance 2. The nurse should alert the provider when a. the infant is dusky and turns cyanotic when crying. b. acrocyanosis is present at age 1 hour. c. the infant‘s blood glucose is 45 mg/dL. d. the infant goes into a deep sleep at age 1 hour. ANS: A An infant who is dusky and becomes cyanotic when crying is showing poor adaptation to extrauterine life. The nurse needs to notify the provider. Acrocyanosis is an expected finding during the early neonatal life. A blood glucose of 45 mg/dL is within normal range for a newborn. Infants enter the period of deep sleep when they are about 1 hour old. PTS:1 DIF: Cognitive Level: Applying OBJ:Nursing Process: Implementation MSC:Client Needs: Physiologic Integrity 3. The nurse needs to assess infants for the development of high levels of bilirubin. Which baby can the nurse check last? a. Was bruised during a difficult delivery b. Developed a cephalhematoma c. Was born prematurely d. Breastfeeds during the first hour of life ANS: D The infant who is fed early will be less likely to retain meconium and reabsorb bilirubin from the intestines back into the circulation. Bruising, cephalhematomas, and prematurity increase the baby‘s risk of high bilirubin. PTS:1 DIF: Cognitive Level: Applying OBJ:Nursing Process: Assessment MSC:Client Needs: Physiologic Integrity 4. An infant has an elevated immunoglobulin M (IgM) level. What action by the nurse is most appropriate? a. Encourage the mother to breastfeed the baby. b. Document the findings in the infant‘s chart. c. Assess the infant for other signs of allergy. d. Take a set of vital signs on the infant, and then notify the provider. ANS: D An elevated level of IgM is associated with exposure to infection in utero because IgM does not cross the placenta. The nurse should take a set of vital signs and notify the provider so further investigation can occur. It is not related to breastfeeding or allergies. The information should be documented, but this is not the most important action. PTS:1 DIF: Cognitive Level: Applying OBJ:Nursing Process: Assessment MSC:Client Needs: Physiologic Integrity 5. To prevent heat loss from convection in a newborn, which action by the nurse is best? a. Place the baby in a warmer. b. Dry the baby after a bath. c. Move infant away from blowing fan. d. Wrap the baby in warmed blankets. ANS: C Convection occurs when infants are exposed to cold air currents. Moving the baby out of the fan‘s air currents will reduce this loss. The warmer prevents heat loss from radiant heat loss. Drying the baby prevents evaporative heat loss. Warm blankets prevent conductive heat loss. PTS:1 DIF: Cognitive Level: Applying OBJ:Nursing Process: Implementation MSC:Client Needs: Physiologic Integrity