TEST 2 (CHAPTERS 8, 9, 10, 12, 13, 14) MATERNITY QUESTIONS AND ANSWERSFLASHCARDS

  What nursing assessment should be reported immediately after an amniotomy? a. Fetal heart rate is regular at 154 beats/min. b. Amniotic fluid is clear with flecks of vernix. c. Amniotic fluid is watery and pale green. d. Maternal temperature is 37.8 C - Correct Answers: C Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise. A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurses initial action? a. Stop the oxytocin infusion. b. Continue the infusion and report the findings to the physician. c. Turn her on her left side and reassess the contractions. d. Administer oxygen by mask. - Correct Answers: A Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur. What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? a. Warm compresses to the perineum b. Cold pack to the perineum c. Warm sitz bath d. Elevation of hips to prevent edema - Correct Answers: B Ice is applied to the perineum to reduce bruising and edema. After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm dilated but contractions are becoming shorter and less frequent. What is this labor pattern considered? a. Normal b. Hypotonic c. Hypertonic d. False - Correct Answers: B The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but NURSINGTB.COM NURSINGTB.COM INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 71 contractions diminish after the active phase. A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. What action by the physician will the nurse anticipate? a. Perform an amniotomy. b. Initiate tocolytic drugs. c. Order a sedative for the patient. d. Plan to do an emergency cesarean section. - Correct Answers: A Medical treatment for hypotonic labor dysfunction includes an amniotomy as the first remedy if the membranes are intact. An infant is delivered with the use of forceps. What should the nurse assess for in the newborn? a. Loss of hair from contact with forceps b. Sacral hematoma c. Facial asymmetry d. Shoulder dislocation - Correct Answers: C Pressure from forceps may injure the infants facial nerve, which is evidenced by facial asymmetry. A new mother is distressed and tearful about the elevated dome over her infants posterior fontanelle. The nurse responds, This condition will resolve itself in a few days. What is the cause? a. Prolonged pressure against the partially dilated cervix b. Small leak of fluid through the posterior fontanelle c. Pressure of the forceps during delivery d. The effect of the vacuum extractor - Correct Answers: D The chignon is due to the effect of the vacuum extractor and will disappear in a few days. A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor wont induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need? What is the lowest Bishop score the patient should have prior to induction? a. 6 b. 8 c. 10 d. 12 - Correct Answers: A The Bishop score evaluates the suitability of the patient for a vaginal delivery. A minimum score of 6 is recommended by the American Congress of Obstetricians and Gynecologists (ACOG). A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). What position will the nurse promote to encourage fetal rotation and pain relief? a. Prone with legs supported and give her a back massage b. Supine with legs bent at the knee c. Standing with support d. Sitting up and leaning forward on the over-bed table - Correct Answers: D A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to sit or kneel leaning forward on a support. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman begs the nurse, Please give me something. What is the most appropriate pain relief intervention for a woman in precipitate labor? a. Get an order for an intravenous narcotic. b. Notify the anesthesiologist for an epidural block. c. Stay and breathe with her during contractions. d. Tell her to bear with it because she is close to delivery - Correct Answers: C The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. What complication should the nurse closely assess for with this patient? a. Chorioamnionitis b. Hemorrhage c. Hypotension d. Amniotic fluid embolism - Correct Answers: A Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse would assess for which adverse effect? a. Maternal tachycardia b. Maternal hypertension c. Fetal bradycardia d. Fetal hypokalemia - Correct Answers: A Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with a dose of propranolol. Which statement indicates a woman understands activity limitations for the management of preterm labor? a. After my shower in the morning, I do the laundry and straighten up the house; then I rest. b. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day. c. I have a 2-year-old to care for, but I try to rest as much as I can. d. I get really bored at home, so I go to the shopping mall for just a little while. - Correct Answers: B Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest. A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. What is the best response? a. The fundus is not assessed until the second postoperative day. b. The fundus is assessed by walking fingers from the side of the uterus to the midline. c. The fundus is assessed only if large clots appear in lochia. d. The fundus is assessed only once every shift. - Correct Answers: B Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage. A pulsating structure is felt during a vaginal examination of a woman in labor. How would the nurse position the woman to prevent compression of a prolapsed cord? a. On her right side with knees flexed b. On her left side with a pillow placed between her legs c. On her back with her head lower than the rest of her body d. Supine with her legs elevated and bent at the knee - Correct Answers: C The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord. Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section. What is the most appropriate nursing diagnosis? a. Anxiety related to the development of postpartum complications b. Ineffective individual coping related to unfamiliarity with procedures c. Risk for ineffective parenting related to emergency cesarean section d. Grieving related to loss of expected birth experience - Correct Answers: D Women who have cesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur. A pregnant womans membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. What would the nurse planning discharge instruction teach the woman to do? a. Report any increase in fetal activity. b. Notify her obstetrician if she has a temperature above 37.8 C (100 F). c. Massage her breasts to promote uterine relaxation. d. Rest in a side-lying Trendelenburg position with hips elevated. - Correct Answers: B For the woman with premature rupture of membranes (PROM) who is not having labor induced right away, teaching combines information about infection and preterm labor. The woman should monitor her temperature and report a temperature greater than 37.8 C (100 F). A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. What side effect should the nurse inform the patient that she might experience? a. Nausea and vomiting b. Headache c. Warm flush d. Urinary frequency - Correct Answers: C Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug. When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how quickly she will recover. How can anxiety affect labor? a. By decreasing a womans pain sensitivity b. By reducing blood flow to the uterus c. By increasing the ability to tolerate pain d. By enhancing maternal pushing through greater muscle tension - Correct Answers: B Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions. During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. What is the best nursing action? a. Give the pain remedy. b. Notify the charge nurse immediately. c. Turn the patient to her back and flex her knees. d. Suggest that the coach give her a back rub. - Correct Answers: B Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be reported immediately. What does the nurse explain is used to soften the cervix with a cervical ripening agent? a. Prostaglandin gel insertion b. Intravenous oxytocin c. Warm saline douches d. Nipple stimulation - Correct Answers: A Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions. The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. What NURSINGTB.COM is the purpose of glucocorticoid administration? a. Prevent infection. b. Increase fetal lung maturity. c. Increase blood flow from placenta. d. Relax the cervix - Correct Answers: B Glucocorticoids assist with improving the lung maturity of a fetus that is preterm. The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. Which laboring patient should the nurse attend to first? a. 18-year-old primigravida with a fetal breech presentation b. 25-year-old multigravida with history of previous cesarean section c. 35-year-old multigravida with history of precipitate birth d. 16-year-old primigravida with a twin pregnancy - Correct Answers: C A precipitate birth is completed in less than 3 hours. Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression. Contractions may be frequent and intense, often from the onset. If the womans tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. Fetal breech presentation, history of cesarean section, and multifetal pregnancy have associated risk factors, but not as immediate as precipitate birth. The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. What will the nurse expect when caring for this patient? a. Elevated uterine resting tone b. Painful and poorly coordinated contractions c. Implementation of fluid restriction d. Use of frequent position chang - Correct Answers: D A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. Painful and poorly coordinated contractions occur with hypertonic labor. What sign(s) of infection should the nurse assess for after an amniotomy? (Select all that apply.) a. Oral temperature of 37 C (99.8 F) b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute c. Flecks of vernix in the amniotic fluid d. Low back pain e. Edematous labia - Correct Answers: B Increase in the FHR above 160 beats/minute frequently precedes a womans temperature elevation. All the other options are normal findings for late pregnancy What are the rationales for labor induction? (Select all that apply.) a. Placenta previa b. Prolapse of cord c. High station of fetus d. Maternal diabetes e. Placental insufficiency - Correct Answers: D, E Maternal diabetes and placental insufficiency are rationales for induction. The other options are contraindications for labor induction. Which interventions could a nurse apply to help stimulate contractions? (Select all that apply.) a. Encouraging the patient to sit upright b. Assisting the patient to ambulate c. Stimulating the nipples d. Offering emotional support e. Allowing the patient to vent frustration - Correct Answers: A, B, C Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor. Offering emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate more effective labor. What complications of overstimulation of uterine contractions may occur? (Select all that apply.) a. Water intoxication b. Impaired placental exchange of oxygen and nutrients c. Increased blood pressure d. Convulsions e. Uterine rupture - Correct Answers: A, B, E The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention. How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? (Select all that apply.) a. Place a warm, moist washcloth over the breast. b. Brush the nipples with a dry washcloth. c. Gently pull on the nipples. d. Apply suction to the nipples with a breast pump. e. Press the palms of her hands down on her breasts. - Correct Answers: B, C, D Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all effective methods of nipple stimulation, which will increase the quality of uterine contractions. A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. What conditions would contraindicate labor induction? (Select all that apply.) a. Maternal gynecoid pelvis b. Placenta previa c. Horizontal cesarean incision d. Prolapsed cord e. Gestational diabetes - Correct Answers: B, D Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord. Gynecoid pelvis is the most favorable shape for vaginal delivery. Induction can be attempted as a VBAC after a horizontal cesarean incision but is contraindicated with a classic (vertical) incision. Gestational diabetes is not a contraindication for labor induction. A woman is preparing for administration of a cervical ripening agent. What nursing actions will the nurse anticipate implementing? (Select all that apply.) a. Insert IV. b. Record a baseline fetal heart rate. c. Explain procedure to patient. d. Instruct patient to ambulate immediately afterward. e. Ensure a tocolytic is available. - Correct Answers: A, B, C The cervical ripening procedure should be explained to the woman and her family. A fetal heart rate baseline is recorded. An intravenous (IV) line with saline or heparin sodium (Hep-Lock) may be placed in case uterine tachysystole (hyperstimulation) occurs and IV tocolytics (drugs that reduce uterine contractions) are needed. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Vital signs and fetal heart rate are also recorded. After an amniotomy, the umbilical cord becomes compressed. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________. - Correct Answers: amnioinfusion A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord. ____________________________ is a lower-than-normal amount of amniotic fluid. - Correct Answers: oligohydramnios Oligohydramnios is a lower amount than normal of amniotic fluid. A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions. - Correct Answers: Laminaria A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water. The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record? a. Increased nasal mucus b. Increased temperature c. Active muscle movements d. High-pitched cry - Correct Answers: D There are many signs of hypoglycemia in the newborn. One is a high-pitched cry. What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery? a. Well-contracted with its upper border at or just below the umbilicus b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus c. Relaxed with its upper border level with the umbilicus d. Relaxed with its upper border two or three fingerbreadths below the umbilicus - Correct Answers: A Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus. What statement made by a new mother indicates she needs additional information about breastfeeding? a. I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast. b. The baby needs to nurse at least 5 minutes on the breast to get the hindmilk. c. The baby has been nursing every 2 to 3 hours. d. If the baby gets fussy between feedings, I give her a bottle of water. - Correct Answers: B Cleansing from front to back prevents contamination from the rectal area. A postpartum woman is not immune to rubella. What will the nurse expect? a. The rubella virus vaccine should be administered before discharge. b. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup. c. The woman should be instructed not to get pregnant until she receives the rubella vaccine. d. No intervention is indicated at this time because the woman is not at risk for rubella. - Correct Answers: A The woman who is not immune to rubella is immunized in the immediate postpartum period because there is no danger of her being pregnant. Which statement indicates the new mother is breastfeeding correctly? a. I will alternate breasts when feeding the baby. b. I keep the baby on a 4-hour feeding schedule. c. I let the baby stay on the first breast only 5 minutes. - Correct Answers: A Alternating breasts for feeding increases milk production, particularly hindmilk, which has a higher protein and fat content The nurse is counseling a lactating mother about diet. What would the nurse include with this information? a. Consume 500 more calories than her usual prepregnancy diet. b. Eat less meat and more fruits and vegetables. c. Drink 3 to 4 tall glasses of fluid daily. d. Eat 1000 more calories than her usual prepregnancy diet. - Correct Answers: A To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories each day over her prepregnancy diet. A woman asks about resumption of her menstrual cycle after childbirth. What should the nurse respond? a. A woman will not ovulate in the absence of menstrual flow. b. Most nonlactating women resume menstruation about 2 months postpartum. c. Generally, a woman does not ovulate in the first few cycles after childbirth. d. The return of menstruation is delayed when a woman does not breastfeed. - Correct Answers: B Menstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding. In what situation will the physician order RhoGAM? a. An unsensitized Rh-negative mother has an Rh-positive infant. b. An Rh-negative mother becomes sensitized. c. A sensitized infant has a rising bilirubin level. d. An unsensitized infant exhibits no outward signs. - Correct Answers: A The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-positive infant. After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat loss? a. Conduction b. Radiation c. Evaporation d. Convection - Correct Answers: C Newborns lose heat quickly after birth as fluid evaporates from their bodies. What will the nurses instructions for a new mother to care for the infants umbilical cord include? a. Keeping the area covered with a sterile dressing b. Dressing the stump with antibiotic ointment at every diaper change c. Fastening the diaper low to allow for air circulation d. Giving the newborn a daily tub bath until the cord falls off - Correct Answers: C Diaper placement below the umbilical stump allows for drying by air circulation. A new mother states her preference to formula feed her newborn. What will the nurse planning discharge instructions tell her to help suppress lactation and promote comfort? a. Wear a well-fitting bra continuously for several days. b. Stand in a warm shower, letting the water spray over the breasts. c. Express small amounts of milk from the breasts several times a day. d. Massage the breasts when they ache. - Correct Answers: A When a mother does not wish to breastfeed, a snug bra worn around the clock can help alleviate discomfort from engorgement. On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, I dont think I did it right. What postpartum psychological stage is this woman most likely in based on this comment? a. Taking in b. Taking hold c. Letting go d. Settling down - Correct Answers: B In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance. A primipara tells the nurse, My afterpains get worse when I am breastfeeding. What is the most appropriate nursing response? a. Ill get you some aspirin to relieve the cramping that you feel. b. Afterpains are more intense with your first baby. c. Breastfeeding releases a hormone that causes your uterus to contract. d. A change of position when youre breastfeeding might help. - Correct Answers: C Breastfeeding mothers may have more afterpains because infant suckling causes the posterior pituitary to release oxytocin, which is a hormone that contracts the uterus. A new mother has decided not to breastfeed her newborn. What information will the nurse include when planning to teach the mother about formula feeding? a. Positioning the bottle so that the nipple is full of formula during the entire feeding b. Heating the infant formula in a microwave c. Burping the infant after 4 ounces and again when the bottle is empty d. Propping a bottle for a feeding - Correct Answers: A The nipple of the bottle should be kept full of formula to reduce the amount of air the infant swallows. In the recovery room, the nurse checks the newly delivered womans fundus following a cesarean section. How would the nurse proceed with this assessment? a. Palpate from the midline to the side of the body. b. Palpate from the symphysis to the umbilicus. c. Palpate from the side of the uterus to the midline. d. Massage the abdomen in a circular motion. - Correct Answers: C The fundus is checked gently by walking the fingers from the side of the uterus to the midline. The nurse instructed a postpartum woman about storing and freezing breast milk. What statement by the woman leads the nurse to determine that the teaching was effective? a. I can thaw frozen breast milk in the microwave. b. Ill put enough breast milk for one day in a container. c. Breast milk can be stored in glass containers. d. Breast milk can be kept in the refrigerator for up to 3 months. - Correct Answers: C Breast milk can be safely stored in glass or clear hard plastic containers. What should the nurse implement for security purposes when bringing the infant from the nursery to the mother? a. Ask, Is this your band number? b. Confirm room number of mother. c. Ask the mother to identify herself verbally. d. Check the band number of the infant with that of the mother. - Correct Answers: D The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number. Below what blood glucose level is the newborn considered hypoglycemic? a. Below 70 mg/dL b. Below 60 mg/dL c. Below 50 mg/dL d. Below 40 mg/dL - Correct Answers: D A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant should be fed to prevent a further drop. The nurse is caring for a woman of Middle Eastern descent on the first postpartum day. Education is provided regarding instruction on use of a sitz bath. What documentation best indicates that the woman has understood the provided instruction? a. Patient correctly performed return demonstration. b. Patient indicated understanding by nodding head with instruction. c. Patient verbalizes I understand. d. Family member indicates patient understands procedure. - Correct Answers: A The nurse may need an interpreter to understand and provide optimal care to the woman and her family. If possible, when discussing sensitive information the interpreter should not be a family member, who might interpret selectively. The interpreter should not be of a group that is in social or religious conflict with the patient and her family, an issue that might arise in many Middle Eastern cultures. It is also important to remember that an affirmative nod from the woman may be a sign of courtesy to the nurse rather than a sign of understanding or agreement. A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurses most appropriate action? a. Contact the hospital chaplain. b. Request the couples clergy. c. Baptize the newborn. d. Ask the physician to baptize the newborn. - Correct Answers: C If the condition of a newborn is poor, the parents may wish to have a baptism performed. The minister or priest is notified. However this is an emergency, so the nurse may perform the baptism by pouring water on the infants forehead while saying, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. If there is any doubt as to whether the infant is alive, the baptism is given conditionally: If you are capable of receiving baptism, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. The physician is attending to the patients immediate health needs. A woman required a cesarean section for safe delivery of her newborn. She is planning to breastfeed and verbalized concern about pain. What is the best suggestion by the nurse? a. Consider formula feeding for the first few days. b. Pumping breast milk would be best for now. c. Take pain medication 30 to 40 minutes prior to nursing. d. Use the football hold when breastfeeding. - Correct Answers: D The best answer is to encourage use of the football hold to decrease pressure on the operative site. There is no indication for the woman to formula feed or pump. Some pain medications should not be taken when breastfeeding. Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select all that apply.) a. Thin, transparent skin b. Vernix only in the body creases c. Folded ear springs back slowly d. Breast tissue under the nipple e. Creases over entire sole - Correct Answers: A, C The only signs of preterm are the thin skin and the slowly responding ear. The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.) a. Leave abdominal dressing open to air. b. Position patient with back to water stream. c. Cover infusion site with rubber glove. d. Provide a shower chair. e. Confirm ambulation ability. - Correct Answers: B, C, D, E The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream. What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.) a. Abdominal tighteners b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts - Correct Answers: A, B, C, D Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period. While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.) a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula d. Cows milk e. Canned evaporated milk - Correct Answers: A, B, C Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infants needs and powdered formula that is mixed as needed. Cows milk and canned evaporated milk are unsuitable because they are nutritionally inadequate and stress the kidneys. The nurse is instructing a woman at 6 months postpartum on weaning her infant from breastfeeding. What interventions will the nurse suggest? (Select all that apply.) a. Omit newborns favorite feeding first. b. Eliminate one feeding at a time. c. Expect the need for comfort feeding. d. Formula will need to be provided to substitute for feeding. e. Pump breasts in place of eliminated feeding. - Correct Answers: B, C, D When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last. One feeding should be eliminated at a time, and the need for comfort feeding should be expected. In younger infants formula will need to be substituted. The mother should not be instructed to pump in place of eliminated feeding or the breasts will continue to produce milk. The nurse assesses a 6-inch stain of lochia rubra on a pad that was worn for 2 hours. The nurse would document this as a(n) ________________ amount of lochia. - Correct Answers: moderate A 6-inch stain on a pad worn for 2 hours is regarded as a moderate amount of lochia discharge. The nurse explains that the three infections that are contraindications to breastfeeding are _______________, _______________, and ________________. - Correct Answers: human immunodeficiency virus (HIV), hepatitis B, hepatitis C Mothers who are HIV positive should not breastfeed because the virus can be transmitted through breast milk, as can the viruses that cause hepatitis B and C. The hormone responsible for milk production is ____________________. - Correct Answers: prolactin During pregnancy, the woman secretes high levels of prolactin, the hormone that causes milk production. Following delivery, increased levels of prolactin lead to lactation. The hormone responsible for milk let-down or ejection from the breasts is ____________. - Correct Answers: oxytocin The milk let-down reflex is caused by the hormone oxytocin. ___________ refers to changes that the reproductive organs, particularly the uterus, undergo after birth to return to their prepregnancy size and condition. - Correct Answers: Involution Involution refers to changes that the reproductive organs, particularly the uterus, undergo after birth to return to their prepregnancy size and condition. What is the first sign of hypovolemic shock from postpartum hemorrhage? a. Cold, clammy skin b. Tachycardia c. Hypotension d. Decreased urinary output - Correct Answers: B Tachycardia is usually the first sign of inadequate blood volume. Although the nurse has massaged the uterus every 15 minutes, it remains flaccid, and the patient continues to pass large clots. What does the nurse recognize these signs indicate? a. Uterine atony b. Uterine dystocia c. Uterine hypoplasia d. Uterine dysfunction - Correct Answers: A Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not compress bleeding vessels. What should the nurses first action be when postpartum hemorrhage from uterine atony is suspected? a. Teach the patient how to massage the abdomen and then get help. b. Start IV fluids to prevent hypovolemia and then notify the registered nurse. c. Begin massaging the fundus while another person notifies the physician. d. Ask the patient to void and reassess fundal tone and location. - Correct Answers: C When the uterus is boggy, the nurse should immediately massage it until it becomes firm. The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. What should the nurses next assessment be? a. Fullness of the bladder b. Amount of lochia c. Blood pressure d. Level of pain - Correct Answers: A Bladder distention can cause uterine atony. The uterus is massaged to firmness and then the bladder is emptied. Massage and putting the infant to the breast of a postpartum patient have been ineffective in controlling a boggy uterus. What will the nurse anticipate might be ordered by the physician? a. Ritodrine b. Magnesium sulfat c. Oxytocin d. Bromocriptine - Correct Answers: C Oxytocin (Pitocin) is the most common drug ordered to control uterine atony. A 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed. What is the nurses most helpful response? a. Stop breastfeeding until the infection clears. b. Pump the breasts to continue milk production, but do not give breast milk to the infant. c. Begin all feedings with the affected breast until the mastitis is resolved. d. Breastfeeding can continue unless there is abscess formation. - Correct Answers: D The woman with mastitis can continue to breastfeed unless an abscess forms. A woman had a vaginal delivery two days ago and is preparing for discharge. What will the nurse plan to NURSINGTB.COM teach the woman to report to help prevent postpartum complications? a. Fever b. Change in lochia from red to white c. Contractions d. Fatigue and irritability - Correct Answers: A Increased temperature is a sign of infection. The other choices are normal in the postpartum period. One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lower leg, temperature elevation of 37 C (99.8 F), rust-colored lochia, and sore breasts. What does the nurse suspect from these symptoms? a. Phlebitis b. Puerperal infection c. Late postpartum hemorrhage d. Mastitis - Correct Answers: A The complaints related to the leg are indicative of phlebitis. The other signs are normal in the postpartum patient. Which statement indicates to the nurse on a postpartum home visit that the patient understands the signs of late postpartum hemorrhage? a. My discharge would change to red after it has been pink or white. b. If I have a postpartum hemorrhage, I will have severe abdominal pain. c. I should be alert for an increase in bright red blood. d. I would pass a large clot that was retained from the placenta. - Correct Answers: A When the nurse teaches the postpartum woman about normal changes in lochia, it is important to explain that a return to red bleeding after it has changed to pink or white may indicate a late postpartum hemorrhage. During a postpartum assessment, a woman reports her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, what does the nurse explain the probable treatment will involve? a. Anticoagulants for 6 weeks b. Application of ice to the affected leg c. Gentle massage of the affected leg d. Passive leg exercises twice a day - Correct Answers: A Anticoagulant therapy is continued with heparin or warfarin (Coumadin) for 6 weeks after birth to minimize the risk of embolism. What statement by the patient leads the nurse to determine a woman with mastitis understands treatment instructions? a. I will apply cold compresses to the painful areas. b. I will take a warm shower before nursing the baby. c. I will nurse first on the affected side. d. I will empty the affected breast every 8 hours. - Correct Answers: B Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast. What is the best response to a postpartum woman who tells the nurse she feels tired and sick all of the time since I had the baby 3 months ago? a. This is a normal response for the body after pregnancy. Try to get more rest. b. Ill bet you will snap out of this funk real soon. c. Why dont you arrange for a babysitter so you and your husband can have a night out? d. Lets talk about this further. I am concerned about how you are feeling. - Correct Answers: D If a postpartum woman seems depressed, it is important to explore her feelings to determine if they are persistent and pervasive The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are visible on both legs. What nursing action is the most appropriate to prevent thrombus formation? a. Have the woman sit in a chair for meals. b. Monitor vital signs every 4 hours and report any changes. c. Tell the woman to remain in bed with her legs elevated. d. Assist the woman with ambulation for short periods of time. - Correct Answers: D Early ambulation and range-of-motion exercises are valuable aids to prevent thrombus formation in the postpartum woman. Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. What does the nurse recognize as the possible cause of these signs and symptoms? a. Dehydration b. Hypovolemic shock c. Endometritis d. Cystitis - Correct Answers: C Fever after 24 hours following delivery is suggestive of an infection. Severe cramping and fever are manifestations of endometritis. At her 6-week postpartum checkup, a woman mentions to the nurse that she cannot sleep and is not eating. She feels guilty because sometimes she believes her infant is dead. What does the nurse recognize as the cause of this womans symptoms? a. Bipolar disorder b. Major depression c. Postpartum blues d. Postpartum depression - Correct Answers: B Major depression is a disorder characterized by deep feelings of worthlessness, guilt, serious sleep and appetite disturbances, and sometimes delusions about the infant being dead. Three weeks after delivering her first child, a woman tells the nurse, I waited so long for this baby and now that she is here, I cant believe how different my life is from what I expected. What is the best nursing response to the womans statement? a. How is your partner adjusting to the change? b. I hear this from a lot of first-time mothers. c. Have you told anyone else about your feelings? d. Tell me how things are different. - Correct Answers: D The nurse may help the woman by being a sympathetic listener. The nurse should elicit the new mothers feelings about motherhood and her infant. After a prolonged labor, a woman vaginally delivered a 10 pound, 3 ounce infant boy. What complication should the nurse be alert for in the immediate postpartum period? a. Cervical laceration b. Hematoma c. Endometritis d. Retained placental fragments - Correct Answers: B Delivering a large infant and a prolonged labor are risk factors for hematoma formation. A woman has had persistent lochia rubra for 2 weeks after her delivery and is experiencing pelvic discomfort. What does the nurse explain is the usual treatment for subinvolution? a. Uterine massage b. Oxytocin infusion c. Dilation and curettage d. Hysterectomy - Correct Answers: C Medical treatment for subinvolution is selected to correct the cause. Treatment may include dilation of the cervix and curettage to remove retained placental fragments from the uterine wall. The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. What action should the nurse implement based on these symptoms? a. Notify the charge nurse of a possible upper respiratory infection. b. Notify the physician of a possible pulmonary embolism. c. Document expected postpartum mucous membrane congestion. d. Medicate with antipyretic remedy for elevated temperature. - Correct Answers: B Symptoms of early pulmonary embolism may not be dynamic. The cough with shortness of breath and temperature elevation is a clue to this possible complication. While caring for a postpartum patient who had a vaginal delivery yesterday, the nurse assesses a firm uterine fundus and a trickle of bright blood. How does the nurse most likely feel and react to this finding? a. Concerned and reports a probable cervical laceration b. Attentive and massages the uterus to expel retained clots c. Distressed and reports a possible clotting disorder d. Satisfied with the normal early postpartum finding - Correct Answers: A The bright trickle of blood with a firm uterus suggests a cervical laceration. The nurse assesses a positive Homans sign when the patients leg is flexed and foot sharply dorsiflexed. Where does the patient report that the pain is felt? a. Groin b. Achilles tendon c. Top of the foot d. Calf of the leg - Correct Answers: D A pain in the calf of the leg when the leg is flexed and the foot is dorsiflexed is a positive Homans sign. Homans sign is suggestive of a deep vein thrombosis. The new mother who had a vaginal delivery yesterday has a white blood cell count of 30,000 cells/dL. What action should the nurse implement? a. Notify the charge nurse of a possible infection. b. Prepare to put the patient in isolation. c. Have the infant removed from the room and returned to the nursery. d. Assess the patient further. - Correct Answers: D The patient should be assessed further for other signs of infection because a white blood cell (WBC) count of 20,000 to 30,000 cells/dL is normal in the early postpartum period. A postpartum patient experiences anaphylactic shock. What is the most likely cause? a. Pulmonary embolism b. Hypertension c. Allergy d. Blood clotting disorder - Correct Answers: C Anaphylactic shock is caused by allergic responses to drugs administered. Cardiogenic shock may be caused by pulmonary embolism or hypertension. Hypovolemic shock could be caused by blood clotting disorders. A woman is prescribed Coumadin (warfarin) to treat deep vein thrombosis. What will the nurse instruct this woman is the antidote for warfarin overdose? a. Vitamin A b. Vitamin B c. Vitamin E d. Vitamin K - Correct Answers: D The antidote for warfarin overdose is vitamin K. A nurse is discussing risk factors for postpartum shock with a childbirth preparation class. What will the nurse include in this education session? (Select all that apply.) a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage - Correct Answers: B, C, D, E Hypertension is not a cause for postpartum shock; all the other options can cause shock. The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it. What would the nurse expect to find on further assessment? (Select all that apply.) a. A firm fundus the size of a grapefruit b. A full bladder c. Retained placental fragments d. Vital signs indicative of shock e. A soft, boggy fundus - Correct Answers: B, E Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy. The nurse instructs the postpartum patient that her nutritional intake should include which food(s) particularly supportive to healing? (Select all that apply.) a. Legumes b. Potatoes and pasta c. Citrus fruits d. Rice e. Cantaloupe - Correct Answers: A, C, E Legumes and foods containing vitamin C are conducive to healing. Starches are not. What will the nurse teach a nursing mother to do to reduce the risk of mastitis? (Select all that apply.) a. Limit fluid intake to 1 liter per day. b. Empty both breasts with each feeding. c. Take warm showers. d. Wear a supportive bra. e. Pump breasts to ensure emptying. - Correct Answers: B, C, D, E Nursing mothers should take in about 3 liters of fluid a day. All the other options are interventions to reduce the risk of mastitis and milk accumulation in the breast. A woman is diagnosed with a urinary tract infection in the postpartum period. What foods can the nurse encourage to increase the acidity of urine? (Select all that apply.) a. Apricots b. Cranberry juice c. Plums d. Prunes - Correct Answers: A, B, C, D Apricots, cranberry juice, plums, and prunes can increase the acidity of urine. Apples are not considered to increase acidity of urine. A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate? (Select all that apply.) a. Provision of IV fluids b. Placement of an indwelling Foley catheter c. Assessment of oxygen saturation d. Administration of anticoagulants e. Blood transfusion - Correct Answers: A, B, C, E Medical management for the patient experiencing hypovolemic shock includes stopping blood loss, giving IV fluids to maintain circulating volume and replace fluids, giving blood transfusions to replenish erythrocytes, and assessment of oxygen saturation. Anticoagulants would not be given. The nurse weighs a saturated perineal pad and finds it to weigh 15 grams. The nurse is aware that this indicates a blood loss of _____ mL. - Correct Answers: 15 The weight of 1 g in a perineal pad is equal to 1 mL of blood loss. The nurse explains that a slower than expected return of the uterus to the nonpregnant state is called _______________. - Correct Answers: Subinvolution Subinvolution is the term applied to the uteruss slower than expected return to a nonpregnant state. A(n) is a collection of blood within the tissues. - Correct Answers: hematoma A hematoma is a collection of blood within the tissues. While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting? a. Molding b. Caput succedaneum c. Cephalohematoma d. Enlarged fontanelle - Correct Answers: C A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line. What is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old infant? a. Molding doesnt cause any problems. Dont worry about it. b. Did you deliver vaginally or by cesarean section? c. The babys head conformed to the shape of the birth canal. It will go away soon. d. A traumatic delivery can cause molding. - Correct Answers: C The newborns head may be out of shape from molding. This refers to the shaping of the fetal head to conform to the size and shape of the birth canal What symptom assessed in the newborn shortly after delivery should be reported? a. Cyanosis of the hands and feet b. Irregular heart rate c. Mucus draining from the nose d. Sternal or chest retractions - Correct Answers: D Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately. When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior? a. The Moro reflex b. The grasp reflex c. An abnormality of the musculoskeletal system d. A neurological abnormality - Correct Answers: A The Moro reflex is a normal neonatal reflex. It is elicited when the infants crib is jarred. The infant responds by drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position. A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding? a. Sucking b. Rooting c. Grasping d. Tonic neck - Correct Answers: B The rooting reflex causes the infants head to turn in the direction of anything that touches the cheek in anticipation of food. What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn? a. Depressed and sunken b. Triangular shaped c. Smaller than the posterior fontanelle d. Open and diamond shaped - Correct Answers: D The anterior fontanelle is diamond shaped and located at the junction of the two parietal and two frontal bones. It should not be raised or sunken, and it closesNbUeRtwSeINenG1T2Ba.CnOdM18 months of age. What statement indicates the parent understands the guidelines for bathing a newborn? a. Ill use a mild soap to clean all of the body parts. b. I am going to add bath oil to the water to keep the babys skin soft. c. I should shampoo the head after washing the rest of the body. d. Ill wash from the feet upward and change the washcloth for the face. - Correct Answers: C The shampoo is done last because the large surface area of the head predisposes the infant to heat loss. The nurse is measuring the vital signs of a full-term newborn. Which finding is abnormal? a. An axillary temperature of 36.6 C (98 F) b. An apical pulse rate of 178 beats/min c. Respirations of 35 breaths/min d. Blood pressure of 80/50 mm Hg - Correct Answers: B The normal range for a newborns pulse rate is 110 to 160 beats/min. A pulse rate outside of this range should be reported. The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2 days after birth? a. Yellow b. Brown c. Greenish brown d. Black and tarry - Correct Answers: A The stool of a breastfed infant is bright yellow, soft, and pasty. The mother of a 2-week-old infant tells the nurse, I think the baby is constipated. Ive noticed she strains when she has a bowel movement. What is nurses most helpful response? a. Give the baby one serving of fruit per day. b. Increase the amount and frequency of her feedings. c. It sounds like the baby is uncomfortable because she is constipated. d. Newborns might strain with bowel movements because their muscles arent fully developed. - Correct Answers: D Straining in the newborn period is normal. It results from underdeveloped abdominal musculature. No treatment is required. A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later? a. 2900 b. 3100 c. 3300 d. 3800 - Correct Answers: C In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight. The parents of a newborn girl express concern about the infants vaginal discharge, which appears to be bloody mucus. What does the nurse explain as the cause? a. Premature stimulation of the ovarian hormones by the pituitary system b. Cessation of female sex hormones transferred in utero from mother to infant c. The increased amount of circulating blood from the mother throughout pregnancy d. Trauma to the genitalia during the birth process - Correct Answers: B Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth. The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. What is the most appropriate nursing response to this mother? a. Tell me how many hours per day your baby sleeps. b. It is normal for newborns to sleep most of the day. c. Newborns generally sleep 12 to 15 hours per day. d. You will find as the baby gets older, he sleeps less. - Correct Answers: A Although it is true that newborns sleep a great deal of any 24-hour period, the nurse must find out what the mother means by too much before giving any information. Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner? a. Infant refuses a feeding b. Infant has an axillary temperature of 97 F c. Infant has three pasty, yellow-brown stools in 24 hours d. Infants diaper is not wet after 8 hours - Correct Answers: D Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to prevent dehydration. On what knowledge would the nurse base a response to a mother who questions, Do you think my baby recognizes my voice? a. Voice recognition is delayed because the ears are not well developed at birth. b. Infants respond to voice by increasing movements and sucking. c. Infants initially respond to low-pitched voices. d. Neonates can distinguish a mothers voice from other sounds in the first days of life. - Correct Answers: D The ability to discriminate between a mothers voice and other voices may occur as early as in the first 3 days of life. The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. What is the most appropriate intervention by the nurse? a. Do nothing because this is a normal occurrence. b. Report the discrepancy to the pediatrician immediately. c. Decrease the interval between the infants feedings. d. Try feeding the infant a different type of formula. - Correct Answers: A It is typical for the newborn to lose 5% to 10% of his or her birth weight in the first 3 to 4 days of life. No change in the plan of care is needed. Parents express concern about the milia on the face and nose of their infant. What is the nurses most helpful response when instructing the parents? a. Contact a pediatric dermatologist for topical medication. b. Squeeze out the white material after cleansing the face. c. Wash the infants face with a mild astringent several times a day. d. Leave the milia alone; it will disappear spontaneously. No treatment is needed. - Correct Answers: D Milia require no treatment. This skin manifestation will disappear spontaneously. The nurse is going to use a bulb syringe to clear mucus from a newborns nose and mouth. What is the nurses first action? a. Place the tip in the nose and squeeze the bulb gently. b. Suction secretions from the nose before the mouth. c. Depress the bulb before inserting the syringe tip into the mouth. d. Insert the tip into the back of the mouth to reach mucus. - Correct Answers: C The bulb is depressed, and then the tip is inserted into the mouth and then the nose. The depression is slowly released, creating the suction. The mother of a 4-day-old calls the pediatricians office because she is concerned about her infants skin. Which finding needs to be reported promptly to the childs pediatrician? a. The hands and feet feel cooler than the rest of the body. b. Skin is peeling on several parts of the infants body. c. There is a small pink patch on the left eyelid and one on the neck. d. Today, the infants skin has a yellowish tinge. - Correct Answers: D Physiological jaundice becomes evident between the second and third days of life and lasts for about 1 week. Evidence of jaundice is reported and the newborn is evaluated. What action does the nurse implement to protect newborns from infection while in the nursery? a. Keep the newborn dressed warmly. b. Adjust room temperature between 23.8 C (75 F) and 26.6 C (80 F). c. Wash hands before touching each infant. d. Wear a disposable gown when giving infant care. - Correct Answers: C Handwashing is the most reliable precaution available to prevent infection. The nurse washes his or her hands between handling different babies. Which assessment of the newborn should be reported? a. Head circumference is 5 cm greater than the chest circumference b. Hands and feet are warm with a blue color c. Temperature is 36.6 C (97.8 F) d. Head has a longer than normal shape to it - Correct Answers: A The circumference of the head should be less than 2 cm greater than that of the chest. All other listed assessments are within the norm Parents of a newborn are worried about dark areas over the sacrum of the newborn. What does the nurse explain this transitory skin discoloration is called? a. Epsteins pearls b. Milia c. Stork bites d. Mongolian spots - Correct Answers: D Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots. The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should be brought to the physicians attention first? a. White blood cell count of 18,000 b. Hemoglobin of 18.5 c. Hematocrit of 56 d. Bilirubin of 15 - Correct Answers: D A bilirubin of 15 is elevated and requires further immediate investigation. The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that apply.) a. Reflexes b. Color c. Heart rate d. Respiration e. Weight - Correct Answers: A, B, C, D The Apgar score is a standardized method of evaluating the newborns condition immediately after delivery. Five objective signs are measured: heart rate, respiration, muscle tone, reflexes, and color. The score is obtained 1 minute after birth and again after 5 minutes. What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.) a. Swaddling b. Rocking c. Offering a pacifier d. Distraction e. Cuddling - Correct Answers: A, B, C, E Swaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective, noninvasive pain remedies. Distraction is not a dependable method of pain reduction with infants. The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of the newborns physiology? (Select all that apply.) a. Very little subcutaneous fat b. Low metabolic rates c. Ineffective sweat glands d. Small fluid reserves e. Low red blood cell counts - Correct Answers: A, C Newborns have very little subcutaneous fat, which offers little insulation against cold. Newborns have ineffective sweat glands and cannot cool themselves through evaporation. Which interventions would be included in the nursing care of the newly circumcised infant? (Select all that apply.) a. Wash penis with warm water. b. Wipe with alcohol swab. c. Gently remove the yellow crust formation. d. Apply diaper loosely. e. Dress with simple bandage. - Correct Answers: A, D Postcircumcision care includes washing with warm water, avoiding alcohol wipes, leaving the yellow crust in place, and diapering loosely. The nurse is aware that a full-term infant is born with which reflexes? (Select all that apply.) a. Blinking b. Sneezing c. Gagging d. Sucking e. Grasping - Correct Answers: A, B, C, D, E All listed reflexes are present in the full-term newborn. The nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology? (Select all that apply.) a. Small glomeruli b. Minimal renal blood flow c. Inactive gastrointestinal (GI) tract d. Excessive fluid loss from the sweat glands e. Immature renal tubules that do not concentrate urine - Correct Answers: A, B, E The newborns glomeruli are small and have only one third of the blood circulation of an adult, and they are unable to effectively concentrate urine. The GI tract is active. The infants sweat glands do not work effectively and allow very little fluid loss through sweat. The nurse in the nursery may use CRIES, PIPP, NIPS, or NPASS as a guide to _____________ assessment. - Correct Answers: pain CRIES, PIPP, NIPS, and NPASS are all 10-point-scale pain assessment guides for infants. The nurse advises the nursing mother that the immune globulin that is found in breast milk is ______________. - Correct Answers: IgA IgA is an immune globulin that is found in breast milk. The nurse instructs the mother that when the neonates stool becomes loose and takes on a greenish-yellow color, this is normal __________ stool. - Correct Answers: transition The transitional stool has lost its dark green meconium color and gradually changes to a loose greenish-yellow stool with mucus. Prancing movements of the legs, seen when an infant is held upright on the examining table, are termed the __________ __________ . - Correct Answers: dancing reflex Prancing movements of the legs, seen when an infant is held upright on the examining table, are termed the dancing reflex. Place the newborn phases of the sleep-wake states in proper order from first to last. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Stability phase b. First reactive phase c. Sleep phase d. Second reactive phase - Correct Answers: B, C, D,A At birth the newborn passes through the phases of sleep-wake states as part of the adjustment to life outside of the uterus: first reactive phase, sleep phase, second reactive phase, stability phase. Put the steps of nasal bulb suctioning for the newborn in the correct order from first to last. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Clean bulb syringe. b. Release pressure. c. Insert narrow portion into nose. d. Compress ball of bulb syringe. e. Remove and empty into receptacle. - Correct Answers: D, C, B, E, A First the ball of the bulb syringe is compressed, and then the narrow portion is inserted into the nose. The pressure is released, and the syringe is removed and emptied into the receptacle. The bulb syringe is cleaned and stored at the end of the procedure. The nurse is assessing a preterm infant. To what does the infants level of maturation refer? a. Actual time the fetus remained in the uterus b. Age on the Dubowitz scoring system c. Infants weight as compared to the gestational age d. Ability of the organs to function outside of the uterus - Correct Answers: D A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this infant is at risk for what? a. Skin breakdown b. Renal failure c. Brain damage d. Heart failure - Correct Answers: C The higher the bilirubin level and the deeper the jaundice, the greater is the risk for neurological damage. Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first few days of life? a. Weak or absent sucking or swallowing reflex b. Inability to digest food properly c. Refusal to take formula by mouth d. Need for a larger quantity of formula at each feeding - Correct Answers: A When the preterm infants sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition. What deficiency causes a preterm infant respiratory distress syndrome? a. Protein b. Estrogen c. Hyaline d. Surfactant - Correct Answers: D The production of surfactant, necessary for the absorption of oxygen by the lungs, is deficient in the preterm infant. How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding? a. Check tube placement by injecting air into the stomach. b. Weigh the infant before the feeding. c. Aspirate stomach contents d. Check serum glucose level. - Correct Answers: C When the preterm infant is gavage fed, the contents of the stomach should be aspirated before the feeding is started. Aspiration of the stomach contents ensures tube placement and also allows the nurse to assess the amount of feeding in the stomach. The nurse explains to a patient in preterm labor that what may be ordered by the physician to accelerate fetal lung maturity? a. Prostaglandins b. Oxytocin c. Magnesium sulfate d. Corticosteroids - Correct Answers: D Surfactant production can be increased by administering corticosteroids to the mother before delivery. The apnea monitor indicates that a preterm infant is having